J.7 DME MAC Award Fee Plan and Self Assessment Template.docx

Attachment J.07 DME MAC Award Fee Plan and Self-Assessment Template

RFP # 75FCMC19R0041

FY 2020 Award Fee Plan and Self-Assessment Template

Award Fee Plan for Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC)

Jurisdiction C

(fill in MAC name) (fill in Contract number)

(fill in contract year, e.g., Implementation/Base, Base period, Option Year 1, Option Year 2, etc.)

Contract Period of Performance (fill in date range)

Award Fee Evaluation Period (fill in date range)

Table of Contents

FY 2020 Award Fee Plan document

OVERVIEW

This document provides the Award Fee Plan for the Jurisdiction C DME MAC contract awarded to MAC X. The performance criteria contained within this plan will be used, along with other performance related information, to determine the amount of award fee earned by the MAC.

The purpose of utilizing the award fee process is to incentivize and reward MAC excellence in the performance of contract requirements critical to program success, while the MAC meets at least minimum acceptable performance levels in all other areas.

The award fee may be awarded in whole, in part, or not at all, based on evaluated performance exceeding minimum contract requirements.

THE AWARD FEE PLAN

The award fee plan describes how the MAC will be evaluated and how the award fee will be administered. This plan identifies the criteria to be used to evaluate the MAC’s performance as it relates to the award fee criteria for the performance period. This plan also identifies the roles and responsibilities of those who will participate in the evaluations.

The Award Fee Plan:

· Is approved by the Contracting Officer (CO), the Performance Evaluation Board, and the Fee Determining Official (FDO);

· Allocates the fee pool among performance categories;

· Specifies the evaluation cycle;

· Identifies the roles and responsibilities of those who will participate in the evaluation; and

· Describes criteria for evaluating the MAC’s performance.

The FDO may unilaterally change the award fee plan prior to the beginning of an evaluation period. The MAC will be notified of changes to the plan by the CO, in writing, before the start of the affected evaluation period. Changes to this plan that are applicable to a current evaluation period will be incorporated by mutual consent of both parties.

Fee Arrangement.

The fee arrangement is negotiated based on the total estimated cost of the contract. There are regulatory limitations on total fee (cumulative base fee and award fee) for a cost plus award fee contract. The fee consists of two parts, the base fee and the award fee.

Base Fee.

The base fee (which may be zero) can be viewed as the minimum compensation for the resources a MAC uses or the investment it may undertake in order to perform the contract.

Award Fee.

The award fee is the amount of fee set aside in the contract that is available to be earned by the MAC for exceeding minimum contract requirements. The MAC is not guaranteed a minimum amount of award fee. Consequently, some, none, or the entire maximum available award fee may be earned. The amount of the fee awarded to the MAC is unilaterally determined by the government’s evaluation of MAC performance exceeding contract requirements.

Prerequisite for Eligibility for Award Fee.

In order to participate in the award fee program described in this document, the MAC must obtain at least a minimum score of “Satisfactory” in each individual perspective/evaluation criterion for the most recent Contractor Performance Assessment Reporting System (CPARS) evaluation during the evaluation period.

Performance Evaluation Periods

Measured: [Fill in award fee evaluation period, for Implementation/Base, list out separately]

With the exception of an implementation period, the award fee evaluation period begins with the first full month, and ends with the last full month of the contract period, unless otherwise specified. The final determination of the fee earned will be accomplished within 150 days after the end of the contract year.

Organizational Structure for Award Fee Administration The award fee organizational structure is established for administering the award fee provisions of this contract. The organization consists of the following:

Fee Determining Official (FDO).

The FDO is the Director, Medicare Contractor Management Group in the Center for Medicare, Centers for Medicare & Medicaid Services (CMS). The responsibilities of the FDO are to:

· Approve the award fee plan and any significant changes;

· Review the Performance Evaluation Board report, MAC input, and other pertinent performance data; and,

· Make a final determination of award fee earned and payable for each evaluation period.

Performance Evaluation Board (PEB).

The PEB is comprised of the Contracting Officer’s Representative (COR); CO; CO’s Manager; Director, Division of Performance Assessment, Panel Chair; Director, MAC Program Management Division; and Director, Division of MAC Budget & Data Analysis. The responsibilities of the PEB are to:

· Review the Business Function Leads’ evaluations of the MAC’s performance;

· Consider all evaluation information from pertinent sources;

· Prepare a report to the FDO on the recommendation of an award fee to be earned by the MAC; and,

· Substantiate the recommended award fee to the FDO.

Business Function Leads (BFLs).

The BFLs are CMS staff who maintain written records of the MAC’s performance in their assigned evaluation area(s) so that a fair and accurate evaluation is obtained. The BFLs will review and consolidate periodic monitoring information for inclusion in their BFL reports, which are due to the PEB no later than 45 days after the end of the contract year.

MAC Input – to include page limitations and formatting requirements.

The MAC shall provide a written award fee performance evaluation Self-Assessment to the CO and COR within 30 calendar days of the end of the contract year. The MAC shall provide as much detail as is necessary to assist the evaluators in making its final determination; however, the written Self-Assessment shall conform to the following page limitations and formatting requirements:

· All self-assessment documents shall be submitted in Microsoft Word in Times New Roman 12 point font with 1-inch top, bottom, left and right margins.

· The Microsoft Word document shall not have any issues labeled as “errors” when the user would run the Accessibility Checker to ensure compliance with Section 508 of the Rehabilitation Act. Accessibility Checker results that are labeled as “warnings” or “tips” shall be fixed to the extent possible.

· For evaluations that have both Implementation and Operational criteria, the written Self-Assessment shall not exceed 27 pages in length (5 pages for Implementation and 22 pages for Operations).

· For evaluations that only have Operational criteria, the Self-Assessment shall not exceed 22 pages in length.

· In addition to the overall page limitation, the evaluation for the Program Improvement and Collaboration award fee criterion shall not exceed 10 pages. In addition, illustrative charts and graphs are permissible for this criteria; however, capturing all/most of the narrative in a chart with a different font is not permissible. A narrative chart must be in Times New Roman 12 point font.

· When preparing the Self-Assessment, the MAC shall use the Award Fee Self-Assessment Template provided below (the latter portion of this combined document).

· The Award Fee Plan portion of this combined Award Fee Plan and Self-Assessment document does not count towards the Self-Assessment page limit and shall not be submitted with the Self-Assessment.

Notification to the MAC.

The MAC shall receive written notification of the award fee determination within 150 days of the end of the contract year.

AWARD FEE CATEGORIES - SCORING

1. Award Fee Criteria - Summary

Award Fee Criteria for Implementation The CMS will assess MAC performance against stated criteria in the following areas:

· Successful Claims Workload Cutover

· Risk Mitigation

Award Fee Criteria for Operations The CMS will assess MAC performance against stated criteria in the following areas:

· Program Improvement and Collaboration

· Appeals - Medicare Redetermination Notice (MRN) Timeliness

· Medical Review (MR) - Accuracy

· System Security – OY plans ONLY

· Comprehensive Error Rate Testing (CERT) – OY 4 ONLY

The FDO will consider any other information available which relates to the MAC’s performance of all other contract requirements in the final determination of fee earned.

Distribution of Award Fee Pool

Implementation The award fee will be distributed in the following manner for the implementation period:

Operations The award fee will be distributed in the following manner for the operational period:

The DISTRIBUTION TABLE below varies for the Base and Option Years as the System Security and CERT criteria is not applicable in every year.

BY

OY 1/2/3/5/6/7

OY4 CERT

OY4 No CERT

*BY equals Base Year, OY equals Option Year, PM equals Program Management, MIP equals Medicare Integrity Program, and RAC equals Recovery Audit Contractor

In the event that an award fee criterion is no longer applicable, CMS reserves the right to reallocate the award fee pool associated with that criterion among the remaining award fee criteria and disperse accordingly.

In addition, CMS will determine an overall adjectival rating for the MAC’s award fee performance based on the percentage of award fee earned in compliance with the chart below. If a MAC does not earn award fee because it is ineligible due to its CPARS rating(s), the overall award fee adjectival rating will automatically be “Unsatisfactory.”

REFERENCE: Federal Acquisition Regulation (FAR) 16.401(e)(3)

Award Fee Process

At the end of the award fee evaluation period, the COR reviews the work performed during the period. The COR and the CMS BFLs evaluate the MAC’s performance in accordance with the performance metrics and the Statement of Work (SOW). The COR and the CMS BFLs make a recommendation regarding the percentage of fee to be awarded. This recommendation is subject to the CO’s review of the MAC’s performance of the contract.

This recommendation is provided to the PEB and, finally, the FDO. The FDO has the prerogative to change the recommendation. Within 150 days after the end of the contract year, the FDO will make a determination and an official letter will be issued by the CO advising the MAC of the award fee earned.

Award Fee Criteria – Detailed Narratives

Implementation Criteria The MAC shall be evaluated using the following implementation evaluation criteria:

Successful Claims Workload Cutover The MAC successfully implements each workload segment on the final approved implementation plan cutover date. Successful implementation means that 95 percent of clean claims are processed within the claims payment floor and ceiling specified in IOM Pub. 100-04, Chapter 1, sections 80.2.1.1 and 80.2.1.2.

Risk Mitigation The MAC appropriately mitigates and/or takes action when risks affect implementation and/or operations. In addition, the MAC proactively communicates with CMS regarding any impending problems during the implementation period.

Operations Criteria The MAC shall be evaluated using the following operational evaluation criteria:

Program Improvement and Collaboration This award fee criterion measures the MAC’s ability to: propose and implement program improvements that have a tangible or intangible benefit to the government; and collaborate with other key stakeholders to the benefit of the Medicare program. The table below provides illustrative examples of performance for each percentage category. This table is intended to serve as a guide to illustrate how CMS will determine if the MAC will earn 100 percent, 75 percent, or 50 percent of the award fee pool for this criterion.

· The MAC supports new and/or current CMS approaches to improve operational efficiency; financial stewardship of administrative and trust fund dollars; and the provider experience.

· Is an active member in a “lessons learned” workgroup with other MACs which results in viable recommendations to CMS for jurisdiction-wide issues, resulting in positive program improvements and/or cost savings.

· The MAC willingly shares “workarounds” that it developed with other MACs, to the benefit of overall operations.

· The MAC takes a very active role in reviewing CMS Change Requests (CRs); offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes. The MAC provides feedback during CR testing that alerts CMS to problems with business requirements and/or potential problems with CR implementation.

· Is an active member in a “lessons learned” workgroup with other MACs that result in viable recommendations to CMS for jurisdiction-wide issues.

· The MAC takes an active role in reviewing CMS CRs; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes.

50%

· The MAC proposes process improvements or innovations that may provide tangible or intangible benefit to the government.

· Participates in a “lessons learned” workgroup with other MACs.

· The MAC occasionally takes an active role in reviewing CMS CRs; offering constructive feedback when additional information or clearer direction is needed; making suggestions to CMS for how to better facilitate significant changes.

The data source for this criterion is the CO and the COR who will evaluate on an ongoing basis.

Appeals - Medicare Redetermination Notice (MRN) Timeliness This criterion measures the Medicare Administrative Contractor’s (MAC’s) timeliness in processing and sending 100 percent of redetermination notices within 60 calendar days of receipt during the award fee evaluation period.

Eligibility:

In order to be eligible for participation in this criterion, the MAC shall process at least 90 percent of redetermination cases within 60 calendar days of receipt for each month of the award fee evaluation period. If the MAC has one or more months during the period in which the MAC does not successfully process and send 90 percent or more redeterminations within 60 calendar days, the MAC is not eligible for participation in this criterion.

Award Fee:

The award fee for this criterion will be earned based on the number of months the MAC achieves a 100 percent performance level during the award fee evaluation period. The percentage of award fee earned will be calculated by dividing the number of months that the 100 percent timeliness standard was met by the total number of months in the award fee evaluation period. For example, if there are six (6) months in the award fee evaluation period and the MAC achieves the 100 percent rate for four (4) of the six (6) months, the MAC would earn 67 percent of the award fee for this criterion. The amount of award fee earned is rounded to the nearest whole percentage. In the example above, 4 of 6 months yields 66.66 percent, rounded to 67 percent award fee.

Data:

The data source for this criterion is the Centers for Medicare & Medicaid Services (CMS) Contractor Reporting of Operational and Workload Data (CROWD) CMS-2592 report. Redetermination timeliness is calculated by dividing the sum of redeterminations cleared in 60 days (Line 15) by the total cleared (Lines 15 + 16). Redeterminations for which additional documentation is submitted are not included in this criterion.

Throughout the year, for internal monitoring purposes, CMS will conduct a monthly review of the workload numbers submitted on the CMS 2592 reports. Before conducting the award fee evaluation, CMS staff will verify the data used for review with the MAC. The CMS will also review the self-assessment data provided by each MAC. The MAC shall explain discrepancies between the self-assessment data and CMS results, if the overall outcome of the award fee evaluation is impacted. The CMS data will serve as the basis for the award fee evaluation recommendation in instances where minor discrepancies that do not impact the overall award fee assessment are noted.

The evaluation of this criterion will be completed as a desk review, by CMS.

Rounding:

The performance threshold for this evaluation is set at 99.95 percent. Performance percentages are displayed with two decimal places. Normal rounding procedures are employed to determine all percentages. For example, completing 21,001 of 21,012 cases timely will provide a result of 0.999476. This result is rounded and displayed with two decimal places for a final result of 99.95 percent. Likewise, completing 21,000 of 21,012 cases timely will provide a result of 0.999429. This result is rounded and displayed with two decimal places for a final result of 99.94 percent.

In determining whether award fee performance expectations are met, use the following example as a guide: since the performance threshold is established at 99.95 percent, a percentage of 99.95 or higher will satisfy CMS requirements. A performance percentage of less than 99.95 will fall below the performance threshold and CMS requirements would not be met in this instance.

Medical Review - Accuracy This criterion measures the accuracy of the MAC’s medical record review decisions (please refer to Chapter 3 of the Program Integrity Manual for a definition of medical record review). To achieve this objective, CMS will select a random sample of Durable Medical Equipment (DME) (herein, “claims” shall refer to claim lines, unless not applicable, such as with Diagnosis Related Group (DRG) claims) that the MAC has conducted medical record review on either a prepayment or post-payment basis, or a combination of both, during the evaluation period. This sample shall exclude those claims that were reviewed on either a prepayment or post-payment basis by the Recovery Auditors, Zone Program Integrity Contractors (ZPICs)/Unified Program Integrity Contractors (UPICs), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT), or other review entity; subjected to prior authorization; or selected by CMS for probe and educate concurrent review or monthly accuracy review process (to the degree known at the time the universe file is compiled).

Step-by-Step Process

Step 1: Providing the Universe File

Each month, the MAC shall supply the Medical Review Accuracy Contractor (MRAC) with one file containing a list of the entire universe of claims that were subjected to medical record review. This universe shall contain finalized claims from the prior month. This list must comply with the specified format agreed upon by the MRAC and the MAC and be received by the MRAC by the 20th of the month, or the next business day should the 20th fall on a weekend or holiday.

This universe file list shall be submitted via:

· Email attachment to:

MRAC email box (MRACmail@ReliGroupInc.com)

On or before the required submission date, the password shall be communicated to Christopher Cummings adhering to CMS encryption of sensitive information security policies via telephone: 202-657-1588, or via email to the MRAC email box (MRACmail@ReliGroupInc.com). (Please include courtesy copy to Heather Wetherson (Heather.Wetherson@cms.hhs.gov) and Nancy Allert (Nancy.Allert@cms.hhs.gov))

Step 2: Sample Selection

The sample will be pulled from the universe of claims on which medical record review was conducted throughout the period of performance. Using random sampling, approximately 10 claims will be selected each month of the evaluation period to achieve the required total claim count within the award fee period. The MRAC will notify the MAC via email of the sample claims selected for review within five business days after the 20th day of the month or receipt of universe file if the date was adjusted due to the 20th falling on a weekend or holiday. If the award fee evaluation period is seven months or less in length, a total of 50 claims will be selected for review during the award fee period. If the award fee evaluation period is eight months or greater in length, a total of 100 claims will be selected for review during the award fee period. There will be no claims selected from the last two months of the award fee evaluation period to allow for timely evaluation and dissemination of results by CMS.

Step 3: Submission of Documentation to the MRAC

The MACs shall submit the complete documentation package for the sampled claims to the MRAC so that it is received within five business days of the date of the claim selection. This documentation package shall include:

1. All documents reviewed by the MAC, for all lines on the claim subjected to medical record review, when making the medical record review decision;

2. Documentation indicating the specific focus of the review; and

3. Documentation of the determination made (paid, denied, reduced) and the detailed rationale behind the determination (nurses notes, screen shots of internal resources or the Common Working File, denial codes with explanations and/or denial letters, information about technical or system denials and reductions that occurred after the medical record review).

It is important the MACs submit all documentation to support the medical record review decision to the MRAC because, in general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a dispute request that was not in the documentation package submitted to the MRAC.

The documentation package shall be submitted via one of the following methods:

· Postal mail to:

RELI Group Inc.

ATTN: MRAC c/o Christopher Cummings 7125 Ambassador Road, Suite 100 Windsor Mill, MD 21244

· Encrypted/secure CD to:

RELI Group Inc.

ATTN: MRAC c/o Christopher Cummings 7125 Ambassador Road, Suite 100 Windsor Mill, MD 21244

On or before the required submission date, the password shall be emailed to the MRAC email box (MRACmail@ReliGroupInc.com) with a copy to Heather Wetherson (Heather.Wetherson@cms.hhs.gov) and Nancy Allert (Nancy.Allert@cms.hhs.gov).

· Email Attachment to:

MRACmail@ReliGroupInc.com

1. The MAC shall only submit the complete documentation package for the sampled claims to the MRAC via encrypted/secure email when the file size is 15 megabytes (MB) per attachment, for a maximum file size of 30 MB per email. If the documentation package file size is larger than 30 MB, the MAC shall not send multiple email submissions to the MRAC, but shall use an alternative documentation submission method.

2. On or before the required submission date, the password shall be communicated to Christopher Cummings adhering to CMS encryption of sensitive information security policies via telephone: 202-657-1588. (Please note: the MRAC does not accept the information via fax.)

3. Images must be in either TIF or PDF format.

· Secure Electronic File Transfer via Electronic Submission of Medical Documentation (esMD).

Step 4: Review of Claims

Independent MRAC reviewers will re-review these sampled claims, utilizing the same documentation that the MAC used in the original review, to evaluate the accuracy of the MAC’s medical record review determination. In other words, the independent reviewers will re-review these claims to ensure they were properly paid or denied based on Medicare coverage, coding, and billing rules. The review will be pass/fail (i.e., no partial credit will be applied, such as when a claim supports a lower utilization than that billed). These reviews will be completed within 20 business days. CMS may allow for communication between the MAC and MRAC for the purpose of clarifying issues that may result in a preventable error finding (e.g., an explanation of submitted error codes, focus of review, and information about technical or system denials and reductions that occurred after the medical record review).

Review results will be emailed to the designated MAC points of contact one day after completion of the MRAC reviews for the month.

Step 5: Review of Agree Claims

As part of the CMS quality control oversight of the MR Accuracy Award Fee project, each month CMS reviews a random sample of claims where the medical record review decision of the MRAC and the MACs are the same (that is, agree claim). These claims are already included in the MAC’s MR Accuracy Award Fee sample. The agree claims are selected from the same month as the sample claims. The MAC will be notified of an agree claim selection only when the CMS review decision of the agree claim is not the same as the MRAC and MAC.

When the CMS review decision of an agree claim is not the same as the MRAC and MAC, the claim is counted as an inaccurate determination (i.e., fail) and will follow the process below:

· CMS will notify the MAC of the CMS decision, including the CMS review comments, via email on the same day that CMS finalizes the results for that month’s disputes.

· The MAC will have seven business days to request a dispute review with CMS for the failed agree claim. The MAC shall submit an email dispute request to its CMS COR, with a copy to Nancy.Allert@cms.hhs.gov and Heather.Wetherson@cms.hhs.gov, which includes the rationale for the dispute. CMS will issue a final determination to the agree claim dispute via email as soon as it is available.

· Once finalized, CMS will update, as needed, the CMS agree claim determination and share the final determination with the MAC POCs via email.

The final CMS determination on the claim will be included in the MAC’s Award Fee evaluation at the end of their Award Fee period.

Step 6: Disputes

Should the independent reviewer come to a different decision than the MAC, the MAC will have the option of disputing this finding with CMS. Each MAC has seven business days from the day the results are sent via email to the MAC to request a dispute review with CMS. Each MAC shall request the dispute via email to the MRAC (MRACmail@religroup.inc) with a copy to the MAC’s CMS COR, Nancy Allert (Nancy.Allert@cms.hhs.gov) and Heather Wetherson (Heather.Wetherson@cms.hhs.gov). The email shall include the detailed rationale for the dispute. In general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a dispute request that was not in the documentation package submitted to the MRAC. However, on a case-by-case basis, the MAC may request consideration to submit additional documentation to CMS. CMS expects this would be permitted in rare situations for the purpose of clarifying issues that may result in a preventable error finding (e.g., illegible documentation).

Using the medical record and any additional documentation submitted by the MAC to the MRAC for review, the CMS dispute panel will complete the review. If supporting evidence for the dispute is missing or lacking, the CMS dispute panel will uphold the adverse decision. CMS will provide the MAC with CMS’ final determination via email when this information is available. If the CMS dispute panel identifies a new issue that is within the specific focus of the MAC review, not identified by the MRAC, and would result in an adverse decision for the MAC, the MAC will have the option of disputing this new finding with CMS.

The MAC has three business days from the day the dispute results are sent via email to the MAC to request a new finding dispute review with CMS. The MAC shall submit an email request for a CMS dispute review to its CMS COR, with a copy to Nancy Allert (Nancy.Allert@cms.hhs.gov) and Heather Wetherson (Heather.Wetherson@cms.hhs.gov), which includes the rationale for the dispute. In general, the CMS dispute panel will not consider additional documentation sent to CMS as part of a new finding dispute request that was not in the documentation package submitted to the MRAC. However, on a case-by-case basis, the MAC may request consideration to submit additional documentation to CMS. CMS expects this would be permitted in rare situations for the purpose of clarifying issues that may result in a preventable error finding (e.g., illegible documentation).

Using the medical record and any additional documentation available from the original CMS dispute panel and the newly submitted MAC dispute rationale, the CMS dispute panel will complete the new finding review. If supporting evidence for the dispute is missing or lacking, the CMS dispute panel will uphold the adverse decision. CMS will email the results of the new finding review to the MAC POCs when this information is available.

Step 7: Calculating the Accuracy Rate

The formula for calculating the accuracy rate is 100 multiplied by the number of claims where the MR staff made an accurate determination divided by the number of claims in the sample.

The formula is displayed mathematically as shown below:

100 X (# of claims where MR staff made an accurate determination) = Accuracy Rate # of claims in the Sample

Award fee for this criterion will be earned as follows:

Trial Month for New Contracts

For any MAC contract starting its first MR accuracy evaluation periods during FY 2020, the first scheduled month of the MR Accuracy award fee criterion award fee period will be used as a trial month. During this trial period, all steps will be followed by both the MAC and the MRAC, including medical review, but the results will not count toward the award fee criterion. The process outlined above shall be followed by the MACs during the trial month. For example, MACs with MR Accuracy award fee periods beginning in January 2020 shall submit its universe of claims for that month to the MRAC on the February 20th. The month of January will be considered the trial month.

During review of the trial month’s claims, the MRAC will identify any technical, medical documentation, or other issues that may impact the ability to conduct fair and thorough reviews in accordance with the MR Accuracy award fee criterion. CMS will discuss with the MRAC and the MAC any issues identified during the trial month, as needed, after the trial month has been completed. This process will be used as a means to mitigate future problems that may lead to preventable error findings.

Adjudication of Claims Reviewed

The final claim decision made through the accuracy review process (i.e., by the independent reviews or CMS) shall be considered the final adjudication of the claim unless the claim has already been appealed by the provider based on the MAC’s initial decision or unless otherwise directed by CMS. Accordingly, the MAC shall collect overpayments or reimburse underpayments if the MAC’s claim decision is found to be erroneous through the accuracy review process and the claim has not been appealed. If the claim has been appealed based on the MAC’s initial decision or the decision made via the accuracy review process, the appeal decision shall be considered the final adjudication of the claim for purposes of handling overpayments and underpayments. However, decisions made under the accuracy review process shall remain final for purposes of the award fee criterion, regardless of the appeal results.

It is expected that each MAC will continue to focus medical record review efforts on claim types that are most problematic in its jurisdiction. Accordingly, CMS will monitor the MAC’s adherence to its improper payment reduction strategy and other program requirements.

System Security

[THIS CRITERION WOULD BE N/A IN THE BASE YEAR]

This criterion measures the MAC’s compliance with CMS’s system security standards. The following chart displays risk rankings on any applicable Section 912 evaluation which will be used by CMS to determine award fee earned for each of the MACs.

The rating methodology used by CMS is as follows:

* If any of the medium or high risk findings are a repeat from a prior year, then this percentage amount will be reduced by 15%.

Comprehensive Error Rate Testing (CERT) [For a MAC with a Base Year that occurred in FY 2014 or later, this criterion is being provided for information purposes only in the Base, OY1, OY2, or OY3 plan.

This criterion will be evaluated as part of the OY4 award fee determination but shall encompass performance for a five year period.]

This criterion is intended to foster collaboration among the MACs with the focus of decreasing the national Durable Medical Equipment (hereinafter referred to as DME) Medicare Fee-for-Service (FFS) improper payment rate. The criterion will measure the MAC’s ability to lower the national DME Medicare FFS improper payment rate over a five year period of its contract. More specifically, CMS will measure the percentage change (decrease or increase) in the national DME Medicare FFS improper payment rate over a five year period of the contract. This criterion will only apply to the fifth year of the contract, Option Year 4 (OY4) (i.e., the change in the national DME Medicare FFS improper payment rate between the Base Year and OY4). The percent change (decrease or increase) in the national DME Medicare FFS improper payment rate between Base Year and OY4 will be used for purposes of calculating award fee earned. If CMS opts to not renew the contract for any reason before OY4 begins, no award fee will be earned based on this criterion.

The percent change (decrease or increase) in the national DME Medicare FFS improper payment rate will be calculated by subtracting the comparison score (A) from the baseline score (B). The baseline score will be the national DME Medicare FFS improper payment rate calculated during the Base Year period of performance, applying data used for publication of the national Medicare FFS improper payment rate in the HHS Agency Financial Report during the Base Year. The comparison score will be the national DME Medicare FFS improper payment rate calculated during the OY4 period of performance, applying data used for publication of the national Medicare FFS improper payment rate in the HHS Agency Financial Report during OY4.

The formula for calculating percent change will be as follows:

(B-A)/B

The MAC will earn award fee as follows:

*Only contracts starting its Base Year in FY2014 or after will have this criterion included in its Award Fee plan. Also, while this criterion will only be evaluated as part of the OY4 award fee determination, it will encompass performance throughout a five year period.

FY 2020 Award Fee Plan Self-Assessment document

Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) [fill in MAC name]

DME MAC Jurisdiction C Contract Number [insert contract number]

Award Fee Evaluation Period: [insert Award Fee Eval period]

1. Executive Summary:

The Executive Summary of the MAC’s Award Fee Self-Assessment shall provide a high- level overview of the MAC’s performance during the award fee period.

Implementation Award Fee Evaluation Criteria Analysis This section of the report shall detail the MAC’s assessment of its performance against the award fee criteria for the implementation related award fee evaluation period. This template provides guidance on what minimum information shall be included in the MAC’s Self-Assessment.

1. Implementation Criteria Instructions Implementation Criteria: Due Date, Page Limitations, and Formatting Requirements The MAC shall provide a written award fee performance evaluation Self-Assessment to the CO and COR within 30 calendar days of the end of the contract year. The MAC shall provide as much detail as is necessary to assist the evaluators in making its final determination; however, the written Self-Assessment shall conform to the following page limitations and formatting requirements:

· All self-assessment documents shall be submitted in Microsoft Word in Times New Roman 12 point font with 1-inch top, bottom, left and right margins.

· The Microsoft Word document shall not have any issues labeled as “errors” when the user would run the Accessibility Checker to ensure compliance with Section 508 of the Rehabilitation Act. Accessibility Checker results that are labeled as “warnings” or “tips” shall be fixed to the extent possible.

· For evaluations that have both Implementation and Operational criteria, the written Self-Assessment shall not exceed 27 pages in length (5 pages for Implementation and 22 pages for Operations).

· In addition to the overall page limitation, the evaluation for the Program Improvement and Collaboration award fee criterion shall not exceed 10 pages. In addition, illustrative charts and graphs are permissible for this criteria; however, capturing all/most of the narrative in a chart with a different font is not permissible. A narrative chart must be in Times New Roman 12 point font.

· When preparing the Self-Assessment, the MAC shall use the Award Fee Self-Assessment Template provided below.

· The Award Fee Plan portion of this combined Award Fee Plan and Self-Assessment document does not count towards the Self-Assessment page limit and shall not be submitted with the Self-Assessment.

Implementation Criteria:

The following is [MAC’s] assessment of its performance on the following implementation award fee criteria:

Successful Claims Workload Cutover

MAC Assessment: The MAC shall provide narrative, by workload segment, describing its performance in implementing each workload segment. The narrative shall include the approved implementation plan cutover date and the actual date the workload was implemented.

Risk Mitigation

MAC Assessment: The MAC shall provide narrative, by workload segment, describing any applicable implementation risks, and what actions were taken to mitigate such risk.

Operational Award Fee Evaluation Criteria Analysis

This section of the report shall detail the MAC’s assessment of its performance against the award fee criteria for the award fee evaluation period. This template provides guidance on what minimum information shall be included in the MAC’s Self-Assessment.

1. Operational Criteria Instructions Operational Criteria: Due Date, Page Limitations, and Formatting Requirements The MAC shall provide a written award fee performance evaluation Self-Assessment to the CO and COR within 30 calendar days of the end of the contract year. The MAC shall provide as much detail as is necessary to assist the evaluators in making its final determination; however, the written Self-Assessment shall conform to the following page limitations and formatting requirements:

· All self-assessment documents shall be submitted in Microsoft Word in Times New Roman 12 point font with 1-inch top, bottom, left and right margins.

· The Microsoft Word document shall not have any issues labeled as “errors” when the user would run the Accessibility Checker to ensure compliance with Section 508 of the Rehabilitation Act. Accessibility Checker results that are labeled as “warnings” or “tips” shall be fixed to the extent possible.

· For evaluations that have both Implementation and Operational criteria, the written Self-Assessment shall not exceed 27 pages in length (5 pages for Implementation and 22 pages for Operations).

· For evaluations that only have Operational criteria, the Self-Assessment shall not exceed 22 pages in length.

· In addition to the overall page limitation, the evaluation for the Program Improvement and Collaboration award fee criterion shall not exceed 10 pages. In addition, illustrative charts and graphs are permissible for this criteria; however, capturing all/most of the narrative in a chart with a different font is not permissible. A narrative chart must be in Times New Roman 12 point font.

· When preparing the Self-Assessment, the MAC shall use the Award Fee Self-Assessment Template provided below.

· The Award Fee Plan portion of this combined Award Fee Plan and Self-Assessment document does not count towards the Self-Assessment page limit and shall not be submitted with the Self-Assessment.

Operational Criteria:

The following is [MAC’s] assessment of its performance on the following operational award fee criteria:

Program Improvement and Collaboration

MAC Assessment: The [MAC’s] performance in this area warrants a score of [100%, 75%, 50% or 0%] for this criterion during the award fee period. The MAC shall include narrative to substantiate its score in this area. The narrative needs to be clear and concise with specific examples that demonstrate the MAC’s efforts during this POP relative to Program Improvement and Collaboration. The MAC’s input shall articulate benefits to the government for examples that are provided. Improvements and collaborative efforts discussed shall also include the associated specific, measureable benefits such as demonstrated cost savings, efficiency improvements, operational improvements, etc.

Note: Any contractor (MAC) that has a connection to another contractor, also serving as a MAC, through a parent organization or affiliation, or where a single (MAC) contractor has multiple jurisdictions/multiple contracts, shall ensure its assessment is specific to the jurisdiction being evaluated. (Refer to your OCI, if the contract/contractor is listed this note applies.) If cost savings are being stated as a benefit, the cost savings should not be for the overall corporation but rather to the specific jurisdiction/contract that is being evaluated. If a stated benefit is a reduction of staff time or reduction of full-time equivalents, the saving should be specific to the jurisdiction/contract being evaluated. Evaluations shall address the jurisdiction/contract that is being evaluated. Similarly, if an initiative or activity will cross periods of performance, the MAC, while being able to discuss the overall plan, shall only provide the direct benefit received during the POP being evaluated.

The MAC’s self-assessment for this criterion shall be no more than 10 pages and shall follow the formatting requirements.

Appeals - Medicare Redetermination Notice (MRN) Timeliness

MAC Assessment: This criterion was [___ Met ___Partially Met___Not Met]

Redetermination Timeliness

Month/ Year

(displayed with 2 decimal places) 90 Percent eligibility met?

Yes or No If eligibility met – does month qualify for fee?

Yes or No

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Explanation of Untimely Cases With respect to the above requested data, the MAC should highlight any instances where the monthly performance level for processing redeterminations in a timely manner fell below 100 percent, and the inability to meet CMS expectations for this criterion was attributed to CMS guidance or a CMS technical direction letter. The MAC shall reference any pertinent Request for Consideration of Excusable Cause (RCEC) documentation.

MACs shall be prepared to provide screen prints showing data from the applicable lines and columns of the CMS 2592 report, upon request. This information will only be requested if a discrepancy that cannot easily be verified or explained exists between the CMS 2592 data and the award fee evaluation self-assessment data provided by the MAC. These separate attachments will not be counted as part of the self-assessment page count.

Eligibility: The MAC [___achieved ___did not achieve] at least a 90 percent redetermination timeliness rate for each month of the award fee evaluation period and is therefore [___eligible ___ineligible] for this award fee criterion.

Award Fee Earned: Based on the data listed above, [the MAC] met the 100 percent redetermination timeliness performance threshold for____ months of the ____month award fee evaluation period and therefore, should earn ____ percent of the available award fee pool…