Attachment_J.1_BFCC_IDIQ_Statement_of_Work.docx

SECTION C – DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

Beneficiary and Family Centered Care (BFCC) QIO IDIQ Requirements

C.3 BFCC-QIO IDIQ Services

C.1 BFCC-QIO CONTRACT PURPOSE

The purpose of the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) contract is to improve healthcare services for Medicare beneficiaries through BFCC-QIO performance of numerous statutory review functions, including, but not limited to, quality of care reviews, beneficiary complaint reviews, discharge and termination of service appeals in various provider settings, medical necessity reviews, and Emergency Medical Treatment and Labor Act (EMTALA) reviews. CMS wants to ensure that care provided by the Medicare Program is medically necessary, reasonable, meets professionally recognized standards of care, is provided in the appropriate setting, and complies with certain standards under the EMTALA.

C.2 QIO PROGRAM

Background and Overview The statutory authority for this Statement of Work (SOW) is found in Part B of Title XI of the Social Security Act, hereinafter referred to as “the Act.” The statutory provisions originated with the Peer Review Improvement Act of 1982 (P.L. 97-248, §§ 141-143, 96 Stat. 324) that established the Utilization and Quality Control Peer Review Organization program, now known as the Quality Improvement Organization (QIO) program. These provisions were significantly amended by the Trade Adjustment Assistance Extension Act of 2011 (P.L. 112-40, § 261, 125 Stat. 401).

The statutory mission of the Program, as set forth in Section 1862(g) of the Act, involves the Secretary entering into contracts with Quality Improvement Organizations (QIOs) for purposes of making determinations about whether items and services provided to Medicare beneficiaries are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and are not for custodial care. In addition, the Secretary must enter into these contracts to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Toward those goals, Section 1154(a) of the Act requires the QIO contractors to perform one or more functions listed in that section.

Among the statutory duties is the review of some or all of the professional activities of providers and practitioners in the QIO area, subject to the terms of their contracts, in the provision of health care items or services to Medicare beneficiaries; such reviews are for purposes of determining whether services are or were reasonable and medically necessary, whether the quality of the services meets professionally recognized standards of care, and, for inpatient services, whether the proposed services could be effectively provided more economically on an outpatient basis or in a different type of inpatient facility. These reviews are integral to the determination of whether items and services should be payable under the Medicare program.

Section 1154(a)(18) also includes provisions that involve broader authority for QIOs to improve the effectiveness, efficiency, economy, and quality of services under the Medicare program. Section 1154(a)(10) of the Act, for example, specifically requires that the QIO “coordinate activities, including information exchanges, which are consistent with economical and efficient operation of programs among appropriate public and private agencies or organizations, including other public or private review organizations as may be appropriate.” The Centers for Medicare & Medicaid Services (CMS) regards this as authority for the QIO to coordinate and operate a broad range of collaborative and community activities among private and public entities, as long as the predicted outcome will likely directly benefit the Medicare program. In addition, Section 1156(c) of the Act states that it is the duty of each QIO to use such authority or influence as it may possess as a professional organization, and to enlist the support of any other professional or governmental organization having influence or authority over health care practitioners or entities furnishing services in its area, in assuring that each practitioner or entity shall comply with all obligations imposed on them under Section 1156(a) of the Act. Under these obligations, providers and practitioners must assure that they shall provide services economically and only when, and to the extent medically necessary and that those services will be of a quality that meets professionally recognized standards of care.

Section 1867(d)(3) of the Act requires the Secretary of Health and Human Services (HHS) to request a QIO to assess whether an individual had an emergency medical condition which had not been stabilized and to provide a report to the Secretary in certain circumstances. As part of the implementation of this provision, CMS and the Office of the Inspector General consult with QIOs in order to determine whether, with respect to EMTALA requirements, an individual had an emergency medical condition that had not been stabilized, and whether a medical screening examination, stabilizing treatment or a transfer was appropriate.

Oversight and Program Administration CMS is responsible for oversight and administration of the Quality Improvement Organization (QIO) Program. The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. HHS National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as:

· Improving quality of care for beneficiaries;

· Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and

· Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; beneficiary requested appeals of notices/termination of services; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related statute.

Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) IDIQ Attachment J.1 BFCC IDIQ Statement of Work

Strategic Goals While the principle objective of this contract is to carry out the goals listed in section 1862(g) of the Act, CMS wants to fulfill the QIO program requirement in a manner that supports CMS in its efforts to seek to improve health and health care for all Medicare beneficiaries and promote quality of care to ensure the right care at the right time, every time. CMS seeks to align the goals of the QIO program in general, and successful performance of this contract with current CMS agency goals and priorities. It is anticipated that these goals may evolve over the period of performance of this contract.

QIO Program Structure The QIO Program is separated according to two core functions: case review and quality improvement. Each contract within the QIO program structure will support at least one of these functions.

Case Review Activities Beneficiary & Family Centered Care Quality Improvement Organizations (BFCC-QIOs) conduct statutorily mandated case review activities and focus on interventions to help Medicare beneficiaries exercise their right to high-quality health care. BFCC-QIOs manage all beneficiary complaints and quality of care reviews to ensure consistency in the case review process while taking into consideration local factors important to beneficiaries and their families. BFCC-QIOs also handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services.

Quality Improvement Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) conduct quality improvement work to bring Medicare beneficiaries, providers, and communities together in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality across the nation. QIN-QIOs are skilled in creating opportunities for providers to learn from each other, applying advanced improvement and analytical methods, engaging patients and families, and structuring processes for sustaining positive change.

C.2.1 QIO Eligibility Requirements

Section 1152 of the Social Security Act and 42 CFR Part 475 provide the authority for CMS to enter into contracts with entities to perform QIO functions. In awarding such contracts, CMS complies with the Federal Acquisition Regulation (Title 48 CFR) unless the Secretary determines that a specific provision is inconsistent with the purposes of Title XI, Part B of the Social Security Act. In order to be awarded a QIO contract, an entity must meet the following qualifying requirements:

· Have a governing body that includes at least one individual who is a representative of healthcare providers and at least one individual who is a representative of consumers (42 CFR 475.101(a))

· Demonstrate capability to meet the eligibility requirements and perform the activities specified by CMS in the solicitation for award of a QIO contract (42 CFR 475.101(b)(1))

· Demonstrate the ability to perform case reviews as set forth in 42 CFR 475.102 and/or perform quality improvement as set forth in 42 CFR 475.103 (42 CFR 475.101(b)(2))

· Demonstrate the ability to actively engage beneficiaries, families, and consumers in case reviews and/or quality improvement activities (42 CFR 475.101(c))

· Demonstrate the ability to perform QIO functions with objectivity and impartiality and in a fair and neutral manner (42 CFR 475.1010(d))

· Demonstrate that it is not a healthcare facility, affiliate, or payer organization. QIOs may not perform reviews of healthcare services other than the review of the quality of care (42 CFR 475.105).

C.2.2 QIO Responsibilities

Only those entities awarded a contract with CMS to perform as a QIO may represent their organization as a QIO. The QIO Program has numerous support contractors but, they are not QIOs. QIOs perform a function or functions defined in Section 1154(a) of the Social Security Act (42 U.S.C. 1320c-3(a)) in accordance with the terms that CMS defines in its QIO contracts.

QIO contracts may require performance of one or more functions governed by statute as defined in 42 U.S.C. 1320c-3(a)(1) through (18). These statutory responsibilities may include the following:

1. Review the provision of health care services and items for which payment may be made. Involve healthcare practitioners of the type under review in such reviews. Determine through review whether services were reasonable and medically necessary, meet professionally recognized standards, and, if provided in an inpatient setting, could be provided more economically on an outpatient basis or in an inpatient facility of a different type. (42 U.S.C. 1320c-3(a)(1))

2. Determine, on the basis of the review described above, whether payment shall be made, provided that determinations to deny payment because the quality of care did not meet professional standards are based on criteria developed by the Secretary (42 U.S.C. 1320c-3(a)(2))

3. Notify the healthcare provider, patient, and the agency or organization responsible for the payment of claims of the review determination within specific parameters (42 U.S.C. 1320c-3(a)(3))

4. Conduct a reasonable proportion of quality of service reviews among the different cases and settings. Review both inpatient and outpatient services provided by Medicare cost plans under section 1876 pursuant to a risk-sharing contract. Maintain a beneficiary outreach program designed to apprise individuals receiving care under Medicare health plans of the QIO program. (42 U.S.C. 1320c-3(a)(4))

5. Consult with nurses and other professional healthcare practitioners and providers of healthcare services with respect to the organization's responsibility for the review of the professional activities of such practitioners and providers (42 U.S.C. 1320c-3(a)(5))

6. Apply professionally developed norms of care, diagnosis, and treatment. Provide a physician representative to meet several times a year with medical and administrative staff of each hospital whose services are reviewed by the organization. Publish not less often than annually its review findings. (42 U.S.C. 1320c-3(a)(6))

7. Utilize the services of persons who are practitioners of, or specialists in, the various areas it reviews, make professional inquiries, examine pertinent records, and inspect facilities in support of its reviews (42 U.S.C. 1320c-3(a)(7))

8. Carry out reviews to approve exceptions to the payment exclusion for assistants at surgery in a cataract operation as specified in Section 1862(a)(15) of the Social Security Act (42 U.S.C. 1320c-3(a)(8))

9. Collect, maintain, and permit access to information relevant to its functions and notify appropriate state boards in the event of a violation of section 1156(a) (42 U.S.C. 1320c-3(a)(9))

10. Coordinate activities for economical and efficient operation of the program (42 U.S.C. 1320c-3(a)(10))

11. Make available its facilities and resources for contracting with private and other public entities that pay for health care to provide similar review services (42 U.S.C. 1320c-3(a)(11))

12. Review ambulatory surgical procedures specified pursuant to section 1833(i)(1)(A) of the Social Security Act (42 U.S.C. 1320c-3(a)(12))

13. Review early readmission cases (42 U.S.C. 1320c-3(a)(13))

14. Review all written complaints from Medicare beneficiaries about the quality of services (42 U.S.C. 1320c-3(a)(14))

15. Perform on-site reviews (42 U.S.C. 1320c-3(a)(15))

16. Upon request from the Secretary or CMS pursuant to section 1867(d) of the Act, review hospital and physician performance for compliance with the Emergency Medical Treatment and Labor Act (42 U.S.C. 1320c-3(a)(16))

17. Offer quality improvement assistance pertaining to prescription drug therapy to providers, practitioners, and Medicare health plans (42 U.S.C. 1320c-3(a)(17))

18. Perform activities deemed necessary by the Secretary for purposes of improving the quality of care (42 U.S.C. 1320c-3(a)(18))

In order to fulfill these statutory responsibilities, QIOs may perform activities that include, but are not limited to, the following:

· Establishing methods and procedures for involvement of healthcare practitioners in performing reviews of healthcare services and investigating complaints

· Maintaining current knowledge of Medicare programs in order to conclusively determine whether payments must be made for services under Title XVIII of the Social Security Act

· Entering into Memoranda of Agreement with healthcare providers, payers, and other organizations prior to conducting Medicare case reviews in the service areas and for the types of cases it will have authority to review, and conducting outreach to inform beneficiaries about how to exercise their right to QIO reviews

· Establishing procedures for notifying any patient, practitioner, provider, and any organization responsible for payment to communicate with them about the QIO review determination and rights to reconsideration or appeal

· Planning for and maintaining sufficient staffing to assure that resources are allocated to performing reviews by duly licensed professionals for all of the different cases and settings

Establishing methods for identifying cases where there is a likelihood that quality of services do not meet professionally recognized standards of care

· Coordinating activities and information exchanges across QIO contractors and Program stakeholders such as public and private organizations involved in healthcare delivery

· Publishing at least annually a report of QIO activities and findings

· Performing any other services to improve the quality of care for services under Title XVIII of the Social Security Act that CMS determines are appropriate for performance under QIO contract awards

· Maintaining procedures to continuously monitor, mitigate, or avoid any actual, potential, or apparent conflicts of interest of the QIO organization, its employees and subcontractors when performing any function of the QIO contract

Section 1153 of the Social Security Act requires that CMS ensure there is no duplication of the functions carried out by QIOs if more than one QIO operates in the same area. QIO contractors should assist CMS and work together with other stakeholders to identify and mitigate any duplication of effort identified in their geographic or service area.

C.3 BFCC-QIO IDIQ SERVICES

The BFCC component of the QIO Program is an effort to measurably improve the quality of healthcare for Medicare beneficiaries as well as all individuals protected under EMTALA generally. It also intends to provide peer review for purposes of determining the appropriateness of payment under Medicare. The results of all activities are used to make recommendations on quality improvement initiatives and to develop recommendations to CMS for focused reviews.

BFCC Core Functions The BFCC Core Functions are presented in Figure 2.

Figure 2. BFCC Core Functions

This BFCC-QIO IDIQ contract requires performance of numerous statutory case reviews, claims review and related services in designated area(s) including BFCC program assessment and management of overall contract operations. These services include but are not limited to contract management, program assessment, BFCC Core Functions, QIO Responsibilities, and any activities necessary to fulfill the statutory responsibilities. Performance under this contract will be conducted under the terms and conditions of this Base Contract and pursuant to Task Orders issued during the contract term.

In carrying out its responsibilities for all BFCC functions, BFCC-QIOs shall collaborate with CMS contractors and other entities, including but not limited to the BFCC NCORC, QIN-QIOs, QIO NCC, BFCC-SC, State Survey Agencies (SSAs), Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Qualified Independent Contractors (QICs), Unified Program Integrity Contractor (UPIC), Zone Program Integrity Contractor (ZPIC), Office of Inspector General (OIG), Office for Civil Rights (OCR), the Office of Medicare Hearings and Appeals (OMHA), the Departmental Appeals Board, pertinent state-based organizations and appropriate federal grant partners.

BFCC-QIOs will operate seven (7) days a week to allow for a beneficiary and family-centered care approach. The intake of cases shall occur seven (7) days per week. On Monday through Friday, the BFCC-QIO shall be staffed from 9:00 a.m. to 5:00 p.m. and on weekends and holidays from 11:00 a.m. to 3:00 p.m. Because the BFCC-QIO may operate in more than one time zone, CMS expects that staffing will cover the above-noted times in each time zone within the BFCC-QIO CMS Region.

Beneficiary Oversight Case and claim validations are conducted for the purpose of beneficiary oversight. A claim review is used to identify and recover improper payments after paying a claim. The overall goal is to reduce improper payments by identifying and addressing coverage and coding billing errors for all provider types. Validations are conducted based on Medicare coverage policies to determine whether services and/or items for which payment may be made (whole or in part) under Medicare are reasonable, sufficient and medically necessary.

Beneficiary Protection Case reviews are conducted for the purpose of beneficiary protection. Case review is a statutory requirement of the QIO Program. BFCC-QIO contractors provide case-review services to improve healthcare delivery through a wide variety of statutory review functions, including but not limited to quality of care reviews, beneficiary complaint reviews, discharge and termination of service appeals in various provider settings, medical necessity reviews, and Emergency Medical Treatment and Labor Act (EMTALA) reviews. BFCC-QIOs conduct individual case reviews in accordance with applicable law, instructions in the QIO Manual, and other administrative directives. Individual case reviews will include a number of ancillary activities, such as post-review activities, communication with beneficiaries and/or providers, referral of cases to other entities, and other routine responsibilities. BFCC-QIOs enter all case review activities into the CMS-designated case-review systems on an ongoing basis. The CMS system of record for BFCC program of activity (case/claims reviews) is the Quality Management and Review System (QMARS). BFCC-QIOs are required to perform individual case review to fulfill mandatory review requirements in an efficient manner that provides quality services at the lowest possible cost/price.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. Currently, the SSN-based Health Insurance Claim Number (HICN) is used with CMS business partners including the Social Security Administration, United States Railroad Retirement Board, State Medicaid Agencies, health care providers, and health plans. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based HICN on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. The MBI is confidential like the SSN and should be protected as Personally Identifiable Information.

Beneficiary/Stakeholder Engagement Person and Family Engagement (PFE) activities are required to increase beneficiary knowledge, skill, and confidence to take an active role in managing their health and healthcare. Engagement with providers is required to ensure that limited English proficient (LEP) beneficiaries receive language access services (including competent interpreters and the translation of vital documents); and individuals with disabilities receive auxiliary aids and services (including sign language interpreters, materials in Braille and accessible electronic formats for patient portals to electronic health records [EHRs]). These activities are not intended to be all-inclusive. CMS expects BFCC-QIOs to leverage innovation, knowledge and experience within their service areas to maximize impact under this function resulting in both beneficiary and provider satisfaction.

The BFCC-QIO shall focus on building and maintaining program awareness to include special emphasis on the beneficiary support systems. These are the family members, caregivers, advocates, or representatives involved in critical decisions and management of the health and/or overall living of older independent beneficiaries. Outreach initiatives shall consider that such family members, caregivers, advocates, or representatives may not be Medicare eligible and are unaware of QIOs, Medicare policies, benefits, and patient support programs. For beneficiary families and representatives to be successful advocates to the patient, they must be equipped with the knowledge and tools to assist in beneficiary support and care. Providers and practitioners should be encouraged to implement strategies and processes to effectively engage the beneficiary support system as part of their standard practice with older beneficiaries. Example, the beneficiary’s support system may be the provider/practitioner’s primary resource to ensure that medication and other medical instruction to the beneficiary are consistently followed.

Raising program awareness is the first step to maintaining program awareness. Assumptions cannot be made on the awareness, level of knowledge, or the ability to use the knowledge and support programs of Medicare by beneficiaries, their support systems, providers, and practitioners. The circumstances affecting awareness must be addressed at all levels. Effective dissemination of information on BFCC-QIO existence and work to the communities, providers and practitioners within the QIO’s area is the foundation to effecting widespread change in the healthcare system by involving all responsible parties.

Analytics and Data-Driven Improvements, Innovation, and Collaboration BFCC-QIOs and the BFCC NCORC will use data resulting from BFCC program task orders, BFCC SC, and other CMS approved sources to identify quality improvement efforts that target specific populations, community, state, or region, within the service area, when the data reveals gaps or disparities in care. Using data to support the development of intervention strategies shall include but is not limited to the following:

a. Performing root cause analyses (RCAs);

b. Utilizing a change methodology such as the Model for Improvement, Lean, Six Sigma or other methodologies to promote rapid cycle testing and continuous quality improvement;

c. Establishing benchmarks or interim measures that map to one or more local/ national goal(s) and/or aims;

d. Identifying short, medium, and long-term outcomes and performance measures;

e. Providing ongoing analyses to support BFCC program related activity; and

f. Monitor outcome and process measures for implementation of quality improvement interventions and outcome measures over time.

BFCC-QIO Task Orders In performing its work, the BFCC-QIO may consider servicing multiple areas and the unique needs and characteristics of the Medicare population and health care providers. Services under this contract may be requested on a regional or national basis.

Note: Special Projects may be performed in a designated area, regionally or nationally.

Table 1 represents examples of task orders/tasks broken out by the categories described above. This list is not intended to be all-inclusive.

Table 1. BFCC-QIO Task Orders

REGIONAL TASK ORDERS

BFCC Case Review Services

· Quality of Care Reviews, including beneficiary complaint reviews and general quality of care reviews

· Beneficiary appeals of denials of hospital admissions, discharge and termination of services (Grijalva, BIPA and Weichardt appeals)

· Reconsiderations

· Medical Necessity Reviews

· EMTALA Reviews

· Sanctions and/or Sanction Activities

· Quality Improvement Initiatives (QIIs)

· Monitoring Physician Acknowledgement Statement

· Person/Patient and Family Engagement

· Immediate Advocacy

· Pre-Admission/Admission Hospital Issued Notice of Non-coverage (HINN)

· Any additional statutory requirements

· Other BFCC program related tasks

NATIONAL TASK ORDERS

Claim Reviews, Monitoring & Oversight

· Short Stay (2 Midnight) Reviews

· Higher-Weighted Diagnosis Related Group (HWDRG) Reviews

· Readmissions Reviews

· Person/Patient and Family Engagement

· Healthcare Navigation

· Medication Oversight

· CMS Directed Surveys

· National Coordinating & Oversight Review Center (BFCC-NCORC)

· BFCC Program Monitoring & Evaluation

· Performance Audits

· Claims

· Cases

· Focused Reviews

· Intensified Reviews

· Data Analytics and Management

SPECIAL PROJECTS

TASK ORDERS

· Special Innovation Projects (SIPs) shall stem from BFCC program data that identify trends and patterns based on the following:

· Beneficiary Complaints/Concerns

· Beneficiary Appeals

· Focused Reviews

· Quality Improvement Initiatives

· State-based Innovation & Local Level Flexibility Improvement Projects

· SIPs may be performed in a designated area, regionally or nationally

Comprehensive Contract Management A comprehensive contract management plan is required for overall contract operations and a comprehensive work plan is required for each task order.

The comprehensive contract management plan will be results-oriented and, at a minimum, include effective lines of communication, budget and cost controls, Internal Quality Improvement Program (IQIP), project schedule management, development of comprehensive task order work plans, call center operations, resource management to include staffing matrices by task/subtask, progress reviews and performance monitoring, risk management, change management, timely delivery and reporting, and clearly defined roles, responsibilities, lines of authority, resources appropriately aligned to services and deliverables, and compliance with Base Contract Sections C.3.1 Collaboration, Accountability, and Transparency, C.3.2 Contractor Performance Measurement, C.3.3 Transition Requirements, C.4 Technical Considerations, and C.5 General Requirements.

Each BFCC-QIO and BFCC NCORC must develop and maintain an IQIP, also known as an Internal Quality Control (IQC) program or a Continuous Internal Quality Improvement Program (CIQIP), which complies with provisions in the QIO Manual. The purpose of the IQIP requirement is to support and foster an environment of continuous quality improvement within the QIO through ongoing assessment and improvement in areas that are critical for successful contract performance.

Comprehensive task order work plans, at a minimum, will include the following:

· Resource planning activities, key milestones (including due dates), risk mitigation strategies to ensure success, plan to avoid duplication of effort, and task descriptions including a detailed description of activities necessary to complete each task;

· The identification of the appropriate personnel resources available to ensure completion of the work outlined in the task order. Consultants may be utilized only upon receiving permission from the COR and Contracting Officer;

· The integrated communication plan, which will include names of potential partners/stakeholders, dates, and timeframes for the task order work;

· Task Order Work Plan Timetable that details the schedule for completion of each task;

· Strategies for Person/Patient and Family Engagement; and

· Any additional strategies or plans required under an individual task order.

Personnel Requirements The personnel requirements for the overall contract including all Task Orders comprise two categories: key personnel and other recommended personnel. For both categories, the title is provided along with the required qualifications. The designated key personnel position is required for overall contract management of BFCC-QIO services, except the NCORC key personnel may vary. There may be additional key personnel and other recommended personnel with qualifications listed in individual Task Orders that are unique to those task orders. Key Personnel positions are identified in Table 2.

Table 2. Key Personnel Positions

KEY PERSONNEL

IDIQ/Executive Director

(1 FTE)

· Proven ability to manage the contract at a strategic level including managing and navigating internal and external customer relationships.

· Demonstrated experience with having authority and accountability for meeting all contract deliverables and requirements within budget and the use of appropriate tools to track project deliverables such as project plans, and timelines.

· Demonstrated experience and skills in excellent oral and written communication spanning executives to the general public.

· Proven skill and experience in innovative continuous learning approaches to drive delivery system transformation.

Results-Driven Services

Task order requirements will be issued with the expectation of achievement of bold goals through innovation, broad reach, data-driven methodologies suitable for spread that demonstrate value to beneficiaries and the QIO program qualitatively and/or financially.

For task order services, CMS prefers results-driven offers characterized by activities or initiatives that provide the best value, return on investment, and for beneficiaries, promotes:

· Safety – avoidance of harm

· Timeliness – reduce wait time for both patients and providers

· Efficiency – reduce waste

· Effectiveness – evidence-based care

· Patient/Person Centeredness – honors the individual and respects choice

· Equity – closes racial, geographic, gender, age, sexual preference and ethnic gaps

· Other Department priorities

C.3.1 Collaboration, Accountability and Transparency The BFCC-QIO IDIQ contract is strategically positioned for collaboration and transparency across multiple programs. However, overall success in transforming the healthcare system extends well beyond individual quality improvement program operations.

Collaboration Each BFCC-QIO and the BFCC NCORC, will collaborate with stakeholders within and outside of the CMS quality programs.

Partner and Stakeholder Recruitment and Collaboration BFCC-QIOs shall recruit partners and stakeholders, beneficiaries, providers and/or practitioners under each Task Order within the BFCC-QIO service area to engage in positive, productive and collaborative partnerships. Examples of these types of activities include, but are not limited to:

a. Recruiting advocates to promote beneficiary, family and patient advocate/representative engagement that may assist practices and their provider teams to connect with their beneficiaries and families.

b. Recruiting key stakeholders, associations and groups.

c. Recruiting federal, state and local stakeholders to advance and/or support existing initiatives.

d. Collaborating with CMS Innovation Center model teams, including, but not limited to testing and established models for healthcare delivery, learning systems, and payment models to ensure there is no duplication of effort.

e. Collaborate with CMS support contractors such as the BFCC NCORC, BFCC-SC, QIN NCC, QIN-QIOs, QIO Independent Evaluation Center, ESRD Networks, HIINs, TCPI, and other Network of Quality Improvement and Innovation Contractors (NQIIC) in areas such as sharing performance success from previous and current work, non-identifiable data for quality improvement efforts, LAN collaborative successful interventions and lessons learned, as well as, interventions proven to be effective at sustaining CMS initiatives.

Partnerships and Collaboration BFCC-QIOs must coordinate certain of its activities with those of stakeholder organizations in its service area that are working on comparable efforts or interested in teaming with the BFCC-QIOs. Stakeholders are government entities and private organizations that have common goals with those of the BFCC-QIO/Experts to work on measures/interventions related to healthcare quality. Coordination with stakeholders may involve creating, joining, and/or supporting partnerships with organizations with similar goals and objectives, or facilitating ongoing discussion among the various stakeholders. Innovative approaches to partnering are encouraged and may be inclusive of efficiencies, methods and/or strategies to generate commitments. The nature of the activity to coordinate must be consistent with the terms of the contract to avoid any perceived or actual conflicts of interests. The BFCC-QIO must adhere to the requirement covering conflict of interest reference in Section H.1.

BFCC-QIOs shall collaborate with other healthcare quality improvement and delivery system reform initiatives within and outside of CMS and avoid duplication of work with other CMS contractors involved in those initiatives.

Accountability BFCC-QIOs will document beneficiary/practice/clinician/provider demographic information including participation in other models or programs. Information on practice/clinician/provider participation in other models or programs will be used for knowledge management as well as increasing synergy and teamwork, while avoiding overlap and duplication of effort.

To facilitate the tracking of beneficiaries/practice/clinician/provider participation in other models or programs and to avoid overlap and duplication of effort, BFCC-QIOs will be required to perform an initial and at least annual environmental scan on participating practice/clinician/provider under any tasks ordered from the BFCC-QIO IDIQ contract, and report the results to CMS. BFCC-QIOs may work collaboratively with CMS, HHS and other federal partners for alignment, synergy, and to prevent duplication of effort.

Within 90 days of award of any task order for services to be performed in a designated geographic area, BFCC-QIOs will:

a. Scan the local and immediate environment to identify others who may be receiving HHS or other federal support for related work;

b. Reach out and discuss how to prevent duplication of effort and achieve synergy with others who are working in the geographic area; and

c. Document and report the BFCC-QIO’s actions and plans to prevent duplication of effort.

Transparency Results data generated by BFCC-QIOs from task orders issued under this contract will be shared across the CMS quality programs, which means that performance data will be visible and apparent to other Quality Program contractors.

Some of the potential types of results, by state and/or territory that CMS may share with the quality programs community include, but are not limited to:

· Non-contractual measures, particularly leading indicators that recognize BFCC-QIOs that have moved aggressively to build a foundation for quality improvement;

· Publicly reported performance;

· Performance for non-contractual time periods;

· Annual, and to the extent available, quarterly performance for contract measures, by state or territory.

Open and transparent sharing across the quality programs community offers a chance to rapidly identify opportunities to accelerate improvement in health care and protection for the beneficiaries we serve. When we share successes and challenges on a regular basis, the entire quality programs community of practice can more efficiently spread what is working across the country to maximize our collective use of performance data, learn from each other, and accelerate improvement.

BFCC-QIOs have considerable experience with sharing results with providers to support improved health care for our beneficiaries. CMS will benefit from constructively sharing results that support advancement of quality improvement and promote a positive dialogue among the quality programs community and CMS. It is important that CMS and BFCC-QIOs model transparency and openness in the use of data to accelerate improvement.

In addition, BFCC-QIOs shall demonstrate transparency through reporting on an annual basis the QIO Annual Medical Services Review Report in accordance with the CMS reporting template and participate in other transparency activities as directed by CMS. The annual report must be publicly available on the BFCC-QIO website. The Annual Medical Services Review Report shall include state-level data and QIO-area- level data.

C.3.2 Contract Performance Measurement

CMS will conduct monitoring activities throughout the course of the contract and will act upon findings as necessary. Information used for these monitoring purposes includes but is not limited to:

· Deliverables submitted by the BFCC-QIO to CMS in accordance with task order Schedules of Deliverables,

· Data for measures indicated in Task Order(s)

· Data from the BFCC-QIO’s Internal Quality Control Program,

· Other data submitted by BFCC-QIOs as required by CMS,

· Additional information gathered via email, phone, video, or in-person visits.

BFCC-QIOs shall cooperate with the COR on all CMS monitoring processes and address any concerns identified by the COR. CMS will take appropriate contract action (e.g., providing warning for the need for adjustment, instituting a formal correction plan, terminating an activity, or recommending early termination of a contract because of failure to meet contract timelines or performance as specified in the contract and Task Order(s)). This means that the BFCC-QIO shall comply with the Contract, task orders, task order Schedules of Deliverables, Evaluation Measures Tables, and any subsequent modifications (including HCQIS Memorandums) issued by CMS.

Additionally, there will be multiple periods of more formal evaluation under this contract. The first evaluation will occur at the end of the 12th month of the contract. Subsequent evaluations will occur at the end of the 24, 36, 48 and 54th month of the contract. The evaluations will be based on the most recent data available to CMS (under special circumstances, BFCC-QIOs will be evaluated on no less than 6 months of data if 12 full months of data is not available). The performance results of the evaluation at each evaluation period (that is, 12, 24, 36, 48 and 54th months) will be used, in addition to ongoing monitoring activities, to determine the BFCC-QIO’s performance on the overall contract.

Overall Contract Evaluation The results of the annual (12, 24, 36, 48th month) and 54th month evaluation periods, in addition to ongoing monitoring activities, will be used to determine how the contractor performed on the overall contract.

If CMS chooses, CMS may notify the BFCC-QIO of the intention not to renew the BFCC-QIO contract, and inform the BFCC-QIO of the BFCC-QIO’s rights under the current statute.

Any failure at one or more of the annual or 54th month evaluations for any Task Order may result in the BFCC-QIO receiving an adverse past performance evaluation. Further, failure may impact the BFCC-QIO’s ability to continue similar work in or be eligible for future QIO Program awards.

CMS reserves the right at any point, prior to the notification of CMS’ intention not to renew the contract, to revise measures or adjust the expected minimum thresholds for satisfactory performance or remove criteria from a Task Order evaluation protocol for any reason, including, but not limited to, data gathered based on experience with the amount of improvement achieved during the contract cycle or in pilot projects currently in progress, information gathered through evaluation of the BFCC-QIO performance overall, or any unforeseen circumstances. Further, in accordance with standard contract procedures, CMS reserves the right at any time to discontinue all or part of one or more Task Order(s) for one or more region(s), state(s), or territory(ies) in the QIO area or any other part of this contract regardless of BFCC-QIO performance on Task Order(s).

C.3.3 Transition Requirements

Contract Start-Up Upon task order award, the BFCC-QIO awardee will provide a plan for contract start-up that will subsequently be included in the Comprehensive Contract Management Plan. The contract start-up plan, at a minimum, will include a milestone chart detailing the timelines and stages of transition from the effective date of contract performance until the BFCC-QIO assumes sole responsibility for the BFCC-QIO program work and incorporate plans to communicate and cooperate with the current incumbent BFCC-QIO.

Contract start-up activities will primarily be performed from initial task order award until full performance begins with Case Review services. However, there may be some start-up activities that may not be completed prior to the start of Case Review services. Any contract start-up activities that impact the provision of Case Review services to beneficiaries must be completed timely as there will be no lapse in service to beneficiaries.

Contract Phase-Out At the end of the incumbent BFCC-QIO’s contract, the incumbent BFCC-QIO will provide transition/ phase-out support to the successor BFCC-QIO Contractor selected by CMS (refer to FAR 52.237-3 Continuity of Services).

This transition will begin no more than 120 days before the end of the 12th SoW QIO contract and the aim will be for it to end at the incumbent BFCC-QIO contract’s end date. During this period, the incumbent BFCC-QIO shall work with the successor BFCC-QIO, CMS Staff, and other identified CMS contractors to assure continued operation of the BFCC-QIO program.

Before the transition begins, the incumbent BFCC-QIO will provide CMS with a transition plan. The transition plan will provide adequate coverage to assure uninterrupted service of BFCC-QIO services for the BFCC-QIO program.

Prior to the 60th day before the last day of the incumbent BFCC-QIO’s contract, the incumbent BFCC-QIO will follow all actions identified within the current QualityNet Startup and Shutdown Procedures. The incumbent BFCC-QIO will transition information systems activities as directed by CMS.

Transition Plan The BFCC-QIO Contractor’s Transition Plan shall provide detailed methods that will be used to ensure a smooth transition from the incumbent BFCC-QIO’s operation to operation by the successor BFCC-QIO. At a minimum, the Transition Plan shall include the following:

1. Organizational Chart that

a. Displays internal and external organizational relationships

b. Identifies the individuals (at all organizational levels) who will be responsible for the transition and their respective roles; detail the lines of communication and how the incumbent BFCC-QIO will interface with CMS during this phase of contract performance.

2. A milestone chart detailing the timelines and stages of transition

3. Phase-Out

a. A plan to transition (without any lag time), receipt and processing of all expedited and fast-track appeals.

b. A list of all pending case reviews with points of contact that the successor contractor will be required to complete.

Transition of Case Review Materials Any case record received on/after December 1, 2023 that cannot be entered/processed in QMARS, should be scanned into a PDF format and stored on the HCQIS file share. For easy navigation, the case should adhere to the following naming convention \Case Type Name\YYMMDD_CaseType.pdf

C.4 TECHNICAL CONSIDERATIONS

The BFCC-QIO undertaking task orders under this BFCC-QIO IDIQ contract shall comply with all requirements outlined in this contract, together with statutory and regulatory provisions and any amendments to those provisions that might occur during the course of the contract and formal instruction from CMS, through the CO.

The Glossary of Terms and Acronyms (Attachment J.6) shall be used when interpreting the requirements of this contract.

C.4.1 Technical Requirements

The following links provide the technical requirements for this contract:

· QIO Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019035.html

· Code of Federal Regulations: http://www.ecfr.gov

· 42 CFR Parts 405

· 42 CFR Parts 422

· 42 CFR Parts 475

· 42 CFR Part 476

· 42 CFR Part 478

· 42 CFR Part 480

· 42 CFR §§ 489.20 and 489.24

· 42 CFR Part 1004

· 508 Compliance Standards: http://508.hhs.gov C.4.2 Information Technology Architecture for the QIO Program

The BFCC-QIO must be knowledgeable of a wide range of information technology systems as referenced in the Information Systems Security Requirements attachment (Attachment J.9). The attachment includes a link to the list of known systems that may be used by the contractor and provides high level details of the systems and applications. The core functionality, support systems and interdependencies of each system are described in the attachment. While those users of the system that are QIOs (“QIO users”) will not directly interface with all of systems and applications described, the inclusion of the support and subsystem descriptions will assist each QIO in obtaining a global view of the Health Care Quality Information System (HCQIS) infrastructure.

C.4.3 Infrastructure Operations Support and Data Management Unless otherwise directed by CMS, the BFCC-QIO shall adhere to the most current version of the policies and procedures outlined and posted on any of the HCQIS identified websites (e.g. QIOnet, QualityNet, etc.). These include, but are not limited to, the Quality Improvement Organization Infrastructure Operations and Support Manual, the Quality Improvement Organization Network Information Technology (IT) Administrator Manual, the HCQIS Database Systems Administrator Guide, the QualityNet System Security Policy, and the QualityNet Incident Response Procedures. Please note that name changes can/will occur so specifics can be provided upon contract award. The contractor shall comply with all present and future statutes as well as federal, HHS, and CMS regulations and program instructions relating to providing a secure computer operations environment. Additional policies, procedures, updates in documents may be released, requiring the contractor to comply.

The BFCC-QIO shall not develop software products for use by other contractors, partners, etc. without written prior approval from CMS. In addition, no funds from this contract shall be used for data collection activities not specified in this contract without prior approval from the COR and in accordance with other CMS administrative guidance.

All non-QualityNet information systems are restricted from any official U.S. Government business involving the processing, storage, or transmission of QualityNet information unless authorized by a CMS QNet Information System Security Officer (ISSO) in writing. This includes, but is not limited to your corporate-supplied workstation, unauthorized external storage devices, and personal computer.

The BFCC-QIO shall maintain all necessary documentation that meets or exceeds the performance standards specified in the Infrastructure Operations Support and Data Management chapter of the QIO Manual and provide all deliverables as specified in task order Schedules of Deliverables.

C.4.3.1 Hardware/Software

HCQIS environment contractors that require access to HCQIS resources outside of web-facing websites, are required to connect as follows:

a) Application Developer Organization (ADO)

HCQIS Contractor Furnished Equipment (CFE) – contractor will be responsible for providing necessary hardware, software and internet connectivity.