B01- SOW Revenue Enhancement Service v2.pdf

STATEMENT OF WORK

Revenue Enhancement Services for Billings Area Indian Health Service

1.0 GENERAL:

This statement of work (SOW) describes the requirements of the IDIQ Contract for non-personal Revenue Enhancement Services to be performed at the health centers and hospitals located within Billings Area Indian Health Service (BIL-IHS).

1.1 Scope: The Contractor shall provide remote Revenue Enhancement Services that support the mission of the Indian Health Service. All services under this contract shall be performed off-site, and any on-site presence must be limited, pre-approved, and shall not create a personal services relationship or allow the Government to supervise or direct contractor personnel.

1.2 Background: The Billings Area Indian Health Service (BIL-IHS) oversees the delivery of public health, environmental health, health care services and community-based disease prevention services to more than 70,000 American Indian and Alaska Native people in Montana and Wyoming. These services are delivered through five IHS-operated Service Units, where most have satellite clinics associated with them.

1.3 Purpose: The contractor shall be responsible for performing the revenue generation services only when requested by the Service Unit or Area Office. Tasks will be initiated through an authorized task order and not expected to be continuous daily integration with Government operations. Instead, the Contractor shall remotely review records, conduct audits, perform coding and billing assessments, complete revenue enhancement analyses, and provide consultative recommendations only when initiated through official Government requests.

1.4 Period of Performance:

One (1) Base period of twelve (12) months from the date of award.

1.5 Places of Performance:

Although all work is to be performed remotely, services may be requested by any of the following locations:

Blackfeet Service Unit (BFSU):

o Blackfeet Community Hospital; Browning Montana (Service Unit) o Heart Butte Health Station; Heart Butte, Montana (Satellite Clinic)

Crow Service Unit (CSU):

o Crow/Northern Cheyenne Hospital; Crow Agency, Montana (Service Unit) o Lodge Grass Health Clinic; Lodge Grass, Montana (Satellite Clinic) o Pryor Health Station; Pryor, Montana (Satellite Clinic)

Fort Belknap Service Unit (FBSU);

o Fort Belknap Hospital; Harlem, Montana (Service Unit) o Eagle Child Health Station; Hays, Montana (Satellite Clinic)

Fort Peck Service Unit (FPSU);

o Verne E. Gibbs Clinic; Poplar, Montana (Service Unit) o Chief Redstone Clinic; Wolf Point, Montana (Satellite Clinic)

Northern Cheyenne Service Unit (NCSU);

o Northern Cheyenne Health Clinic; Lame Deer, Montana (Service Unit)

1.6 Hours of Operation:

Normal Business Hours for the Service Units and Area Office are Monday thru Friday; 8:00am – 5:00pm (MST), excluding federally recognized holidays.

1.7 Federal Holidays:

The following holidays are observed by the Billings Area IHS: New Year’s Day, Washington’s Birthday, Martin Luther King’s Birthday, Memorial Day, Juneteenth, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving, Christmas, any day specifically declared to be a national holiday.

1.8 Task Orders:

Work shall be initiated only when a Service Unit or the Area Office issues an approved task order, specifying the required services, level of effort, and period of performance for each task order.

**No services beyond those authorized by a task order shall be performed**

1.9 Changes to the Statement of Work:

Any changes to this SOW shall be authorized and approved only through written correspondence from the Contracting Officer (CO). Costs incurred by the contractor through the actions of parties other than the CO shall be borne by the contractor.

2.0 PERFORMANCE REQUIREMENTS:

2.1 Personnel Qualifications

The Contractor shall have qualified personnel with expertise in medical coding, accounts receivable, billing, Charge Master functions, and transaction code assignment. All personnel shall perform work independently and remotely.

2.2 Non-Personal Services Standard

The Government will not supervise contractor employees or control the method by which work is performed. The Contractor is responsible for directing, supervising, and managing its personnel at all times.

2.3 Revenue Enhancement Services:

Services shall include duties and responsibilities that encompass revenue enhancement / revenue cycle management coordination to assist the Service Units of the BIL-IHS. Services may include review of PCC, Superbill, and EHR documentation; auditing; accuracy assessments; reporting; and revenue generation analysis.

Contractor shall:

Possess a minimum of three (3) years of experience with private/Medicare and Medicaid billing industry.

Be responsible for recording, keeping, and securing backup for transaction information by the Government for maximum of three (3) years and not less than one (1) year.

Provide personnel with experience of that for Billing and Accounts Receivable.

Provide services to review data from PCC/Superbill/EHR to ensure IHS is receiving appropriate levels of reimbursements based on codes and provider documentation.

Contractor Personnel shall:

Be familiar with Electronic Health Record (EHR) systems.

Follow Health Information Portability Accountability Act (HIPAA), Federal, State, and Indian Health Services policies.

Apply ICD-10-CM, CPT/HCPCS, and industry coding guidelines Provide remote audit recommendations and revenue analysis reports Offer off-site expertise in Charge Master and transaction code work.

2.4 Consultant Services & Compliance Auditing Functions and Processes:

Consultant and audit services shall be performed remotely. These services shall be provided on revenue generation cycle functions and processes. Contractor personnel shall participate only as remote advisors, not as operational members of multidisciplinary revenue teams.

The contractor shall provide on the job training for individual staff and program development on the various functions of the revenue enhancement process. The contractor will also serve as a technical advisor to the Service

Unit multi-disciplinary revenue enhancement teams at the Service Units in addressing the revenue enhancement work plan.

The contractor will identify key management objectives and accountability in the revenue generation cycle. Develop timelines to accomplish key management objectives and develop methods for accountability.

Eliminate redundancy of work within the revenue generation cycle, refine and implement new or assist to re-establish workflow processes. Identify best possible physical location of staff in the revenue generation process. Provide staff training to accommodate new tasks for each job per workflow process changes.

The contractor will develop a concurrent program for providers and other staff to improve documentation to ensure proper and accurate coding for revenue generation purposes.

Perform compliance audits on individual processes per request of the Service Units or Area Office in accordance with Standard Auditing Practices.

The contractor will be responsible for their own travel, lodging and other miscellaneous travel arrangements.

2.5 Third Party Resource Billing

The Contractor shall provide remote third-party billing services for Private Insurance, Medicaid/CHIP, VA, Medicare Part A and B, and any claims requiring medical coding review.

The Contractor shall perform all billing activities through secure, Government-authorized remote access to the RPMS system. Direct access to RPMS via VPN shall be granted only upon IHS approval. The Government will provide all required system access for remote performance.

Remote claim review activities—including editing, approval recommendations, and preparation for export (electronic or hardcopy)—shall include inpatient, outpatient, medical, and ancillary services as assigned through task orders.

The Contractor shall remotely review visit data from PCC, Superbill, and EHR to ensure accuracy and completeness of ICD, CPT, HCPCS, and CDT codes.

Incomplete records shall be flagged and returned to the Government’s Coding Department for correction.

The Contractor shall remotely prepare and submit claims to the appropriate carrier or clearinghouse in accordance with authorized task order requirements.

The Contractor shall not bill for any claims rejected prior to submission. Any claims rejected or denied due to coding errors shall be corrected and re-processed at no additional charge.

The Contractor shall submit a remote Quality Assurance Plan and any associated reports required under each task order. Upon request, the Contractor shall provide report deliverables to the requesting IHS facility within 15 calendar days.

The Indian Health Service may schedule virtual management meetings, as needed, to discuss project requirements and task order performance.

The Contractor is responsible for its own travel, lodging, and related expenses if limited on-site consultation is specifically authorized by a task order.

If an audit or legal action arises after contract expiration, the Contractor shall prepare any remotely accessible documentation required to complete the audit.

The Contractor shall have a minimum of three (3) years of experience in the billing industry, including proof of electronic claim submission and maintenance experience.

All carrier remittances/receipts shall be mailed directly to the appropriate Government lockbox associated with the facility where services were performed.

2.6 Accounts Receivable

The contractor shall provide accounts receivable posting and follow-up services in accordance with the Third Party Internal Controls policy.

2.7 Coding and Data Entry

Shall code and make complete and accurate medical ancillary visits via the IHS EHR, RPMS, PCC and Admission/Discharge/Transfer (ADT) systems.

Apply IHS and National Reporting and Coding Guidelines. The contractor shall code the medical visits and/or inpatient stays assigned by the facility.

The IHS “visit verification coding queue” (VVQ) will be accessed for auditing, accuracy, and completion of all medical visits before a claim can be generated. When processes cannot be completed in the Q – the vendor needs to access the PCC data entry and supervisor options to complete.

Editing, appending, merging, moving data elements and deleting duplicate entries will be part of the process with application of reporting requirements via the PCC system.

The Indian Health Service will schedule management meetings, as needed, to discuss project needs.

The contractor shall remotely review visit documentation and provide recommendations or corrective coding actions, or request clarifications using approved templates. Government staff will complete system entries as needed.

The contractor shall have a minimum of three (3) years experience and/or be a certified coder (copy of certification) with coding.

3.0 GOVERNMENT RESPONSIBILITIES:

The Billings Area IHS will:

Provide remote access credentials and systems authorization; such as:

o RPMS access o EHR access o MFA credentialing

Provide oversight of technical quality without supervising contractor personnel

Monitor compliance with RPMS, EHR, and coding standards

4.0 CONTRACTOR RESPONSIBILITIES:

Contractor Employees: All contractor personnel shall maintain current credentials, certifications, and security clearances as required.

Personnel shall work remotely unless specifically authorized for limited on-site consultation.

Authorized Services: Contractor shall perform only those services specifically ordered through authorized task orders.

Customer Service: The Contractor shall identify a lead point-of-contact to assist IHS staff with administrative questions and issues related to services performed through this contract.

Coding, Data Entry, Auditing, and Reporting:

The contractor shall:

• Perform coding and audit functions remotely

• Review documentation and request clarifications using approved templates

• Provide coding recommendations; Government staff shall complete system updates unless otherwise authorized.

Special Contract Requirements: The contractor shall:

o Comply with all federal regulations and comply with the Indian Health Service’s Third Party Resource and Internal Control Policy, the Debt Collection Policy, and the Indian Health Service’s statistical and reporting systems for all departments.

o Comply with the American Hospital Association (AHA) Official Coding Guidelines for ICD and the Current Procedural Terminology (CPT) Guidelines, and any specific IHS coding and data entry policies and procedures.

o Provide all laptops, software, clearinghouse systems, claims scrubbers, analytics platforms o Submit their proposed software requiring connectivity to undergo ATO/ISSA review.

Invoices: The Contractor shall submit invoices no later than the 5th of each month. Invoices shall be broken down per Contract Line Item Number (CLIN) to ensure matching in the Invoice Processing Platform (IPP).

5.0 SECURITY & DATA REQUIREMENTS:

All remote access shall comply with IHS Multi-Factor Authentication (MFA), IHS cybersecurity policies, HIPAA, Privacy Act requirements, and Interconnection Security Agreement terms. No data shall be used for purposes outside this contract.

Multi-Factor Authentication (MFA) for Remote Access: The Contractor shall ensure that all personnel, subcontractors, and agents who require remote or logical access to Indian Health Service (IHS) information systems use only the Multi-Factor Authentication (MFA) solution provided and managed by IHS. All remote access must occur exclusively through IHS-authorized access points that enforce MFA for every session.

Prohibited or Restricted Remote Access Methods:

The Contractor shall not use remote access methods that bypass, circumvent, or fail to invoke IHS-provided MFA. This includes, but is not limited to, direct Remote Desktop Protocol (RDP) connections and LAN-to-LAN (L2L) tunnels, unless the Contractor can demonstrate—and the IHS Division of Information Security (DIS) explicitly approves in writing—that such methods fully satisfy IHS MFA enforcement requirements. Remote access may not proceed unless MFA is technically enforced at the connection point in accordance with IHS security controls.

Use of any non-IHS MFA solution or any remote access path that does not enforce IHS-managed MFA is strictly prohibited.

This requirement is supported by the following federal and departmental authorities:

• Federal Information Security Modernization Act (FISMA), 44 U.S.C.

§ 3551 et seq.

• OMB Circular A-130, Managing Information as a Strategic Resource (ICAM / Remote Access)

• NIST SP 800-53 Rev. 5, including IA-2 (Identification and Authentication) and AC-17 (Remote Access)

RPMS: The contractor will have access, and will be required, with restrictions as defined by the Service Unit, to the following Service Unit RPMS modules and other access as requested by the contractor and agreed upon by the Service Unit.

1. Patient Registration System

2. Third Party Billing System

3. Accounts Receivable System

4. Patient Care Component/EHR, Medical and Ancillary Services; and

5. Any others deemed necessary by Service Unit/Area Staff

Security: The Contractor shall obtain completed IHS ISSA Security

Clearance prior to the start of this contract. This clearance will establish that the Contractor has provided sufficient local telecommunication network firewalls and procedures to ensure patient confidentiality and security consistent with HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations, FIPS, and ACR (American College of Radiology) Guidelines.

Interconnection Security Agreement: Before an entity connects to any IHS

System, an ISA must be in place and appropriate security controls must be implemented or configured. All of the staff members are off-site and do not require physical or network access. Any staff member that comes on-site needs to be accompanied by a cleared IHS staff member at all times and cannot gain access to the IHS network without meeting the requirements.

Handling of Data: The Contractor agrees to the extent that it receives or is given access to data necessary for the performance of contract which contains restrictive markings, the Contractor shall treat the data in accordance with such markings unless otherwise specifically authorized in writing by the Contracting Officer.

Security of Data: The Contractor shall comply with any security requirements established by HHS to ensure proper and confidential handling of data and information. The Contractor shall refer to “HHS Cybersecurity Program.”, which is HHS’ Information Security Program Policy, dated June 2010. Data obtained for this contract shall not be used to create databases or any other product not intended for use specifically in this project. All data containing personal identifiers shall be handled in accordance with the Privacy Act of 1974 (Public Law 93-579). No data is to be released to anyone without the specific approval of the COR and the Contracting Officer

Business Associate Agreement (BAA): Pursuant to the Health Insurance

Portability and Accountability Act (HIPAA) and its implementing regulation, the Standards of Privacy of Individual Identifiable Health Information at 45 C.F.R. Part 160 and 164, Subpart A and I: (“Privacy Rule”), the Indian Health Service is required to enter into an agreement with the Business Associate, pursuant to which the Business Associate shall comply with and appropriately safeguard Protected Health Information (PHI) that it will use and disclose when planning functions, activities, or services for the Indian Health Service.

The Business Associate by signing the contract shall comply with the following terms in addition to other applicable contract terms and conditions relating to the safekeeping, use and disclosure of PHI.

Section 508 Compliance: Contractor shall conform to Federal 508 requirements which address accessibility for personnel with disabilities.

Contractor shall procure a waiver if Section 508 applicability does not exist or relates to the contract. Please refer to http://www.section508.gov for more information. Section 508 applies only to contractor-developed deliverables (documents, reports, dashboards). Contractors do not need to submit a Product Assessment Template unless proposing contractor-owned software that will be accessed by Government personnel.

Additional Requirements Concerning Data, Data Rights, and Computer

Software: Notwithstanding any other clause concerning data, data rights and computer software and hardware under this Contract: all data produced, recorded, transferred or manipulated under this Contract shall remain the exclusive property of the Government irrespective or the manner or method of recording or storage and no matter what form of computer mechanism is used in the processing of said information or data. The Government shall retain exclusive rights and domain over any by-product produced under this Contract, or any other use of the data produced under this Contract by either plan or accident.

Permission for use, maintenance, disclosure, and disposition of data is at the sole discretion of the Indian Health Service.

6.0 APPLICABLE DOCUMENTS:

Division of Business Office Enhancement (DBOE) and Office of Information Technology (OIT) Website Website: http://www.ihs.gov/businessoffice/index.cfm

Freedom of Information Act Website: http://www.ihs.gov/FOIA/

Health Insurance Portability and Accountability Act (HIPPA) Website: http://www.ihs.gov/HIPAA/

Indian Health Manual Part 2 – Services to Indians and Others Chapter 6 – Patient Registration System Website: Chapter 6 - Patient Registration System | Part 2 Chapter 7 – Health Insurance Portability and Accountability Act Privacy Rule and the Privacy Act Website: Chapter 7 - Health Insurance Portability and Accountability Act Privacy Rule and the Privacy Act | Part 2

Part 3 – Professional Services Chapter 3 – Health Information Management Website: Chapter 3 - Health Information Management | Part 3

Part 5 – Management Services Chapter 1 – Third-Party Revenue Accounts Management and Internal Controls Website: Chapter 1 - Third-Party Revenue Accounts Management And Internal Controls | Part 5 Chapter 15 – Records Management Website: Chapter 15 - Records Management Program | Part 5

Part 8 – Information Resources Management Chapter 8 – Information Technology Security for Remote Access Chapter 12 – Information Technology Security Chapter 18 – Encryption Chapter 20 – Section 508 Implementation Website: Parts and Chapters | Indian Health Manual

Part 9 – Finance and Accounting Chapter 4 – Debt Management Website: Chapter 4 - Debt Management | Part 9

Indian Health Service (IHS) Privacy Program Website: http://www.ihs.gov/PrivacyAct/

Resource and Patient Management System (RPMS) Website: http://www/ihs.gov/RPMS/index.cfm http://www.ihs.gov/businessoffice/index.cfm http://www.ihs.gov/FOIA/ http://www.ihs.gov/HIPAA/ https://www.ihs.gov/ihm/pc/part-2/p2c6/ https://www.ihs.gov/ihm/pc/part-2/chapter-7-health-insurance-portability-and-accountability-act-privacy-rule-and-the-privacy-act/ https://www.ihs.gov/ihm/pc/part-2/chapter-7-health-insurance-portability-and-accountability-act-privacy-rule-and-the-privacy-act/ https://www.ihs.gov/ihm/pc/part-3/p3c3/ https://www.ihs.gov/ihm/pc/part-5/chapter-1-third-party-revenue-accounts-management-and-internal-controls/ https://www.ihs.gov/ihm/pc/part-5/chapter-1-third-party-revenue-accounts-management-and-internal-controls/ https://www.ihs.gov/ihm/pc/part-5/p5c15/ https://www.ihs.gov/ihm/pc/ https://www.ihs.gov/ihm/pc/part-9/p9c4/ http://www.ihs.gov/PrivacyAct/ http://www/ihs.gov/RPMS/index.cfm

7.0 DEFINITIONS:

Acceptance: Constitutes acknowledgement that the supplies or services conform to the applicable contract quality and quantity requirements, except as provided in FAR subpart 46.5 and subject to other terms and conditions of the contract.

Approval: Acknowledgement by the designated Government official that submittals, deliverables, or administrative documents (e.g., insurance certificates, installation schedules, planned utility interruptions, etc.) conform to contractual requirements. Government approval does not relieve the Contractor from responsibility for compliance with contractual requirements.

Contracting Officer (CO): A Government employee authorized and warranted to issue contracts, and to make subsequent modification(s). The CO has full authority to make determinations on all changes and disputes regarding the contract.

Contracting Officer’s Representative (COR): An individual who is authorized/appointed by the contracting officer, that is responsible for monitoring the technical and administrative aspects of contractor performance throughout the contract lifecycle.

Contractor: The individual awarded a legal binding contract to provide Psychologist Services as described in this performance work statement.

Customer: Patients, staff, and visitors of an IHS service unit and health center.

Credentialing: The process of verifying information about contractor employees to ensure legitimacy and experience. Credentialing is an activity that may be broken into three distinct phases:

1. Data gathering, verification, storage, dissemination and recommendation to the customer

2. Analysis of collected information and development of a recommendation

3. Decision-making based upon recommendations (governing body)

Federal Acquisition Regulation (FAR): The FAR is the primary regulation for use by all Federal Executive agencies in their acquisition of supplies and services with appropriated funds.

Health Center: A facility physically separated from a hospital, with a full range of ambulatory services including at least primary care physicians, nursing, laboratory, and x-ray which are available at least 40 hours a week for outpatient care.

Quality Assurance Surveillance Plan (QASP): A written document prepared and used by the government for Quality Assurance surveillance of the contractor’s performance.

Service Unit: The administrative unit of Billings IHS requesting the contracted services.

Written: Defined as either electronic or telefax or transcribed transmission.

8.0 DELIVERABLES:

For each task order, the Contractor shall provide the following reports with the invoice:

Detailed remote coding logs (by CLIN, provider, clinic type) Audit reports and revenue generation findings Task-specific deliverables required by the ordering activity

9.0 PRICE SCHEDULE:

Contract Line Item Description

BASE YEAR

MIN MAX UNIT UNIT PRICE CEILING PRICE

CLIN 1 - Revenue Generation Cycle Consultant Services 40 440 HR $ - $0.00

CLIN 2 - Third Party Billing 7,000 50,000 EA $ - $0.00

CLIN 3 - Accounts Receivable 160 2080 HR $ - $0.00

CLIN 4 - Coding and Data Entry 8,000 360,000 EA $ - $0.00

CLIN 5 - Auditing/Coding Queue 40 410 HR $ - $0.00

CLIN 6 - Inpatient Coding & Reporting 40 940 HR $ - $0.00

CLIN 7 - Compliance Auditing 40 440 HR $ - $0.00

The minimums and maximums are established as quantities, while the ceiling price will be established based on the unit prices multiplied by the maximum quantities. The overall contract ceiling is the total of all CLIN ceilings.

All services under all CLINs will be performed remotely. Onsite work is not required and will only occur when expressly authorized in a Task Order, and never for routine performance. No CLINs require onsite presence for standard execution.

10.0 BENCHMARKS AND ACCURACY RATES:

CLIN 2: The benchmark for third party billing services is 100 claims per day per service unit.

CLIN 3: The benchmark for accounts receivable management is 100 accounts per day per service unit.

CLIN 4: The benchmark for coding and data entry is 100 visits per day with a 5% error rate for coding and 2% error rate for data entry. NOTE: Visits with more than one health professional and multiples visits with the same health professional that take place during the same day at a single location within the hospital (including the hospital-based satellite) constitute a single visit.

CLIN 7: The benchmark for audits is 10% of completed encounters per quarter.