D.1_MRAC_SOW.docx

MEDICAL REVIEW ACCURACY CONTRACTOR (MRAC) STATEMENT OF WORK (SOW)

Medical Review Accuracy Contractor (MRAC) Statement of Work (SOW)

May 2023

I. SCOPE

The Center for Program Integrity (CPI) is seeking a contractor to monitor the accuracy of CMS’ Medicare and Medicaid Medical Review Contractors (MRCs) medical review (MR) decision making, their ability to implement Medicare and Medicaid coverage, coding, payment, and billing policies, and the identification of potential fraud, waste, or abuse (FWA) patterns and/or trends. MRCs are defined as the Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractor (SMRC), with workstreams in Program Integrity (SMRC PI) and Healthcare Fraud Prevention Partnership (SMRC HFPP), Unified Program Integrity Contractors (UPICs), and the Railroad Retirement Board Specialty MAC (RRB SMAC SMAC).

A. Purpose of Contract CPI is seeking the Medical Review Accuracy Contractor (MRAC) to measure the accuracy rate for each MRC by reviewing a representative sample of claims based on the universe reviewed monthly by each MRC. At a minimum, the MRAC’s claim reviews require the use of clinical review judgment in the evaluation of medical records and related documents to determine whether the MRCs made accurate claim decisions in compliance with Medicare and Medicaid coverage, coding, payment, and billing policies (i.e., Code of Federal Regulations (CFR), National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and in accordance with the MRC-specific requirements in the CMS Internet Only Manuals (IOMs) and the Medicaid State statutes, regulations and manuals). In addition, for PI MR and PI purposes, the reviews require that the MRAC evaluate not only each claim but the entire pool of related claims as a whole for FWA patterns and/or trends.

B. Background The CPI’s Division of Medical Review (DMR) is accountable for the evaluation of medical records and related documents to determine whether Medicare claims were billed in compliance with Medicare and Medicaid coverage, coding, payment, and billing policies. As part of this oversight, CPI is seeking to monitor the accuracy of the MRCs medical review decision- making and ability to implement Medicare coverage, coding, payment and billing polices. Specific work related to the DMR hereafter will be referred to as “Standard.”

The CPI’s Division of Program Integrity Support Contracts (DPISC) is accountable for the evaluation of medical records and related documents to determine whether the Medicare and Medicaid investigations’ claims were billed in compliance with Medicare and Medicaid coverage, coding, payment, and billing policies. In addition, the evaluation includes whether claims contain FWA patterns and/or trends, which may support the allegation of potential FWA. Specific work related to the DPISC hereafter will be referred to as “PI”. The statutory and regulatory authority for MR of Medicare and Medicaid claims is referenced in the following:

· Social Security Act (SSA), Section 1833(e) which states, in part, “….no payment shall be made to any provider…unless there has been furnished such information as may be necessary in order to determine the amounts due such provider…;’

· SSA, Section 1862(a)(1) states no Medicare payment shall be made for expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

· SSA, Section 1936: Medicaid Integrity Program

· 42 CFR 421.4 for the MACs

· 42 USC 1396u-6: Medicaid Integrity Program

· 42 CFR 455- PI: Medicaid

C. General Assumptions and Constraints

· The total number of Standard and PI medical reviews to be conducted by the MRAC is based on CMS guidance to the MRCs, Pandemics, Local and/or National disasters and/or any other unforeseen situations where CMS determines the MRCs MR workload would be increased or decreased.

· The MRAC shall furnish the Information Technology (IT) environment and any equipment required by its personnel to complete the medical review project/tasks and reports.

· CPI is not acquiring the MRAC’s facilities or IT systems (hardware or software) used to support performance of the work.

· The MRAC shall provide individuals who are completely trained and capable of doing all tasks pertinent to their job function. It is the MRAC’s responsibility to ensure their employees are current on all licenses/certifications necessary that relates to the execution of services under this contract.

· The MRAC shall establish Joint Operating Agreements (JOAs) for the purpose of establishing efficient processes for communication between the MRAC and the MRCs. These processes at a minimum shall include a procedure for obtaining the required medical records and related documentation from the MRCs. Refer to Task 1.1 for more information.

· Standard workload:

· The number of rebuttals and claims reviewed per MAC, SMRC and RRB SMAC shall total the number of estimated claims (7,200 – 12,000) for each contract year. The claims reviewed shall be taken from the Standard workload SLIN.

· The claims sampled and reviewed by the MRAC shall be a mix of claim types based on the monthly universe sent/uploaded by the MRC.

· The MRAC shall adjust the total number of claims reviewed per month in order to accommodate all rebuttal workload to not exceed the ceiling number of “estimated claims”.

· CPI, in collaboration with the MRAC, will review and adjust the Standard workload numbers as necessary.

· Program Integrity (PI) workload:

· The number of rebuttals and claims reviewed per UPIC, SMRC PI and SMRC HFPP shall total the number of estimated claims (6,200 - 8,000). The claims reviewed shall be taken from the PI workload SLIN.

· The claims sampled and reviewed by the MRAC shall be a mix of claim types based on the monthly universe sent/uploaded by the MRC.

· The MRAC shall adjust the total number of claims reviewed per month in order to accommodate all rebuttal workload to not exceed the ceiling number of “estimated claims”.

· CPI, in collaboration with the MRAC, will review and adjust the PI workload numbers as necessary.

II. REQUIREMENTS

A. General Requirements Independently, and not as an agent of the Government, the MRAC shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform the requirements of this Statement of Work (SOW).

CPI will provide administrative support, which, at a minimum may include:

· Help communicating with Medicare contractors,

· Policy interpretations, and

· Other support deemed necessary by CPI to allow the MRAC to perform its tasks efficiently.

1. Section 508 Accessibility Standards Section 508 of the Rehabilitation Act, as amended by the Workforce Investment Act of 1998 (P.L. 105-220) requires that when Federal agencies develop, procure, maintain, or use information and communication technology (ICT), it shall be accessible to people with disabilities. Federal employees and members of the public who have disabilities must have access to, and use of, information and data that is comparable to people without disabilities. For more information on applicable provisions of 36 CFR Part 1194 refer to Appendix A.

2. Information Security Requirements The MRAC shall possess appropriate hardware, software, and telecommunications equipment to meet the requirements in this SOW. As required, the MRAC shall:

· Process, store, facilitate transport of, or host/maintain Federal information;

· Comply with the Federal, Department of Health and Human Services (HHS), CMS Information Security Program Policies and the CMS Business Partners System Security Manual;

· Obtain and maintain the Authority to Operate (ATO) for a Secure File Transfer Protocol (SFTP) data server and/or other methods approved by CMS to receive medical records/documentation from the MRC’s.

· The SFTP server will remain as a backup system until the Recovery Audit Contract Data Warehouse (RACDW) and the Unified Case Management (UCM) MR capabilities are operational.

· For the SFTP data server, the MRAC shall:

· Provide installation link, instructions via virtual training and testing for CMS Contracting Officer’s Representative (COR)/Alternate Contracting Officer’s Representative (ACOR)/Standard Business Function Leads (BFLs) and with each MRC’s Point of Contact (POCs), and

· Create a mailbox address/telephone number (available during normal business hours) to receive and provide technical assistance during and after the SFTP onboarding process.

· Comply with the CMS security requirements, policies, procedures, standards, and guidelines at: https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/informationsecurity?redirect=/informationsecurity and,

· For additional information refer to Appendix B & C.

3. Key Personnel The MRAC shall provide appropriate personnel who shall be designated as “key” personnel. All key personnel positions require Contracting Officer (CO) approval before the personnel are assigned to or removed from this contract. All proposed substitutions must be submitted, in writing, to the CO at least 30 days prior to the proposed substitution or as soon as reasonably known. Each request shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume and any other information required by CPI to ensure that the proposed candidate meets the SOW requirements for the Key Personnel position.

As Applicable, all proposed Key Personnel and substitutions must meet the requirement of never having been sanctioned or excluded from the Medicare/Medicaid programs and that any current or prior licensure has no restrictions and/or disciplinary actions.

The MRAC COR/ACOR shall verify the evidence provided by the MRAC before recommending approval. Unless otherwise approved by the CO, the key personnel noted below shall possess the following minimum work experience and educational requirements and be a full-time employee on the contract. The key personnel positions for this contract are as follows:

A. Program Manager (PM) The PM’s roles and responsibilities, at a minimum, shall include day-to-day contact with the MRAC COR/ACOR and BFLs and general oversight of the contract performance including obtaining and maintaining the necessary personnel to conduct MRAC work in accordance with the SOW. The PM shall collaborate with the Contract Medical Director CMD/MR Manager(s) to obtain the necessary information required for the timely submission of Standard and PI required reports.

Experience: Prior work experience in the Medicare and/or Medicaid programs (both are preferred), and working experience with either a utilization review firm or in a health care claims processing organization. As well as, at least three years of experience as a manager responsible for developing coverage or medical necessity policy and guidelines, and managing complex systems and work flow. MR experience is also preferred.

Education: A master’s degree from an accredited institution or in lieu of the master’s degree a bachelor’s degree from an accredited institution with two years of professional experience in a related field as stated in the “Experience” section above.

B. Contract Medical Director (CMD) The CMD’s roles and responsibilities, at a minimum shall include providing support to the Program Manager with oversight of the Quality Assurance (QA) activities, providing consultation for the Standard and Program Integrity medical reviews regarding policy, medical necessity, coding issues and FWA patterns/trends and attending conference calls/meetings as per Task 3.

Experience: Prior work experience in a role that involved developing coverage or medical necessity policies and guidelines, for either the Medicare and Medicaid programs, a utilization review firm, or a health care claims processing organization, as well as, knowledge of the Medicare and Medicaid programs coverage and payment rules. The CMD shall also have clinical review judgment experience and MR experience in the area of Medicare and Medicaid PI investigation of FWA are required. Public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices is preferred.

Education: The CMD shall be either a Doctor of Medicine, a Doctor of Osteopathy or equivalent and currently licensed to practice medicine in the United States.

C. Medical Review (MR) Manager(s)

The Medical Review Manager(s) roles and responsibilities, at a minimum shall include the development, oversight, and implementation of the Standard and Program Integrity medical review processes while supervising the medical review nurses. The MR Manager(s) shall participate in collaboration with the PM, CMD, and other Contract staff as applicable to ensure medical reviews are completed accurately and timely. Also attends conference calls/meetings as per Task 3.

If one Full Time Equivalent (FTE) (fulfilled by one individual) is proposed for both the Standard MR Manager and the PI Manager positions, the proposed individual must meet the requirements of both positions.

Education/Licenses: Board Certified in Nursing and currently licensed to practice nursing in the United States as a registered nurse (RN).

Standard MR Manager Shall have primary responsibility for the development, oversight and implementation of the MR program and related QC/QA processes for the MACs, SMRC, and RRB SMAC while working collaboratively with the PM/CMD. In addition, the Standard MR Manager has the responsibility to provide the PM with the necessary information required for the timely submission of Standard reports.

Experience: Clinical experience in either an acute care hospital, skilled nursing facility, or an office/clinic-based medical practice. As well, at least two-years of supervisory experience with Medicare and Medicaid program’s coverage and payment rules, including processing of Medicare and Medicaid claims using clinical review judgment. Experience in MR processes of MACs, SMRC or RRB SMAC is preferred.

PI MR Manager Shall have primary responsibility for the development, oversight and implementation of the medical review program and related QC/QA processes of UPICs and SMRC (PI and HFPP) while working collaboratively with the PM/CMD. In addition, the PI MR Manager has the responsibility to provide the PM with the necessary information required for the timely submission of PI reports.

Experience: Clinical experience in either an acute care hospital, skilled nursing facility, or an office/clinic-based medical practice. As well, at least two-years of supervisory experience with Medicare and Medicaid program’s coverage and payment rules, including processing of Medicare and Medicaid claims using clinical review judgment. At least one year of MR experience in Medicare and Medicaid PI investigation/detection or a related field that demonstrates expertise in reviewing, analyzing, developing information, and making appropriate decisions in support of allegations of FWA. Experience in MR processes of UPIC, SMRC PI or SMRC HFPPs is preferred.

B. Specific Requirements Unless otherwise marked as such, task and sub-tasks under this section applies to both Standard and PI MR workload. Standard MR shall include the medical claim review of MACs, SMRC, and RRB SMAC. PI MR shall include the medical claim review of UPICs, SMRC PI, and SMRC HFPP.

Task 1 – Transition-In Period There shall be a 60-day transition-in period initiated at the time of contract award. During this transition period, the contractor shall work with CPI and the outgoing contractor to minimize disruption of services. During transition period it is expected that:

· The contractor will submit a Transition-In Plan to the MRAC COR two business days after the kickoff meeting.

· At a minimum, the Transition-In Plan shall address the following:

· Description of transition activities;

· Transition schedule, including key milestone events and migration activities led by the Contractor;

· Identification of staff and resources;

· List of deliverables and how these deliverables will be managed during the transition;

· Transition meetings, as necessary, with the incoming Contractor(s);

· Communications and reporting during the transition period;

· Risks and issue mitigation;

· Other information deemed necessary by the Contractor or requested by CMS.

· The contractor shall work collaboratively with the outgoing contractor identified by CPI to ensure a seamless transition of the transitioned activities i.e., participation in transition meetings, coordination of the transfer of activities, and identification and accounting for other tasks required for a successful transition.

· The contractor will receive a list of MRC’s POCs, JOA Templates and a copy of the Accuracy Review Agreement/Disagreement Worksheet from the COR.

· The outgoing contractor will be responsible for accepting all reviews during the Transition-In period until the incoming contractor is fully operational (JOA’s are signed and the ATO has been granted).

· The outgoing contractor will work on and/or complete all accepted reviews within the SOW established due dates. However, once the incoming contractor is fully operational, all outstanding/ accepted reviews by the outgoing Contractor will be transferred for completion by the incoming contractor.

· The contractor shall be prepared to accept reviews at the conclusion of the Transition-In period.

· The contractor must meet the following conditions, no later than 60-days after contract award (i.e., end of the Transition-In period), before the contractor is able to begin accepting and completing medical reviews:

a. All key positions for all labor categories have been fulfilled,

b. The JOAs are finalized and signed by each MRC,

c. Obtain and maintain the ATO for a Secure File Transfer Protocol (SFTP) data server and/or other methods approved by CMS to receive medical records/documentation from the MRCs, and

d. Obtained the required connectivity to the various systems i.e., Common Working File (CWF), RACDW, UCM, in order to conduct medical reviews.

Task 1.1 – JOAs The MRAC shall execute JOAs with all of the Standard and PI MRCs to delineate roles and responsibilities, facilitate efficient processes for communication, establish guidelines and shared expectations between the MRAC and the MRCs. The JOA shall be executed within 60 days from the date of contract award. The JOAs are a living document and shall be updated, at a minimum, annually and/or as needed to reflect current processes. Changes to the JOAs shall be reviewed and approved by the MRAC COR/ACOR and BFLs.

Task 1.2 - Project Plan The MRAC shall develop and submit a detailed project plan. The project plan includes the steps illustrating how the contractor will implement, execute and accomplished the SOW tasks. Standard medical reviews shall include the medical review of the MACs, SMRC, and RRB SMAC. PI MR shall include the medical review of the UPICs, SMRC PI, and SMRC HFPP. The project plan shall include, at a minimum:

· Detailed timetables,

· Identification of resources and staffing,

· Detailed approach towards meeting the deliverables, and

· Project milestones.

The draft project plan will be submitted and discussed at the kick-off meeting. The draft plan shall be modified by the contractor based on MRAC COR/ACOR’s comments and recommendations. A final plan is to be submitted for MRAC COR/ACOR approval within five business days after receipt of comments.

The project plan shall be reviewed at the beginning of each contract year. If there are no changes, the contractor shall notify the MRAC COR/ACOR via email that no changes were made to the plan. If there are changes, the draft plan with changes shall be submitted to the MRAC COR/ACOR for review. A final revised plan shall be submitted for approval within five business days after receipt of comments.

Task 1.3 – Information Technology (IT) Systems Project Plan The MRAC shall develop a draft IT Systems Project plan no later than 10 business days after the kick-off meeting. The IT Systems Project plan should include at a minimum:

· Identification of resources

· Identification of the required hardware, software and telecommunications equipment to undertake this requirement

· Documentation of any and all mainframe and server systems, modules, and programs utilized for the Contractor’s work pertaining to this contract

· Securely receive and utilize data from CMS

· Back-up all data on a weekly basis (at a minimum) and maintain old reports

The draft IT systems project plan shall be modified by the contractor based on MRAC COR/ACOR’s comments and recommendations. A final IT plan is to be submitted for MRAC COR/ACOR approval within five business days after receipt of comments. The plan shall be reviewed at the beginning of each contract year. If there are no changes, the contractor shall notify the MRAC COR/ACOR via email that no changes were made to the plan. If there are changes, the draft plan with changes shall be submitted to the MRAC COR/ACOR for review and a final revised plan shall be submitted for approval within five business days after receipt of comments

Task 1.4 –Quality Control/Quality Assurance (QC/ QA) Plan The MRAC shall develop and submit a draft QC/QA plan within 15 business days after kick-off meeting. The QC/QA plan shall ensure that each SOW task is performed consistently and accurately. The MRAC shall provide the draft QC/QA plan to the MRAC COR/ACOR via email. Standard medical reviews shall include the medical review of the MACs, SMRC, and RRB SMAC. PI MR shall include the medical review of the UPICs, SMRC PI, and SMRC HFPP. The MRAC shall present and maintain a QC/QA plan for the assessment and training of Standard and PI MR personnel (including subcontractors). The plan shall include, at a minimum:

· Procedures and processes used to perform QC/QA functions to include specific measures for reporting and resolving corrective actions;

· Delineation of specific personnel responsibilities to perform this function;

· An objective process to assign staff to review projects, ensuring that the correct level of expertise is available;

· Rate and frequency by which quality control functions are performed;

· Procedures and processes used to disseminate information to MRAC personnel of policy and procedures changes as well as systematic issues identified during QC reviews; A process to address how the MRAC will monitor and maintain accuracy in decision- making (Inter-Rater Reliability (IRR) process);

· Training methods/plan shall be put in place to familiarize the MRAC’s medical reviewers/support staff with techniques and procedures for completing the medical review process. Training shall include knowledge of Medicare and/or Medicaid statutory/regulatory requirements/guidance required to make a claim payment decision, and the identification of potential FWA patterns/trends for PI reviews only; and

· The MRAC’s training plan and maintenance of training materials shall consider changes in CPI/CMS regulations, guidance, manuals, or forms.

The draft QA/QC plan shall be modified by the contractor after receiving the MRAC COR/ACOR’s comments and recommendations. A final QA/QC plan is to be submitted for MRAC COR/ACOR approval within five business days after receipt of comments. The plan shall be reviewed at the beginning of each contract year. If there are no changes, the contractor shall notify the MRAC COR/ACOR via email that no changes were made to the plan. If there are changes, the draft plan with changes shall be submitted to the MRAC COR/ACOR for review and a final revised plan shall be submitted for approval within five business days after receipt of comments.

Task 2 – Administrative Requirements The Contractor shall provide administrative support throughout the contract period. The Contractor shall ensure that all development products and projects are managed to obtain the greatest value for CMS. Additionally, the Contractor shall coordinate resources that minimizes risks and costs, while maximizing value for CMS.

Task 2.1 Kick-off Meeting The Contractor shall coordinate with the CO and MRAC COR/ACOR to schedule and conduct a kickoff meeting with CMS within seven business days after contract award. The contractor shall be responsible for taking minutes during the kick-off meeting in order to document the discussion, provide action items, and next steps on the project. The contractor shall submit a kick-off meeting agenda to the COR at least three business days prior to the meeting. The kick-off meeting shall address, at a minimum, the following topics:

· Approach overview

· Introduction of key staff

· Transition-In Activities

· The Project Plan

· Review by the contractor of its understanding of the work to be accomplished under this SOW to ensure that all parties have a common understanding of the work to be performed and of the respective responsibilities and obligations of the parties to that end

· Review by both CMS and the contractor of the agreed-upon method to resolve, track, and report on issues

· Briefing by the contractor regarding the contractor’s particular strengths, key personnel and team experience, working style, and critical success factors

· Discussion regarding expectations on individual state Project Plans and proposed or potential activities necessary to conduct this scope of work

· Overall plan for communicating with CMS and the states

· Action items necessary to start the work

Task 3 – Meetings/Conference Calls Teleconference and/or Videoconference is an acceptable format for all meetings. The Government reserves the right to meet in person. The meeting schedule shall be flexible and can change as needed. The MRAC shall provide phone lines and/or video conference access where applicable.

The MRAC shall be available for phone/video calls and email request from the MRAC COR/ACOR and BFLs in regards to findings, reports, or medical review procedures concerning assigned projects on an as needed basis.

The MRAC shall attend the following conference calls via phone/video:

Task 3.1 – Bi-weekly Status Meeting Conference Call The MRAC shall arrange and facilitate a conference/video call meeting to occur twice a month with the MRAC COR/ACOR, BFLs and other CPI staff as deemed necessary. The MRAC shall collaborate with the MRAC COR/ACOR regarding the meeting time and agenda. All key personnel shall participate in the calls. The MRAC shall provide a summary of the previous activities and provide comments relating to procedural matters and policy clarifications.

The MRAC shall prepare the agenda and take meeting minutes for each meeting. The agenda shall be submitted to the MRAC COR/ACOR within two business day prior to the meeting. The meeting minutes shall be distributed to the MRAC COR/ACOR and BFLs within two business days after the meeting for review and approval.

Task 3.2 – MR Manager’s Conference Call The appropriate key personnel shall participate in this conference/video calls hosted by CPI on a monthly basis. Meeting appointments and times will be sent to the MRAC upon award of this contract.

Task 3.3 – Medicare Part A/B and Durable Medical Equipment (DME) Collaboration Conference Calls The MRAC shall participate in the Medicare Part A/B Collaboration, Medicare Part A/B Inter Reliability Rate (IRR), DME Collaboration and DME IRR conference calls unless otherwise directed by the MRAC COR/ACOR. Appropriate key personnel shall attend these meetings. These conference calls occur four to six times per year. Conference call information will be provided after contract award.

Task 3.4 – CPI Annual PI Meeting The MRAC shall participate by attending as directed by the MRAC COR/ACOR. The meeting is anticipated to be held annually via videoconference. Appropriate key personnel shall participate.

Task 3.5 – DME Coordination (DCM) Spring/Fall Bi-Annual Meeting The MRAC shall participate by attending as directed by the MRAC COR/ACOR. The meeting is anticipated to be held bi-annually via videoconference. Appropriate key personnel shall participate.

Task 3.6 – Ad hoc Conference Calls and/or Meetings The MRAC shall participate in ad hoc conference calls and/or meetings related to MR processes or procedures and FWA as directed by MRAC COR/ACOR. Appropriate key personnel shall participate.

Task 4 – Accuracy Medical Review Process for the Standard and PI Workload

General Requirements MR for the purpose of making coverage determinations shall be performed by RNs or physicians licensed to practice Nursing/medicine in the United States and have not been sanctioned by the licensing board . During the review, the nurse and physician reviewers may call upon other health care professionals (e.g., dieticians, therapists, or physician specialists) for advice. Services reviewed by other licensed health care professionals shall be within their scope of practice and the project-specific medical review strategy shall support the need for their specialized expertise in the review of a particular claim type (i.e., speech therapy claim, physical therapy). MR for the purpose of reviewing accurate coding determinations shall be performed by certified professional coders or clinicians with approved coding credentials. The contractor must employ clinical personnel that possess critical thinking skills that can be applied when rendering clinical review judgment based on their clinical expertise and must maintain references to support medical review determinations such as CFRs, IOMs, NCDs/LCDs, State Medicaid statutes, regulations and manuals as applicable for the specific MRC and claim type selected for review.

The purpose of the MR process is to measure the accuracy rate for each MRC by medically reviewing a representative sample of claims that each MRC has previously reviewed. The claim reviews require, at a minimum, the use of clinical review judgment in the evaluation of medical records and related documents to determine whether the MRCs made accurate claim decisions in compliance with Medicare and/or Medi-Medi coverage, coding, payment, billing policies, CFRs, and NCDs/LCDs. For PI reviews, the MRAC shall determine whether the investigation/claims contain patterns and/or trends which may support an allegation of potential FWA.

CMS/CPI is operationalizing the RACDW for the Standard workload and the UCM for the PI workload to be the MR system of record for the MRCs and the MRAC. Until the MR capabilities are operational in both systems, the MRAC shall assist CPI during the development process. Assisting can be defined as creating and uploading testing claims data, disagreement/rebuttals/dispute reports, medical records, claim selection files, attend video conference calls, provide comments on templates, testing the various MR processes as directed by the MRAC COR/ACOR until both systems are operational. The appropriate MRAC staff shall complete the necessary forms/training to obtain access to the RACDW and the UCM systems.

Task 4.1 – Standard Medical Accuracy Reviews for MACs, SMRC, and RRB SMAC The details as to how and what the MRCs will provide for the universe/claims to the MRAC is provided on the JOAs. In general terms, each Standard MRC emails/uploads the universe of claims that were medically reviewed in the prior month via a CPI approved electronic format or via the RACDW (when operational) by the 20th calendar day of the month. The MRAC has five business days to randomly select a representative number of claims (based on the universe) for review and send their claim selections to the MRC POCs via email/RACDW. The MRC has seven business days to gather and upload the associated medical records and related documents/screen prints to MRAC’s SFTP server or via the RACDW (when operational). At any time during this process, the MRAC shall notify the MRC POC, the MRAC COR/ACOR and BFLs if they do not receive the requested information from the MRCs within the specified timeframes.

Upon receipt of the medical records and related documents, the MRAC shall acknowledge receipt via email and complete the medical review within 20 business days unless otherwise specified by the MRAC COR/ACOR (i.e., an assigned special study.) At any time during the review, the MRAC shall send a request for additional information (RFI) to the MRC if there’s information that was missing, not included as required by the JOA or if the MRAC requires clarification from the MRC. The MRAC can establish the number of days of when the MRC needs to provide the RFI documentation.

The MRAC’s claim review shall:

· Determine if the MRCs made accurate MR claim decisions in compliance with Medicare and Medicaid’s coverage, coding, payment, and billing policies.

· Measure the accuracy rate for each MRC by medically reviewing a representative sample of claims that each MRC has previously reviewed.

· Review the specific claim line(s)/purpose as reviewed by the MRCs to determine whether the MRC’s payment decision was correct. If the claim was a full or partial denial, the MRAC shall review the MRC’s reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided.

Within five business days after the review is completed, the MRAC shall report their review decisions where they disagreed with the MRC’s payment decision or rationale by using the Accuracy Review Disagreement Worksheet(s) as per Task 5.1. If the claim was a full or partial denial, the MRAC shall review the MRC reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided.

The Accuracy Review Disagreement Worksheet (s) shall be sent to the MRC’ POCs, encrypted via email, or another format as designated by the MRAC COR, or uploaded to the MRAC’s SFTP server or to the RACDW (when operational). The email shall inform the MRC of the total number of claims reviewed, the number of agree claims, their accuracy rate (based on the review results) and the timelines to submit a rebuttal if the MRC disagrees with the MRAC rationale included on the Accuracy Review Disagreement Worksheets. The MRAC COR/BFLs shall be included in the email.

The MRC has five business days, from the day they receive the Accuracy Review Disagreement Worksheet(s) from the MRAC to submit a rebuttal to the MRAC. The MRAC has seven business days from receipt of the rebuttal to complete the review. If more time is required, the MRC/MRAC shall submit a request for extension with justification to the MRAC COR/BFLs for approval.

If the MRAC upholds its original review decision, the MRC can request a dispute review with CMS via email. The applicable MRAC BFL will contact the MRAC to request the medical records/documentation associated to the disputed claim(s). The MRAC will send/upload the requested documentation via an approved format/system designated by the MRAC COR. Once a final determination is made, CMS will notify the MRC’s POC, the MRAC’s POC and corresponding BFLs via email/CMS MR system.

Task 4.2 – PI Medical Accuracy Reviews for UPICs, SMRC PI and SMRC HFPP The details as to how and what the MRCs will provide for the universe/claims to the MRAC is provided on the JOAs. In general terms, each PI MRC emails/uploads the universe of claims that were medically reviewed in the prior month via a CPI approved electronic format or via UCM (when operational) within five business days of the start of each month. The MRAC has five business days to randomly select a representative number of investigations/claims (based on the universe) for review and send their claim selections to the MRC’ POCs via email/UCM. The MRC has seven business days to gather and upload the associated medical records and related documents/screen prints to MRAC’s SFTP server or UCM (when operational). At any time during this process, the MRAC shall notify the MRC POC, the MRAC COR/ACOR and BFLs if they do not receive the requested information from the MRCs within the specified timeframes.

Upon receipt of the medical records and related documents, the MRAC shall acknowledge receipt via email and complete the medical review within 20 business days unless otherwise specified by the MRAC COR i.e., an assigned special study. At any time during the review, the MRAC shall send a RFI to the MRC if there’s information that was missing, not included as required by the JOA or if the MRAC requires clarification from the MRC. The MRAC can establish the number of days of when the MRC needs to provide the RFI documentation.

The MRAC’s claim review shall:

· Determine if the MRCs made accurate MR claim decisions in compliance with Medicare and Medicaid’s coverage, coding, payment, and billing policies.

· Measure the accuracy rate for each MRC based on the number of claims reviewed.

· Review the specific claim line(s)/purpose as reviewed by the MRCs to determine whether the MRC’s payment decision was correct. If the claim was a full or partial denial, the MRAC shall review the MRC’s reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided.

· Evaluate the entire investigation as a whole for FWA patterns and/or trends, which may support an allegation of potential FWA, such as:

· Evidence of alteration,

· Obliterated sections,

· Missing pages,

· Inserted pages,

· Use of white out, and

· Excessive late entries.

Within five business days after the review is completed, the MRAC shall report their review decisions where they disagreed with the MRC’s payment decision or rationale by using the Accuracy Review Disagreement Worksheet(s) as per Task 5.1 If the claim was a full or partial denial, the MRAC shall review the MRC reviewer’s rationale and error type and subtype to determine if the correct rationale and error type was provided. If the MRAC identifies patterns and/or trends which may support an allegation of potential FWA during the claim review for any of the PI MRCs that was not recognized and/or documented, the MRAC will document it as a pass or fail finding in the review summary.

The Accuracy Review Disagreement worksheet(s) shall be sent to the MRC’ POCs, encrypted via email or another format as designated by the MRAC COR or uploaded to the MRAC’s SFTP server or to the UCM (when operational). The email shall inform the MRC the total number of claims reviewed, the number of agree claims, their accuracy rate (based on the review results) and the timelines to submit a rebuttal if the MRC disagrees with the MRAC’s rationale included on the Accuracy Review Disagreement Worksheet(s). The MRAC COR/BFLs shall be included in the email.

The MRC has five business days, from the day they receive the Accuracy Review Disagreement Worksheet(s) from the MRAC to submit a rebuttal to the MRAC. The MRAC has seven business days from receipt of the rebuttal to complete the review. If more time is required, the MRC/MRAC shall submit a request for extension with justification to the MRAC COR/BFLs for approval.

If the MRAC upholds its original review decision, the MRC can request a dispute review with CMS via email. The applicable MRAC BFL will contact the MRAC to request the medical records/documentation associated to the disputed claim(s). The MRAC will send/upload the requested documentation via an approved format/system designated by the MRAC COR. Once a final determination is made, CMS will notify the MRC’s POC, the MRAC’s POC and corresponding BFLs via email/CMS MR system.

Task 5 – Accuracy Review Worksheet(s)

Task 5.1. The Accuracy Review Disagreement Worksheet When the MRAC disagrees with the MRC’s payment decision on a claim or rationale and for PI MRC’s only, identifies unaddressed patterns/trends which may support an allegation of potential FWA, the MRAC shall complete an Accuracy Review Disagreement Worksheet for each individual reviewed claim as follows:

· For full agreements, the MRAC does not have to report agree claim results except for Task 5.2, and otherwise directed by MRAC COR/BFLs;

· For partial agreements, the MRAC shall include a rationale/observation for each claim decision;

· For full and partial disagreements, the MRAC shall include the disagreement rationale and indicate the correct determination;

· Disagreements with payment decisions affect the MRC’s accuracy rate.

· Disagreements with rationale does not affect the MRC’s accuracy rate.

· For PI claims only, for those claims where the MRAC identifies additional potential FWA patterns/trends that were not reported by the UPIC, they shall be reported as pass or fail.

The Accuracy Review Disagreement worksheet(s) shall include all the regulatory/manual citations current for the period during which the service being billed to support the MRAC’s denial rationale. Upon completion of accuracy reviews, the MRAC shall send, via an approved format designated by CMS (i.e., encrypted email or other CMS system), the Accuracy Review Disagreement Worksheet(s) to the MRC’s POC, the MRAC COR/ACOR and BFLs within five business days.

Task 5.2 The Accuracy Review Agreement Worksheets The Accuracy Review Agreement worksheets shall ONLY apply to the following subtasks:

Task 5.2.1 The MAC Award Fee Agreed Claims Monthly, from the MAC Award Fee claims selected for review where the MRAC agreed fully with the MAC’s decision, the MRAC shall randomly select five MAC Award Fee agreed claims and report the MRAC’s relevant review determinations/observations on the Accuracy Review Agreement Worksheets. The five Accuracy review agreement worksheets along with the associated medical record documentation shall be uploaded to the MRAC SFTP server/RACDW (when available). The MRAC shall notify the MRAC Standard workload BFLs and MRAC COR via email when the documentation is uploaded.

Task 5.2.2. The Prior Authorization Requests (PARs) Monthly, from each prior authorization project, the MRAC shall randomly select five Prior Authorization Requests (PARs) for review where the MRAC fully agreed with the MAC’s decision. The MRAC shall note relevant review determinations/observations on the Accuracy Review Agreement Worksheets. The agreed worksheets, along with the associated medical record documentation shall be uploaded to the MRAC SFTP server/RACDW (when available). The MRAC shall notify the CMS’ PAR POC, the MRAC Standard workload BFLs and MRAC COR via email when the documentation is uploaded.

Task 6 –Reports The MRAC shall comply with the following reporting requirements. Each report shall be submitted to the MRAC COR/ACOR and BFLs via email.

Task 6.1 – End of Contract Year Annual Report The MRAC shall submit a cumulative report of the accuracy rates for the MRCs. The MRAC shall submit this report to the MRAC COR/ACOR and BFLs within 15 business days before the end of the period of performance. The report, at a minimum, shall include the following:

· An attestation that coverage/medical necessity determinations for the Standard and PI MR are made by RNs or therapists and that coding determinations are made by certified coders or clinicians with approved coding credentials in 100 percent of the reviews

· Overall accuracy rates for each MRC

· Narrative section with information about patterns of inappropriate denials and documentation of observations made during the accuracy medical review of the MRC’s claims

· Total number of claims reviewed per MRC

· Total number of agrees and disagrees per MRC

· For PI, the total number of claims where the MRAC identified patterns and/trends which may support an allegation of potential FWA

· Total number of Accuracy Review worksheets sent to the MRCs, MRAC COR/ACOR/BFLs

· Total number of rebuttals sent to the MRCs, MRAC COR/ACOR/BFLs

· Comments to CPI regarding policy issues based on trends identified during the reviews

Task 6.2– End of Fiscal Year Report – Standard Workload Only Starting in Option Year 1, the MRAC shall submit a cumulative report from data collected by current fiscal year (Oct. 1, 202X – Sept. 30, 202X). The MRAC shall submit this report to the COR/ACOR and BFLs within seven business days after the end of the FY. The report, at a minimum, shall include the following data elements:

· The FY cumulative total number of claims reviewed for each MACs, SMRC and RRB SMAC

· The FY cumulative total number of claims reviewed for each program type, i.e., TPE, PARs, RBB, etc.

· The FY cumulative accuracy rate (average in percentage) for each MACs, SMRC and RRB SMAC,

· The FY cumulative total number of disagreements for each MAC, SMRC and RRB SMAC

· The FY cumulative total number of disagreements that were disputed by each MAC, SMRC and RRB SMAC

· The FY cumulative total number of disputes that were overturned as a result of new information provided by the MAC/SMRC/RRB SMAC or after CMS review for each MAC/SMRC/RRB SMAC.

Task 6.3 – Monthly Cost Report The MRAC shall submit monthly workload reports outlining all work accomplished during the previous month by task including any cost. The workload numbers shall be reconciled with the monthly invoice submitted for payment for each task. In addition to required contractual responsibilities for invoicing, the MRAC shall provide detailed documentation to support invoice payment, which shall include but not limited to:

· All incurred costs and invoices including current and cumulative budget and status to date for the period of contract performance

· All contract tasks related travel invoices and receipts including current and cumulative budgetary status to date for the period of contract performance

· The percentage of work completed for each task in this SOW, by period of contract performance

· The number of rebuttals received and completed

· All data based on the month the claims were received for review. Therefore, each monthly report will display all work completed in prior months. For example, the April monthly report would show claims received in February and March but completed in April. The report shall also show the remaining claims to be completed by month. For example, the April report would show that there are still five claims to be reviewed for February and 20 for March at the end of April.

Task 6.4 – Monthly Workload Tracker Report In order to keep track of the MRAC’s workload (sampled, reviewed, in process and completed) the MRAC, at a minimum, shall track the following:

· Total number of claims sampled by month

· Total number of claims reviewed by month

· Number of claims that were not reviewed, if any

· Total number of claims “in review process”

· Total number of disagreements sent to the MRC

· The number of rebuttals received and completed

· The number of claims that were carried over and completed during the report month

· The number of claims that were carried over but were not completed during the report month

· The numbers should be separated for the Standard and PI side

· For the standard workload, the numbers should be reported by program type i.e., TPE, PAR, etc.

The report will display all work completed within the month’s prior billing. For example, the April monthly report would show claims received in February and March but completed in April. The report shall also show the remaining claims to be completed by month. For example, the April report would show that there are still five claims to be reviewed for February and 20 for March at the end of April.

Task 7—Annual Performance Evaluation The MRAC shall participate in an annual performance evaluation to be completed by the MRAC COR/ACOR with input from the BFLs. The evaluation will be conducted at the end of each year of performance. The objective of the performance evaluation is to provide a systematic, quality assurance approach for monitoring and/or evaluating the requirements and standards set forth in the SOW. Effective use of the performance evaluation, along with the MRAC’s QC/QA program, will help to ensure that the MRAC performs in accordance with all of the requirements set forth in the contract documents and that the Government receives the quality of services called for in the contract therefore paying only for acceptable levels of services and products received. The evaluation will be conducted for MRAC’s performance purposes only and documented in the Contractor Performance Assessment and Reporting System (CPARS) at the end of each period of performance.

The evaluation may include all of the SOW requirements. With CPI approval, the MRAC COR/ACOR, and the BFLs may conduct the end of year performance evaluation as a desk review and/or site visit to the contractor’s primary office location.

Task 7.1. Standard – Performance Metrics

· The MRAC shall document the rationale for each full and partial disagreement and include the basis for it in 100 percent of the reviews.

· MR decisions are consistent with CFRs, NCDs/LCDs, statutory coverage, and sound clinical judgment in 100 percent of the reviews.

· MR decisions include reference to CFR, IOMs, NCDs, and LCDs in 100 percent of the reviews.

· CPI will concur with a representative sample of MRAC accuracy review disagreements in 95 percent of the reviews.

Task 7.2. PI – Performance Metrics

· The MRAC shall document the rationale for each full and partial disagreement and include the basis for it in 100 percent of the reviews.

· The MRAC shall considered all allegations identified in the complaint/investigation that could be validated through the review of medical records in 100 percent of the reviews.

· MR decisions are consistent with CFRs, IOMs, NCDs, LCDs, statutory coverage, and sound clinical judgment in 100 percent of the reviews.

· MR decisions include reference to CFR, IOMs, NCDs, LCDs and Medicaid statutes and manuals, in 100 percent of the reviews.

· The MRAC shall evaluate and document potential FWA patterns and/or trends that exists in the medical record and those that were not addressed by the UPIC in 100 percent of the reviews.

· Medicaid MR decisions shall take into consideration state protocols and/or Medicaid guidelines when required by the…