ATTACHMENT D - PWS.pdf

PERFORMANCE WORK STATEMENT (PWS)

MEDICARE PRICER CONTRACT

PERFORMANCE WORK STATEMENT

for the

BUSINESS INTEGRITY &

COMPLIANCE MEDICARE PRICER

CONTRACT

January 25, 2022

PERFORMANCE WORK STATEMENT – CALCULATION OF MEDICARE CLAIMS PRICING

1. INTRODUCTION:

This Performance Work Statement (PWS) describes the need of the Department of Veterans Affairs (VA) Office of Community Care (OCC), Business Integrity & Compliance (BIC) to obtain resources to price healthcare claim data using Medicare payment methodologies so OCC may validate the payment accuracy of claims paid through VA Community Care. Claims that require Medicare pricing are identified by VA for the purpose of internal audits performed by VA auditors.

This PWS sets forth the requirement the contractor must adhere to in the performance of work under this contract. This is a performance-based service in which the contractor shall provide all resources necessary to accomplish established objectives outlined herein.

The overall responsibility of the contractor is to plan, coordinate, organize, manage, and perform the activities described within this document.

2. BACKGROUND:

OCC is responsible for a broad range of activities that support the delivery of health care services to Veterans. In cases where the VA is unable to provide these services within VA facilities, medical providers in the community provide the health care services. Payment for VA Community Care physicians and other health care professional services utilizes a payment methodology based on pricing using regulations promulgated by the Centers for Medicare and Medicaid Services (CMS) as authorized by 38 CFR 17.56.

3. PERIOD OF PERFORMANCE:

The Period of Performance (POP) for this contract is estimated to be as follows.

However, these dates may change based on the contract award date.

Base Period: April 8, 2022 through April 7, 2023 Option Period 1: April 8, 2023 through April 7, 2024 Option Period 2: April 8, 2024 through April 7, 2025 Option Period 3: April 8, 2025 through April 7, 2026 Option Period 4: April 8, 2026 through April 7, 2027

4. TYPE OF CONTRACT:

Firm Fixed Price (FFP)

5. PLACE OF PERFORMANCE

Tasks under this contract shall be performed at the Contractor’s facilities.

6. SCOPE:

General Requirements:

The contractor shall provide the coordination, organization, management, and performance of the activities outlined within the performance period to include support for the Program as described herein. All written deliverables shall be phrased in layperson language. Statistical and other technical terminology shall not be used without providing a glossary of terms.

The contractor shall comply with VA approved formats (to be determined), submission timetables, and schedules.

The contractor shall provide data in clear, understandable terms outlining the outputs and work to be done in delivering the services to be performed under the contract.

Medicare Pricing Requirements:

The contractor shall provide VA with software/technology that allows VA to input individual or bulk medical claim data. In turn, the contractor shall provide VA with the accurate Medicare pricing, to include pricing details for a variety of medical claim types. VA is seeking a reliable source for Medicare pricing information in support of VA internal audits.

As such, the contractor is considered a subject matter expert (SME) in Medicare methodologies, payment, and proper billing guidelines including, but not limited to Inpatient institutional, Outpatient institutional, Professional, and other specialty health care services.

The contractor shall price claims according to Medicare billing requirements using the following, as appropriate:

• Medicare fee schedules,

• Prospective payment systems,

• Medicare payment methodology,

• Medicare National Correct Coding Policy Edits (NCCI), and

• All other Medicare Edits necessary to ensure proper pricing.

The amount of claim data will not exceed a total of 20,000 claims annually and will be disbursed throughout the year.

The pricing shall include all referred inpatient and outpatient, institutional, professional and specialty health care claim data utilizing Medicare guidelines and payment methodologies as well as the application and description of applied Medicare edits. The Contractor must be able to provide claim reimbursement and details for all Medicare fee schedules.

Examples of required fee schedules include, but are not limited to:

• Inpatient Prospective Payment System (IPPS),

• Outpatient Prospective Payment System (OPPS),

• Critical Access Hospital,

• Inpatient Rehabilitation Facilities,

• Inpatient Psychiatric Facility,

• Long-Term Care Hospitals,

• Ambulatory Surgical Centers,

• End Stage Renal Disease (ESRD PPS),

• Medicare Physicians Fee Schedule (MPFS), and

• Anesthesia.

Examples of other required reimbursement capabilities include, but are not limited to:

• Status “C” Carrier Priced services,

• Average Warehouse Pricing (AWP),

• Average Sales Price (ASP),

• Reductions for Non-Physician practitioner services, and

• Modifiers.

The health care claims pricing functions shall be maintained by the contractor.

Accuracy in determining a Medicare price for an episode of care is vitally important for this contract; therefore, the contractor shall have a robust QA program to ensure accuracy levels remain extremely high.

The contractor must be able to return claims priced within $.01 of Medicare reimbursement for VA to successfully conduct internal audits.

The contractor shall be responsible for validating the accuracy of their system and will identify how their system is validated and how often it is validated.

The contractor shall ensure the ability for VA personnel to suspend pricing rules and edits on an as-needed basis.

The contractor shall maintain the ability to price health care claims for a minimum of seven

(7) years prior to the current calendar date. Contractor shall price health care claim data using the appropriate Medicare reimbursement methodology in place on the date of service and apply code edits at the claim level, line level or a combination of both.

The contractor shall remain current in their knowledge of Medicare payment methodologies and demonstrate their ability to keep pace with future Medicare payment policies.

The contractor shall implement annual and quarterly CMS reimbursement methodology updates and changes by the effective date of the change. The contractor shall implement updates for changes without adequate published notice within five (5) business days.

Contractor shall ensure that all Medicare updates are implemented prior to the Medicare effective date. The contractor shall submit a report outlining all changes, as changes occur and are applied, to both the Project Manager and Contracting Officer’s Representative.

The contractor’s pricing system shall be compatible with VA approved browsers: Google Chrome and/or Microsoft Edge.

VA Claim Data to be Provided to Contractor:

Claim data provided to the contractor will be de-identified and will exclude Personally Identifying Information (PII) or Private Health Information (PHI). Additionally, historical claim information will not be provided.

The contractor must be aware some auditing environments may not price data that has been de-identified. As noted above, the claim data for this contract will be de-identified.

Therefore, it is imperative Contractors ensure their pricing system will work with data that has been de-identified.

OCC will provide the following health care claim data elements from medical claims paid by the VA. Bulk claim data will be provided to the contractor in an electronic format such as comma separated (.csv), Excel (.xlsx) or other method specified or approved by VA.

The contractor must be capable of determining the Medicare allowable pricing based solely on the following data elements:

• Electronic Standard Claim Transactions: 837I (Institutional claims) 837P (Professional claims)

• Rendering Provider National Provider Identifier (NPI)

• Services Rendered Locality

• Line-level charge information (Units, Dates of service, Procedure codes, Modifier, Place of Service, Revenue codes)

• Diagnosis Related Group (DRG)

• International Classification of Diseases (ICD) – 9/10 codes

• Patient’s Date of Birth

• Patient’s Sex

• Facility Bill Type

• ICD-10-PCS codes

• Condition codes

• Value codes

• Occurrence codes

The contractor will compute accurate Medicare allowable pricing for each service from the claim data components such as applying the locality, provider specialty, diagnosis, coding, Medicare edits and service component factors.

VA requires flexibility to adjust Fee schedules and other payment or reimbursement rules to include, but not limited to the following:

• For Critical Access Hospital claims, the contractor shall apply the facility specific cost-to- charge ratio for the date of service when applicable per CMS guidelines.

• For End Stage Renal Disease (ESRD) facility claims, the contractor shall apply CMS Quality Incentive Program (QIP) payment adjustments when applicable.

• For Facility claims priced using the CMS Inpatient Prospective Payment System (IPPS), the contractor shall:

o Price as "Health Maintenance Organization (HMO) Paid Claim - No";

o Apply CMS transfer policy pricing; and o Provide all inpatient calculation determinations and payment factors applied.

The contractor will return the VA provided data along with the calculated Medicare pricing results for bulk pricing in an electronic format such as comma separated (.csv), Excel (.xlsx) or other method specified by VA. The contractor must be able to return manually entered individual claims in a savable .pdf although other output formats may be considered after contract award, if it is in VA’s best interest. The returned pricing results transfer process must be accomplished without reliance on or use of PII or PHI.

Additionally, the contractor must ensure their output details what pricing rules and edits were applied on the claim.

While the contractor will not be given PHI or PII, they would be given non-sensitive information to be used for pricing those types of claims (e.g., BMI, Onset, Diagnosis, etc.)

7. MANDATORY TASKS and ASSOCIATED DELIVERABLES:

The contractor shall complete the tasks below and associated deliverables by the scheduled dates within the overall PoP or as may be agreed to with the Contracting Officer’s Representative (COR) and Contracting Officer (CO). If, for any reason, any deliverable cannot be delivered on time according to schedule, the contractor shall provide a written explanation within three (3) business days prior to the due date to the COR.

If the contractor is unable to meet the schedules for deliverables with turn-around times less than three (3) business days, the contractor shall provide to the COR, a written explanation one (1) business day prior to the due date. This written transmittal shall include a firm commitment of when the work shall be completed. This transmittal to the COR shall cite the reasons for the delay and the impact on the overall project. The COR will review the facts and issues collaboratively with the program office and respond in accordance with the contract terms and conditions. All deliverables shall be provided in electronic format.

The contractor shall complete the tasks listed below within the stated timeframes.

Task #1 – Kick-Off Meeting A technical kickoff meeting shall be held within seven (7) business days after award. The Contractor shall coordinate the date, time, and location (can be virtual) with the

Contracting Officer (CO), the Contract Specialist (CS), and the COR. The Contractor shall provide a draft agenda to the CO, CS or COR at least five (5) business days prior to the meeting.

Upon VA approval of a final agenda, the Contractor shall distribute to all meeting attendees. During the kickoff-meeting, the Contractor shall present, for review and approval by the Government, the details of the intended approach, work plan, and project schedule for each effort via a Microsoft Office PowerPoint presentation.

At the conclusion of the meeting, the Contractor shall update the presentation with a final slide entitled “Summary Report” as part of the meeting minutes and shall include notes on any major issues, agreements, or disagreements discussed during the kickoff meeting and will identify any action items and who is responsible for the action item. The draft kickoff meeting notes will be distributed electronically to all attendees for comment.

The Contractor shall address comments and submit the final updated presentation to the CO for review and signature within three (3) business days after the meeting. The Contractor shall also prepare and distribute the meeting minutes of the kickoff meeting to the CO, COR, and all attendees within three (3) business days after the meeting. The Contractor shall obtain concurrence from the COR on the content of the meeting minutes prior to distribution of the document.

The CO signature or approval of the Summary Report confirms the discussion during the Kickoff Meeting; however, it does not authorize any changes nor supersede any of the requirements, terms or conditions included in the PWS.

Deliverables:

A. Kickoff Meeting Presentation & Summary Report B. Kickoff Meeting Minutes

Task #2 – Medicare Pricing with a Manual, Web-Based Portal Input:

The contractor shall provide services to compute Medicare allowable pricing of health care claim data provided by VA. For this task, the Medicare Pricing shall be accomplished using a web-based portal that allows for manual input of health care claim data by all BIC auditors (approximately forty (40) VA employees). Web-Based Portal for manual input will be used to price a minimum of 2,000 claims per year and a maximum of 5,000 claims per year. Any claims over the minimum guaranteed amount will be exercised incrementally as required by VA.

The resultant Medicare Price of the claim data that was input shall be provided to VA in pdf format.

The contractor must have the ability to calculate Medicare prices from manual input into the portal by authorized VA employees.

The returned pricing information shall include:

• Original health care claim data provided by OCC.

• Medicare fee schedule or prospective payment system information used for pricing.

• Medicare allowable pricing amount for the claim.

• Medicare allowable pricing amount per line item.

• Reason and the amount of any claim level or line level adjustments.

• Identification of any line items included in bundled payment amounts to include Medicare edits, Healthcare Common Procedure Coding System (HCPCS), date of service, billed amount, and the HCPCS code in which the payment was bundled.

• Locality used to calculate the Medicare reimbursement pricing to include, at a minimum:

o Wage indexes o Rural adjustments o Health Professional Shortage Area (HPSA) o Taxonomy o Edits that prevented pricing (as applicable) o Edits that reduced pricing (as applicable)

• Medicare edits, HCPCS code, date of service, billed amount, and narrative reason for denial for any denied line items.

The Medicare pricing for an episode of care will be immediately provided following manual entry of VA claim data and its submittal into the contractor’s web-based portal.

If errors are identified by VA, the contractor shall acknowledge receipt of the error, provide notification of the error to the COR and develop a mitigation plan for correcting the error within two (2) business days.

Deliverable:

A. Provide a web-based portal that will produce Medicare prices for episodes of care from a minimum of 2,000 priced claims that will be manually input by VA personnel.

B. Provide a web-based portal that will produce Medicare prices for episodes of care that will be manually input by VA personnel NTE an additional 3,000 claims. (Optional)

Task #3 (Optional) – Medicare Pricing with Bulk Data Input:

The contractor shall provide services to compute Medicare allowable pricing of health care claim data provided by VA. For this task, the Medicare Pricing shall be accomplished using a bulk claim file provided to the vendor electronically. Bulk data files to be used for pricing claims are NTE 15,000 claims/year. The contractor will return the VA provided data along with the calculated Medicare pricing results for bulk pricing in an electronic format such as comma separated (.csv), Excel (.xlsx) or other method specified by VA within two (2) business days of data input.

The returned pricing information shall include:

• Original health care claim data provided by OCC.

• Medicare fee schedule or prospective payment system information used for pricing.

• Medicare allowable pricing amount for the claim.

• Medicare allowable pricing amount per line item.

• Reason and the amount of any claim level or line level adjustments.

• Identification of any line items included in bundled payment amounts to include Medicare edits, Healthcare Common Procedure Coding System (HCPCS), date of service, billed amount, and the HCPCS code in which the payment was bundled.

• Locality used to calculate the Medicare reimbursement pricing to include, at a minimum:

o Wage indexes o Rural adjustments o Health Professional Shortage Area (HPSA) o Taxonomy o Edits that prevented pricing (as applicable) o Edits that reduced pricing (as applicable).

• Medicare edits, HCPCS code, date of service, billed amount, and narrative reason for denial for any denied line items.

The contractor shall return complete pricing information within two (2) business days of initial receipt of the health care claim data. The date of receipt of the claim data by the contractor is considered day one (1) for the purpose of claims pricing timeliness.

If errors are identified by VA, the contractor shall acknowledge receipt of the error, provide notification of the error to the COR and develop a mitigation plan for correcting the error within two (2) business days.

The format for bulk data results will be determined between VA and the contractor after contract award. The contractor will be given ninety (90) calendar days to configure their system to accept bulk data. Once configured and VA provides Bulk Data for pricing, the data results will be made available within one (1) business day after initial receipt. Error mitigation plan shall be received within two (2) business days of notification

Deliverable:

A. The contractor will return the VA provided data along with the calculated Medicare pricing results for bulk pricing in an electronic format such as comma separated (.csv), Excel (.xlsx) or other method specified by VA within 2 business days of data input.

8. DELIVERY SCHEDULE:

Task Deliverable Description Quantity Delivery Date

1A Kickoff Meeting Presentation & Summary Report

NLT seven (7) business days after award

1B Kickoff Meeting Minutes 1 NLT three (3) business days after kick-off meeting

2A

Medicare Pricing with a Web-Based Portal for manual data input – Pricing of all referred inpatient and outpatient healthcare claim data utilizing all appropriate Medicare reimbursement methodologies, with locality

2,000 EA

Contractor must have the ability to calculate Medicare rates from data input by VA on the day of award.

Priced Medicare claim results are due upon entry and submission of VA data into the portal.

2B

(OPTIONAL)

Medicare Pricing with a Web-Based Portal for manual data input – Pricing of all referred inpatient and outpatient healthcare claim data utilizing all appropriate Medicare reimbursement methodologies, with locality.

This Task may be exercised incrementally at any point during the current year period of performance.

NTE

3,000 EA

Contractor must have the ability to calculate Medicare rates from data input by VA on the day of award.

due upon entry and submission of VA data into the portal.

3A

(OPTIONAL)

Medicare Pricing with Bulk Data Input – Pricing of all referred inpatient and outpatient healthcare claim data utilizing all appropriate Medicare reimbursement methodologies, with locality.

This Task may be exercised incrementally at any point during the current year period of performance.

NTE

15,000

EA

Contractor must have the ability to calculate Medicare rates from data input by VA within ninety

(90) calendar days of exercising this task.

due within two (2) business days following data input.

9. QUALITY ASSURANCE SURVEILLANCE PLAN

The Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. Please refer to the contractor instructions located in Attachment A – Quality Assurance Surveillance Plan.