DRAFT Performance Work Statement Third Party Billing RFIV07092026.docx

Consolidated Patient Account Center (CPAC) Third Party Billing Consolidated Patient Account Center (CPAC) Revenue Operations (RO) Performance Work Statement (PWS)

1. SCOPE

The Contractor shall provide all labor and equipment required for generation of Veteran Affairs (VA) and Non-VA outpatient claims to third party healthcare insurance carriers for CPAC sites nationwide.

2. BACKGROUND

The Department of Veterans Affairs (VA) has historically relied on contract services to improve collections through timely and accurate billing of third-party claims. VA’s CPACs are responsible for billing and collecting from insurance companies for medical treatment provided to veterans for Non-Service Connected (NSC) conditions.

2.1. There are 7 regional CPACs located as follows:

Station 730, Asheville, NC- Mid-Atlantic CPAC (MACPAC) Station 731, Smyrna, TN- Mid-South CPAC (MSCPAC) Station 732, Middleton, WI- North Central CPAC (NCCPAC) Station 733, Orlando, FL- Florida Caribbean CPAC (FCCPAC) Station 734, Lebanon, PA- Northeast CPAC (NECPAC) Station 735, Leavenworth, KS- Central Plains CPAC (CPCPAC) Station 736, Las Vegas, NV- West CPAC (WCPAC)

2.2 The Department of Veterans Affairs (VA) is currently undergoing a reorganization that may result in future changes to its organizational structure, processes, responsibilities, and priorities. Such changes could affect the customers, services, or support described in this Performance Work Statement (PWS). Accordingly, the Contractor shall remain adaptable and responsive to evolving VA requirements and work in close coordination with the Government to assess and implement necessary adjustments, as needed. Any resulting changes will be completed by bilateral contract modification.

2.3 Public Law 99-272 grants VA authority to seek reimbursement from third party health insurers for the cost of medical care furnished to an insured non-service connected (NSC) veteran. Public Law 101-508 expanded VA's recovery program by providing authorities to seek reimbursement from third party payers for the cost of medical care provided to ensure service-connected veterans treated for their NSC conditions.

3. OBJECTIVES

The primary objective of this Performance Work Statement (PWS) is to outline the medical billing services for VA Care and VA Care in the Community to generate accurate and timely third-party claims for CPAC sites nationwide.

4. TASKS AND DELIVERABLES

Contractors shall provide services to establish and authorize outpatient medical claims to third party insurance carriers in the VA Veterans Health Information Systems and Technology Architecture (VistA) information system or the most current system in accordance with VA established guidelines. Please be aware, VISTA is a Disk Operating System (DOS) based system, minimum expectation is to manually process 16-25 for VA Care claims, and approximately 12-18 Community Care claims per hour per biller. Our legacy VA systems do not interface with modern Graphical User Interface billing software. Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. Timely completion: Medical claims will be completed by the last calendar day of the month that patient service encounters are assigned. Contractor and employees of contractor cannot utilize VA proprietary tools, such as MACROS or automation tools while performing work.

4.1 Deliverable – Authorization and release of outpatient medical claims Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. The estimated timeframe to complete one claim is approximately 3 minutes.

4.1.1 Timely completion of outpatient medical claims: Medical claims are generated within the month they are received from CPAC

4.1.2 Billing Accuracy: Medical claims are authorized and released in accordance with CPAC guidebooks and VA policy and directives

4.1.3 Work claims rejections: Rejected claims will have an initial review within 5 business days, with follow-up every 15 days.

4.1.4 Accurate canceling claims and assigning correct Reason Not Billable (RNB): Claims are appropriately canceled in VistA or most current system and correct RNB is assigned in Claims Tracking

4.1.5 Resolving billing related questions and concerns: Open lines of communication are always maintained between Contractor and CPAC

4.1.6 Conference call participation: Contractor participates in conference calls, as needed, to improve billing performance

4.1.7 Maintain VistA access (or current system): Contractor shall log onto the VistA system for each CPAC Medical Center at least once every 14 days to maintain this access. If an individual worker does not log on to our systems for a length of 30 days or more, their access must be reset. Resetting access is a time consuming process on our end. For this reason, the company must ensure that all workers log in at least once every 14 days.

4.1.8 Confidentiality: Contractor shall ensure all claims are released in compliance with VA specific requirements.

4.2 Deliverable – Authorization and release of outpatient medical claims tasks for VA Care in the Community Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. The estimated timeframe to complete one claim is approximately 4 minutes.

4.2.1 Timely completion of outpatient medical claims: Medical claims are generated within the month they are received from CPAC

4.2.2 Billing Accuracy: Medical claims are authorized and released in accordance with CPAC guidebooks and VA policy and directives

4.2.3 Work claims rejections/denials: Rejected/denied claims will have an initial review within 5 business days, with follow-up every 15 days.

4.2.4 Accurate canceling claims: Claims are appropriately canceled in VistA or most current system

4.2.5 Assigning correct activity code: Encounters are assigned appropriate activity code.

4.2.6 Resolving billing related questions and concerns: Open lines of communication are always maintained between Contractor and CPAC

4.2.7 Conference call participation: Contractor participates in conference calls, as needed, to improve billing performance

4.2.8 Maintain VistA access and Huron access (or current system): Contractor shall log onto the VistA system for each CPAC Medical Center and Huron at least once every 14 days to maintain access

4.2.9 Confidentiality: Contractor shall ensure all claims are released in compliance with VA specific requirements

4.3 Deliverable: Monthly Itemized Statement – Not Separately Priced

4.3.1 The Contractor shall provide an itemized statement monthly to CPAC(s) Billing Manager and COR, outlining the claims processed and any access problems/issues encountered in the performance of this task. Monthly reports (by the fifth day of each month) on the billing activity shall include, but are not limited to:

4.3.1.1 Summary of quantity of claims processed per facility per reporting period, and cumulative for entire contract to date.

4.3.1.2 Number of claims authorized per biller

4.3.1.3 Unit price and total cost of claims authorized

4.3.1.4 Number of claims canceled

4.3.1.5 Unit price and total cost of claims canceled (for deduction)

4.3.1.6 Number of claims per CPAC broke down per biller and per VAMC

4.4 Deliverable - Monthly Staffing Report – Not Separately Priced The Contractor shall develop and submit a Monthly Staffing Report to CPAC(s) Billing Manager and COR (due by the fifth day of each month). The report should include the name of staff hired for performance under this contract. The report should also include staff no longer working under this contract. The report shall include an anticipated start date or termination date and assigned primary CPAC facility.

4.4.1 Electronic copies shall be delivered using Microsoft 365 Office suite of tools, unless otherwise specified by the COR. Electronic submission shall be made via email, unless otherwise agreed to by the COR.

4.4.2 Contractor must distribute policy, procedures, and regulations released by Medicare, and CMS, on a monthly basis, as applicable. Training on policy, procedures, and regulation releases shall be provided to staff. Tracked updates and training provided to staff shall be included in the monthly staffing report.

4.5 Deliverable - Weekly Pending Workload Report – Not Separately Priced The Contractor shall develop and submit a Weekly Pending Workload Report to CPAC(s) Billing Manager and COR (due by the Monday of each week). The report should include facility, received date, remaining encounters for VA Care and Community Care.

4.5.1 Electronic copies shall be delivered using Microsoft 365 Office suite of tools, unless otherwise specified by the COR. Electronic submission shall be made via email, unless otherwise agreed to by the COR.

5. FORMAL ACCEPTANCE OR REJECTION OF DELIVERABLES

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 Contracting Officer Representative (COR) will have the right to reject or require correction of any deficiencies found in the deliverables. In the event of a rejected deliverable, the Contractor shall be notified in writing by the COR of the specific reasons for rejection. The Contractor shall have five (5) workdays to correct the rejected deliverable and return it per delivery instructions. If for any reason any deliverable cannot be delivered within the scheduled timeframe, the Contractor is required to explain why in writing to the COR by the delivery due date, including a firm commitment of when work shall be completed. This notice to the COR shall cite the reasons for the delay, and the impact on the overall project. The COR will forward the notice and reasons for the delay to the CO with comments. The CO will then review the facts and issue a response, in accordance with applicable regulations. The Contracting Officer’s Representative (COR) for the Contract is a government official who has been delegated specific technical, functional and oversight responsibilities for this contract. The COR is designated in the COR appointment letter, issued by the Contracting Officer, and is responsible for inspection and acceptance of all services and documents.

5.1 Acceptance Criteria

Certification by the Government of satisfactory services provided is contingent upon the Contractor performing in accordance with the performance standards contained in the Performance Requirements Summary Matrix (Section 12.3.1) and all terms and conditions of this contract including all modifications.

5.2 Government Acceptance Period

The COR will have ten (10) business days to review draft deliverables and make comments. The Contractor shall have five (5) business days to make corrections. Upon receipt of the final deliverables, the COR will have two (2) business days for final review prior to acceptance or providing documented reasons for non-acceptance. Should the Government fail to complete the review within the review period the Deliverable will become acceptable by default, unless prior to the expiration of the ten (10) business days the Government notifies the Contractor in writing to the contrary. The final submission should be deemed approved if the Government has not rejected it in thirty (30) calendar days.

6. COMMUNICATION REGARDING BILLING ISSUES

Direct communication regarding billing issues should be addressed to the Billing Manager or Supervisor. Names and contact information will be provided after the award.

7. PERFORMANCE DETAILS

7.1 Indefinite Delivery Indefinite Quantity (IDIQ) Period of Performance: Sixty (60) month ordering period.

7.2 Period of Performance and quantities will be established for each Task Order

7.3 There are eleven (11) Federal holidays set by law (U.S.C. Title 5 Section 6103):

Under current definitions, five are set by date:

If any of the above falls on a Saturday, then Friday shall be observed as a holiday. Similarly, if one falls on a Sunday, then Monday shall be observed as a holiday.

The other six are set by a day of the week and month:

7.4 Place of Performance

The physical location of performance of work activity will be the responsibility of the Contractor. No space will be provided by the CPAC. Contractors shall provide a remote and secure business setting for healthcare billing. Patient confidentiality and database security must be always maintained.

7.5 Hours of Operation

The normal operating hours for the Federal Government are Monday – Friday, 8:00am – 4:30pm local area time. VA and CPAC employees must be able to communicate with the Contractor’s key personnel from 8:30 am to 5:00 pm ET during all federal workdays.

8 OTHER TERMS, CONDITIONS, AND PROVISIONS

8.1 Non-billable

If an outpatient medical care encounter is determined to be not billable the Contractor shall cancel the claim and/or enter a reason not billable (RNB) in the Veteran Health Information Systems and Technology (VistA), Web VistA Integration Reporting and Revenue (Web VIRR), or most current system Integrated Billing Software Package at no charge to the VA. VA estimates 10% of daily workload will be determined not billable

8.2 Non-Disclosure/Non-Use Agreement

Contractor shall ensure that each contracted employee completes a Non-Disclosure Statement before performing any work. The Non-Disclosure / Non-Use statement shall be cosigned by a corporate official (Contractor Task Manager or higher) and sent to the COR.

9 INFORMATION ASSURANCE

9.1 General Security Requirements

The Contractor shall establish appropriate administrative, technical, and physical safeguards to protect any and all Government data, to ensure the confidentiality, integrity, and availability of government data. As a minimum, this shall include provisions for personnel security, electronic security, and physical security as listed in the sections that follow.

9.2 Health Insurance Portability and Accountability Act (HIPAA) The Contractor shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P.L. 104-191) requirements, specifically the administrative simplification provisions of the law and the associated rules and regulations published by the Secretary, Health and Human Services (HHS). This includes the Standards for Electronic Transactions, the Standards for Privacy of Individually Identifiable Health Information and the Security Standards. It is expected that the contractor shall comply with all HIPAA-related rules and regulations as they are published (including identifiers for providers, employers, health plans, and individuals, and standards for claims attachment transactions).

10 PROTECTION of INFORMATION

10.1 Dissemination of Information/Publishing

There shall be no dissemination or publication, except within and between the Contractor and any subcontractors. This includes VA Guidebooks, Standard Operating Procedures (SOPs), job aids, and other tools to support billing third-party payers, as well as insurance policy information or third-party payer agreements retained by VA. VA approval for publication will require provisions which protect the intellectual property and patent rights of both VA and the Contractor.

10.2 Personally Identifiable Information (PII) and Protected Health Information (PHI) Contractors collecting, storing, or disseminating personal identifiable information (PII) or protected health information (PHI) data must conform to all pertinent regulations, laws, and VA directives related to privacy. Contractors must provide access for VA privacy reviews and assessments and provide appropriate documentation as directed.

11 CONTRACTOR EMPLOYEES

11.1 Key Personnel

Skilled experience in managing insurance billing office with similar volumes and work projected in this PWS. These “Key personnel” whose positions are identified in Sections 11.7.2 and 11.7.3 are the individuals whose resumes were submitted and marked by the vendor as “Key Personnel”. The Contracting Officer (CO) may notify the Contractor and request immediate removal of any personnel assigned to the contract by the Contractor that are deemed to have a conflict of interest with the government or if the performance is deemed to be unsatisfactory. The reason for the removal will be documented, and replacement personnel shall be identified within three business days of the notification. Employment and staffing difficulties shall not be justification for failure to meet established schedules. Company must maintain adequate staffing numbers to meet the workload volume goal throughout the term of the contract; there may be increases or decreases in workload. 30% of employees shall be permanent non-CPAC employees.

11.2 Substitution of Key Personnel

All Contractor requests for approval of substitutions hereunder shall be submitted in writing to the COR and the Contracting Officer at least thirty (30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the Contracting Officer necessary to approve or disapprove the proposed substitution. New personnel shall not commence work until all necessary security requirements, as defined in Sections 13, have been fulfilled and resumes provided and accepted. The COR and the Contracting Officer will evaluate such requests and promptly notify the Contractor of approval or disapproval in writing.

11.3 Management and Oversight

The Contractor shall be responsible for managing and overseeing the activities of all Contractor and subcontractor personnel, used in performance of this effort. The Contractor’s management responsibilities shall include all activities necessary to ensure the accomplishment of timely and effective support, performed in accordance with the requirements contained in the performance work statement.

11.4 Domain Knowledge

The Contractors shall present domain knowledge of outpatient healthcare third party billing. Proposed personnel shall have an in-depth knowledge of health care revenue third party billing in the following areas:

· Knowledge and experience in authorizing claims to third party carriers for outpatient services.

· Knowledge of and ability to apply third party insurance and Medicare guidelines to claims.

11.5 Training

The VA will train the contractor’s key personnel including managers and supervisors on VA VISTA and related applications and will provide applicable training policies and procedures for medical billing. Contractors shall then train their staff. The initial training of key personnel takes approximately three weeks. More training details will be available in the Task Order Performance Work Statements (PWS).

11.6 Staff Qualifications

11.6.1 General Experience: Contractor personnel assigned to this contract shall have expertise in performing outpatient medical billing.

11.6.2 Manager:

Comprehensive knowledge of the principles, practices, laws, rules, and regulations related to billing for healthcare services and the submission of healthcare claims. Provides management oversight, guidance, corrective measures, and direction for monitoring activities designed to ensure the integrity and accuracy of healthcare claims. The Incumbent serves as CPAC’s expert technical authority on matters relating to VHA’s Consolidated Billing departments and the interface with process drivers at the medical centers for which the individual CPAC supports. Exercises management responsibility for complex billing activities for all the facilities assigned to the CPAC. Implement and manage all aspects of billing activities for CPAC clients and a wide range of stakeholders. Manager must have minimum 5 years of outpatient third party medical billing claims submissions experience. Additional experience preferred in supporting Durable Medical Equipment (DME) and Dental, customer service, and work claim rejections. Manager should have demonstrated 2-3 years in a management role.

11.6.3 Supervisor:

Incumbent serves as Billing Supervisor responsible for the timely and accurate preparation and submission of claims for healthcare services, equipment, and/or medication. The Supervisor makes assignments based on the complexity of healthcare services, procedures, equipment, etc., provided, stabling deadlines and quality requirements. Comprehensive knowledge of framework of regulatory material regarding healthcare billing such as Medicare, TRICARE, and CHAMPVA guidelines, Sharing Agreements, Worker’s Compensation, appropriate Public Laws, HIPPA rules and regulations. Knowledge of coding of diseases and procedures using ICD-10, CPT, and HCPCS coding systems. Supervisor must have minimum 3 years of outpatient third party medical billing claims submissions. Additional experience preferred in supporting Durable Medical Equipment (DME) and Dental, customer service, and work claim rejections. Supervisor should have demonstrated 1-2 years in a supervisor role.

12. QUALITY ASSURANCE

12.1 Contractor Quality Assurance

The contractor shall complete monthly internal quality reviews of completed work by each individual biller. Expectation of 95% or better as described in 12.3.1 Performance Requirements Summary Matrix.

12.2 Government Quality Assurance

The VA Quality Assurance will perform quarterly independent quality reviews (QR) on individual billers. Results will be provided to the contractor, and any remedies needed shall be completed within 10 days.

12.3 Quality Assurance Surveillance Plan (QASP)

In addition to independent quality reviews by the CPAC Revenue Operations program, the Government intends to utilize a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the Contractor’s performance. The oversight provided for the QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input for the Contractor Performance Assessment Reporting system. The QASP will be finalized immediately following the award and a copy provided to the Contractor afterward. The QASP is a living document and may be updated by the Government as necessary.

12.3.1 Performance Requirements Summary Matrix

By monitoring the Contractor, the COR will determine whether the performance levels set forth in the order have been attained. Performance standards are specified in the following Performance Requirements Summary Matrix in the Standard and Acceptable Quality Level columns.

100% of contractor billing leadership attend conference call.

Validated attendance lists

100% of contractor billing leadership attend conference call.

Validated attendance lists