E.8 Section M – Evaluation Factors for Award.pdf

Draft RFP: 75FCMC25RJ003, Amend. 01 Exhibit 8: Section M – Evaluation Factors for Award

Pg. 1

SECTION M – EVALUATION FACTORS FOR AWARD

M.1 Evaluation – Commercial items

The Government will award three contracts resulting from this solicitation to the responsible offeror(s) on the basis of the lowest evaluated price of proposals meeting or exceeding the acceptability standards for non-cost factors. The six technical factors identified in Section L.6 shall be used to evaluate offers.

Three firm fixed Contingency-Fee type contracts will be awarded in accordance with this solicitation that includes awards of Regions 3 and 4 that cover specific regions to review Part A/B Claims and Region 5 that covers Durable Medical Equipment and Home Health & Hospice claims for the entire country. The Centers for Medicare & Medicaid Services (CMS) will conduct a comprehensive evaluation of all proposals and select the offer based upon an assessment of the proposals that, in the Government’s estimation, provides a technically acceptable approach to performing the Statement of Work while providing the lowest firm fixed contingency fee percentage to the Government. Award will be made after the following steps for each region:

Step 1: Determine Technical Acceptability: The evaluation factors that establish the requirements of acceptability are set forth in E.7 Section L.6. If the offeror fails to demonstrate the necessary qualifications in all technical factors, it will be eliminated from the competition and its proposal will not be reviewed further.

Step 2: Determine Lowest Price/Contingency Fee: The Government will review the offeror’s business proposal to determine which offeror has the lowest firm fixed price contingency fee for each RAC Region.

Step 3: Responsibility Determination, Determination Conflict of Interest and 508 Compliance:

After completion of Step 2 – Determine Lowest Price/Contingency Fee, for the apparent successful offeror(s) the Government will determine whether the offeror is responsible, in accordance with FAR 9.104, and demonstrated compliance with Conflict of Interest and FAR 9.504(e) requirements and the 508 accessibility standards.

Each offeror’s proposal will be evaluated by applying the following technical qualifications:

Factor 1- Legislative

Rating Description

Pass The Offeror has demonstrated:

• appropriate clinical knowledge of, and experience with, the payment rules and regulations under the Social Security Act, Title XVIII, Section 1893 or the contractor has, or will contract with, another entity that has such knowledgeable and experienced staff; AND

• The Offeror is not a fiscal intermediary under section 1816, a carrier under section 1842, or a Medicare administrative contractor under section 1874A; AND

Pg. 2

• more than 3 years direct management experience and a proficiency for cost control or recovery audits with private insurers, health care providers, health plans, under the Medicaid program under title XIX, or under Social Security Act, Section 1893.

Fail The Offeror has not demonstrated:

• appropriate clinical knowledge of, and experience with, the payment rules and regulations under the Social Security Act, Title XVIII, Section 1893 or the contractor has, or will contract with, another entity that has such knowledgeable and experienced staff; OR

• The Offeror is not a fiscal intermediary under section 1816, a carrier under section 1842, or a Medicare administrative contractor under section 1874A; OR

• more than 3 years direct management experience and a proficiency for cost control or recovery audits with private insurers, health care providers, health plans, under the Medicaid program under title XIX, or under Social Security Act, Section 1893.

Factor 2- Identification of Improper Payments (Evaluators should consider the following when rating this criteria)

Pass The Offeror has an acceptable:

• knowledge and experience with the process of developing and implementing system edits for automated review determinations; AND

• knowledge and experience in developing and performing complex review of medical records and submitted documentation to identify improper payments; AND

• knowledge and experience with developing training modules and providing material to educate staff; AND

• knowledge and experience with requirements for communicating detailed and concise claim review findings to billing providers, in compliance with Medicare Program Integrity Manual and RAC SOW requirements; AND

• knowledge and experience with large data repositories for the management of claim review processes

Fail The Offeror does not have acceptable:

• knowledge and experience with the process of developing and implementing system edits for automated review determinations; OR

• knowledge and experience in developing and performing complex review of medical records and submitted documentation to identify improper payments; OR

• knowledge and experience with developing training modules and providing material to educate staff; OR

• knowledge and experience with requirements for communicating detailed and concise claim review findings to billing providers, in compliance with Medicare Program Integrity Manual and RAC SOW requirements; OR

• knowledge and experience with large data repositories for the management of claim review processes.

Factor 3- General RAC Website, Web Portal, and Communications Plan (Evaluators should consider the following when rating this criteria)

Pg. 3

• approach to develop and maintain a separate and distinct Medicare FFS RAC website to communicate with the provider community that will meet the requirements as outlined in the

SOW; AND

• approach to develop and maintain a secure web-based application to serve as a provider portal as described in the RAC SOW; AND

• approach to develop and maintain a customer service center that identifies how the Offeror will assure accurate and timely responses to Medicare providers and other prospective stakeholders;

AND

• plan that describes all potential or existing outreach methods for all eligible provider types;

AND

• communication plan for Medicare contractors, inclusive of JOAs, with all applicable Medicare contractors.

Fail The Offeror does not have an acceptable:

• approach to develop and maintain a separate and distinct Medicare FFS RAC website to communicate with the provider community that will meet the requirements as outlined in the

SOW; OR

• approach to develop and maintain a secure web-based application to serve as a provider portal as described in the RAC SOW; OR

• approach to develop and maintain a customer service center that identifies how the Offeror will assure accurate and timely responses to Medicare providers and other prospective stakeholders;

OR

• plan that describes all potential or existing outreach methods for all eligible provider types; OR

• communication plan for Medicare contractors, inclusive of JOAs, with all applicable Medicare contractors.

Factor 4- Quality Assurance and Accuracy (Evaluators should consider the following when rating this criteria)

• internal Quality Assurance Plan that includes steps toward correcting instances of the quality and/or accuracy failing to meet the expected standards, as outlined in the SOW; AND

• plan to establish and maintain the SOW required support and participation in the

Medicare Appeals Process and/or Debt Collection Improvement Act Process; AND

• plan for obtaining an annual Statement of Standards for Attestation Engagements (SSAE) No.

18 review Type II Audit by an independent CPA.

Fail The Offeror does not have an acceptable:

• internal Quality Assurance Plan that includes steps toward correcting instances of the quality and/or accuracy failing to meet the expected standards, as outlined in the SOW; OR

• plan to establish and maintain the SOW required support and participation in the

Medicare Appeals Process and/or Debt Collection Improvement Act Process; OR

• plan for obtaining an annual Statement of Standards for Attestation Engagements (SSAE) No.

18 review Type II Audit by an independent CPA.

Pg. 4

Factor 5- Capability to meet all IT Systems, Security Specifications, and Data Accessibility Requirements (Evaluators should consider the following when rating this criteria)

• system and business processes to ensure compliance with the Health Insurance Portability and

Accountability Act (HIPAA) when using or disclosing protected health information (PHI);

AND

• Business and system processes to ensure security documents are uploaded timely and security controls are documented timely in the CMS FISMA Control Tracking System

(CFACTS); AND

• process of obtaining an Authority to Operate (ATO) within 60 days of contract award; AND

• knowledge and ability to maintain a medical record management documentation system; AND

• approach for completing the security plan and accreditation requirements in clause 352.239-71, Security Requirements for Information Technology Resources.

Fail The Offeror does not have acceptable:

• system and business processes to ensure compliance with the Health Insurance Portability and

Accountability Act (HIPAA) when using or disclosing protected health information (PHI); OR

• Business and system processes to ensure security documents are uploaded timely and security controls are documented timely in the CMS FISMA Control Tracking System

(CFACTS); OR

• process of obtaining an Authority to Operate (ATO) within 60 days of contract award; OR

• knowledge and ability to maintain a medical record management documentation system; OR

• approach for completing the security plan and accreditation requirements in clause 352.239-71, Security Requirements for Information Technology Resources.

Factor 6- Key Personnel, Staffing Plan, and Organizational Chart

• Key Personnel and designated backups. All key personnel & designated backups meet minimum SOW requirements; AND

• staffing plan for medical review personnel and other personnel identified in SOW; AND

• organizational chart that aligns with the Offeror’s technical approach

Fail The Offeror does not have acceptable:

• Key Personnel and/or designated backups. One or more Key Personnel or designated backups do not meet minimum SOW requirements; OR

• staffing plan for medical review personnel and other personnel identified in SOW; OR

• organizational chart that does not align with the Offeror’s technical approach

M.2 Volume II – Business Proposal A fair and reasonable price determination will be made through the comparison of proposed contingency fees among those offerors who are technically acceptable and comparison of proposed contingency fees with the independent Government estimate.

Pg. 5

M.3 Volume III - Conflict of Interest & Section 508 Compliance (applicable to the apparent successful Offeror(s) only)

CONFLICT OF INTEREST

In accordance with FAR 9.504(e) and CMS Conflict of Interest Term & Condition, the Government will evaluate the Attachment J.2 “Contractor/Offeror Conflict of Interest” as well as other information, as appropriate. The conflict of interest evaluation will not result in a score/rating as it is only applicable to the apparent successful Offeror.

SECTION 508 COMPLIANCE

For the apparent successful offeror(s), the Government will evaluate the successful offeror’s VPAT to determine if appropriate section 508 materials were submitted, confirm all information provided on the VPAT cover page is correct, confirm that the correct VPAT version has been submitted, and confirm that the offeror has responded to all requested requirements criteria in the SOW. This Section 508 evaluation will not result in a score/rating as it is only applicable to the apparent successful Offeror

M.3 52.233-2 Service of Protest (SEP 2006)

(a) Protests, as defined in section 33.101 of the Federal Acquisition Regulation, that are filed directly with an agency, and copies of any protests that are filed with the Government Accountability Office (GAO), shall be served on the CO (addressed as follows) by obtaining written and dated acknowledgment of receipt from Nicole Hoey at Nicole.Hoey@CMS.HHS.GOV

(b) The copy of any protest shall be received in the office designated above within one day of filing a protest with the GAO.

mailto:Nicole.Hoey@CMS.HHS.GOV