Attachment J.31 - Quality Assurance Surveillance Plan.pdf

Attachment J.31

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

For

Health Care Benefits Services

Contract Number: TBD

Contract Award Date: TBD

1. PURPOSE

This QASP is to ensure the performance of critical requirements listed in the Performance Work Statement (PWS) under Section C of the Contract.

The QASP serves as the plan for surveillance of performance and identifies the performance standards, acceptable quality level, procedures for monitoring and documentation and resources to be employed to incentivize and dis-incentivize. The objective of this QASP is to provide a systematic method to evaluate the services the contractor is required to furnish by the contract. Although this QASP documents the methods to be used for measuring contract requirements, the Contracting Officer’s Representative (COR) may evaluate work any time during the contractor’s work performance.

2. RESPONSIBILITIES

The contractor, not the Government, is responsible for management and quality control actions necessary to meet the terms and conditions of the contract. The contractor is responsible for providing all information to the Government that is necessary to accurately evaluate performance. Each document the contractor provides for review will be maintained by the contractor for inspection for the contract period of performance. All evaluations made by the Contracting Officer (CO) and/or COR will also be documented and filed for further reference, audit, and proof of inspection by the CO and/or COR.

3. ACCEPTABLE QUALITY LEVELS

The Acceptable Quality Levels (AQLs) provided in the Performance Requirements Summary Table (see below), for contractor performance are structured to allow the contractor to manage how the work is performed while providing incentives and disincentives for performance shortfalls. Levels of performance are keyed to the relative importance of the task to the overall performance.

4. PERFORMANCE

The Government desires to maintain a quality standard of completed requirements in the PWS and is responsible for ensuring measurable standards to evaluate performance. This contract requires health care services for Peace Corps Invitees, Volunteers (PCVs) and Returned Peace Corps Volunteers (RPCVs), which requires access to protected health information. Due to the sensitivity and nature of this contract and the adverse events that will occur if inadequate performance is allowed, the level of surveillance and performance standards will be higher than for other

Government contracts. If the contractor has not met the requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

5. REPORTING

At the end of each month, the COR will prepare a written report summarizing the overall results of the quality assurance surveillance of the contractor’s performance.

This written report will become part of the quality assurance documentation. This report will enable the Government to demonstrate whether the contractor is meeting the stated performance standards in the PWS.

PERFORMANCE REQUIREMENTS SUMMARY TABLE:

Quality Control

Required Services

Performance Standards

Acceptabl e Quality Level

(AQL)

Monitoring Method

Incentive/ Disincentive

TASK 1: Audits

1.1 Financial

accuracy Super Gree99.5% Green =99 to 9.49% Red less than 99%n

Green Random audits based on Quality control monitoring.

3-5% per examiner or as requested by management

Performance Evaluation.

Contractor provides COR written evaluation within 7 business days of audit

1.2 Procedural

Accuracy

Super Gree99.5% Green =99 to 9.49% Red less than 99%n –

Green Back end audits based on Quality Control monitoring 3-5% per examiner or as requested by management

Performance Evaluation.

Contractor provides COR written evaluation within 7 business days of audit

1.3 Customer

Satisfactio n

Only acceptable = 97.50% or above

97.5 or higher

Audits of 10 calls/contact s per service rep per month as well as audits of customer complaints

Traini ng and perfor mance standards.

Will include results of audit in the monthly Customer Service

Telephone report

1.4 Report

Contractor errors and/or unaccepta ble audit scores

When an error is assessed, the rebuttal or inquiry must be sent to the Team Lead and others within 2 business days of audit completion

100% in less than 2 business days

Internal review

Monthly reporting by Contractor on overall audit scores and performance

1.5 Contractor

will submit contract data reports as required.

Any responses to errors will be resolved within 2 business days

Reports are submitted on time 100%

Period inspections, observations and file reviews

Monthly reporting within standards

TASK 2: Preferred Provider Network

2.1 Provide

access to

PPN

website via Contracto r website link

99.99% uptime (not including approved Maintenance downtime)

99.99 % uptime

Alerts in place for server failure

.01% variation

2.2 Provide a

process to recomme nd additional providers for inclusion in PPO

Electronic submission of recommended providers submitted for vetting by PPO staff

100 % of eligible providers are contacted.

Notification of newly contracted providers

None

2.3 Provider

terminatio n from

Timely notice of terminated Providers in network

Immediate Notification from PPO Network sent

Prevent processing error In CDR A009 submit

PPO

Network electronicall y as well as updated in PPO Portal.

all providers that are terminated and the reason for the termination

2.3.1 Contractor

alert to PPO Network of issue with provider a.)

up coding b.) balance billing of member c.) consumer complaints

Immediate resolution

System alerts based on URC and PPO discount variables

Service standards

Claims Processing

Required Services

Performance Standards

Acceptabl e Quality

Level

(AQL)

Monitoring Method

Incentive Disincenti ve

3. Provide and maintain an accurate SOP via training manual for processing and payment of claims for Plans 1-4 as identified in PWS

The SOP/Manual must contain the guidelines for evaluating and coding claims for payment in relation to Plan 1- 4 in PWS

As written System alerts and audit measures

Performan ce Standards

3.1

Provide and maintain

SOP

regarding claim processing system regarding evaluation of claims per plan provisions.

Medical Necessity, authorized claim payments and covered services

As written

Operating system houses plans built to coverage and coding stipulations.

Two Tier testing of all plans executed upon build and update

3.2 Notificatio

n to COR of any variation or changes to processing or coding procedures

30 days prior to any operational or system changes

No variation acceptable

Notification via newly proposed procedures, system or vendor changes that may affect outcome changes in relation to claims coding or payment

Fraud Required Services

Performance Standards

Acceptable Quality Level

(AQL)

Monitoring Method

Incentive/ Disincentive

4.

International Provider Fraud

Provide monitoring of fraudulent provider activity and to detect and negate

13 step process to determine the legitimacy of a provider if fraud is suspected

All 13 steps are reviewed and indicated as NA or further investigated

System alerts and Shared Drive Spreadsheet of data

Eliminate fraudulent providers from database and report to local authorities and other similarly situated businesses

4.1

Provide and maintain SOP regarding how to detect and report fraud

Accountability as members of Performant Health Fraud Hub

100% accountability to remain active member

Hub monitors patterns. As member IMG maintains commitment to review and enforce pattern review and resolution

4.2

Notification to COR of any fraudulent activity related to providers in areas of service or attempting to use MOS contacts

Immediate notification

No variation acceptable

Through hub, alerts and gathered data details