DRAFT PWS _FEHB.pdf

DRAFT

Performance Work Statement

Federal Employee Health Benefit (FEHB) Medical Review

General Information:

The Office of Personnel Management’s (OPM) Federal Employees Healthcare Insurance (FEHI) program administers the Federal Employees Health Benefits (FEHB) and the Postal Service Health Benefits (PSHB), for Federal employees, retirees, fire protection personnel, employees of Federally recognized Indian tribes, tribal organizations, and urban Indian organizations (tribal employer), and their eligible family members. FEHI is responsible for resolving disputed health insurance claims between members and their health insurance carrier. Two types of health insurance plans participate in the FEHB and the PSHB Programs: Fee-for-Service (FFS) and Health Maintenance Organizations (HMO) plans. The FEHB administers many healthcare insurance groups. Such as, all FFS contracts to include but not limited to Blue Cross and Blue Shield Service Benefit contract; as well as experience rated HMO plan contracts; and community rated HMO plan contracts.

Each health plan under the FEHI Program contracts with OPM to provide certain health benefits to all members enrolled in its participating plan. Under the terms of the contract, members are entitled to pursue claims disputes by following a formal dispute resolution process described in the plan’s brochure. After giving the plan the opportunity to reconsider its decision, members may request OPM to review the plan’s denial of benefits or benefit limitation. In some cases, because of the complexity of the medical issue/condition involved, it is necessary to obtain an external medical review advisory opinion from a medical consultant before OPM makes a final decision on the claim. Health Insurance 1 is responsible for monitoring the medical review services contract. Nurse consultants determine the medical specialty category and the appropriate medical specialist. The contractor is required to provide an expert opinion by medical specialists appropriate to the disputed claim under review.

The FEHI Medical Review contract will be an indefinite-delivery/indefinite-quantity contract with CLINs based on firm-fixed-prices. All arrangements with the Contractor for services under this contract after award will be made by FEHI Nurse Consultants through the Contracting Officer (CO) and/or the Contracting Officer’s Representative (COR). The CO will designate the COR at the time of contract award. Specific tasks under this contract will be accomplished by work orders (work orders are equivalent to a “task-order contract” as defined in Federal Acquisition Regulation (FAR) 16.501-1) issued by the COR, to be performed at the Contractor’s facility. The COR will provide to the Contractor in writing, a description of each specific proposed task to be performed under the contract, for example, review of disputed health benefits medical and dental claims, consultation services, or special projects.

OPM reserves the right to approve/disapprove any individual assigned by the Contractor to work on any individual medical and dental review case. No additional effort, changes in scope of work, or changes in return due dates will be undertaken on an individual work order without the explicit authorization of the CO and/or COR.

Scope of Work:

The contractor will provide medical and dental health benefits reviews of disputed claims and preservice requests (prior approval and precertification), consultation services, and special projects. OPM will determine the medical specialist category for each disputed claim and the Contractor will assign a medical specialist (Coding Specialist, M.D., D.O., D.D.S., or D.M.D.)

appropriate for each disputed claim. The medical specialist will review the available case documentation for different categories of disputed medical services and will provide the Government a typewritten review analyses resulting from the evaluation of the case file in addition to a paper or electronic copy of all references cited in support of the analyses.

The names of medical reviewers will remain confidential and will not be disclosed to external persons except in legal cases. The various categories of disputed medical services and issues requiring an advisory medical analysis include:

Correct Coding of Services This category involves accuracy of services billed using CPT, DSM, HCPCS, and ADA codes.

Medical, Mental Health, and Substance Use Disorders This category involves questions of whether the diagnosis and/or treatment rendered were for a medical, mental, or substance use condition. This decision generally determines the level of benefit reimbursement.

Durable Medical Equipment Under this category the medical specialist will review available medical information (e.g., statements of medical necessity from the patient's physician, medical records, etc.) and determine if the type of equipment meets the definition of covered durable medical equipment as defined in the plan’s brochure. Any specific definition of durable medical equipment will be provided to the contractor at the time of the review.

Cosmetic/Reconstructive Procedures This category involves reviewing medical records and determining if the procedure was primarily for cosmetic purposes or reconstructive surgery required to correct a functional defect, a congenital anomaly, or to restore/correct a part of the body that was altered because of accidental injury, disease, or surgery. Any specific definition for cosmetic or reconstructive surgery will be provided at the time of the review.

Medical Necessity Questions of medical necessity, as defined in the plan’s brochure, generally involve such issues as an in-patient setting, services of an assistant surgeon, and outpatient services (e.g., diagnostic studies, speech, occupational and physical therapy). The information that the contractor must review will vary according to the type of service in dispute. Issues may also include determination of medical necessity for a member's request for prior approval for a drug treatment or other type of service (e.g., durable medical equipment). We will provide the Contractor the specific definition of “medical necessity” at the time of review.

Dental Services The consultant will review medical and dental information generally involving such issues as whether teeth were sound natural teeth prior to the rendering of dental services for the repair of an accidental injury, periodontal, orthodontic, and oral and maxillofacial surgery benefit determinations.

Maintenance Therapy The consultant will review medical information to determine if the continuation of a rehabilitative therapy or pain management is maintenance therapy.

Custodial Care The consultant will review medical information, such as statements of medical necessity, physical therapy notes, nurses’ notes, etc., and determine if the care was primarily custodial, as defined in the plan’s brochure, or the patient's condition required skilled nursing or an acute level of care. We will provide any specific definition of custodial care at the time of the review.

Experimental/Investigational Since many Health Benefits Plans (Plan) exclude benefits for services and supplies that are experimental or investigational, as defined in the plan’s brochure, the Contractor will review technology evaluation criteria, including review of medical journals, research studies, patient’s medical records, statements from physicians and recognized experts and provide a review analysis.

In some cases, prior to completing the specialist opinion, the Contractor may need to contact agencies such as the National Institutes of Health, National Cancer Institute, Food and Drug Administration, and/or other federal agencies, professional organizations, or field experts.

Surgery - Questions in this general category could entail accuracy of CPT coding, surgery complexity, necessity of an assistant surgeon, hospital versus an outpatient setting, etc. The Contractor will review the provider’s surgery claim form, operative report, patient records, and statements from attending physician(s), and any other supporting information. We will provide any specific definition of experimental/investigational at the time of the review.

Emergency Treatment A Consultant may be asked to review hospital emergency room records and other documents, to determine if services were associated with emergency care. We will provide the Consultant the specific definition of “medical emergency” at the time of the review. Some HMO type Plans do not provide benefits for services rendered outside the HMO network, except for medical emergencies as defined in the plan's brochure.

HMO Issues An analysis on whether an HMO’s decision to deny benefits for services rendered outside of the HMO’s network is justified based on review of the clinical information.

Other Issues:

Other health benefits services that require an advisory medical review analysis from the Contractor such as air ambulance, inpatient hospitalization, and Skilled Nursing Facility.

To ensure the integrity of the Federal Government Systems and in accordance with Executive Order 14028 ‘Improving the Nations’ Cybersecurity’, beginning the first quarter of 2024, each contractor employee accessing government system(s) will require specific instructions and potentially equipment to comply with the Multi-Factor Authentication (MFA) requirements before gaining access to any Government system. The contractor will be responsible for purchasing these devices. Questions related to this shall be sent to either the Contracting Officer (CO) or the COR.

Types of Reviews:

First time review Medical or dental review and coding specialist cases that the Contractor has not previously reviewed.

Cases requiring additional information Medical, dental, or coding specialist case review which results in the need for additional clinical information to complete a medical review analysis, the Contractor has determined that additional clinical information is necessary. The Contractor will notify the COR in writing of the information required and will return the case file. Once the requested documents are received, the COR will issue a revised work order reflecting the case review rate (case re-review for additional information) as established in the contract.

Re-review for new clinical evidence Previous cases reviewed by medical, dental, or coding specialist under the Contractor. This applies to cases which received additional information from the enrollee, the COR is requesting another review by the same medical, dental, or coding specialist who conducted the initial case review. The COR will issue a revised work order reflecting the case review rate (case re-review for additional information) as established in the contract.

Re-review for new question(s) New questions for the Medical, dental, or coding specialist that were previously reviewed by the contractor. Upon assessment of the physician or coding reviewer report, the COR is requesting another review by the same medical, dental, or coding specialist who conducted the initial case review to address revised or additional questions. The COR will issue a revised work order reflecting the case review rate (case re-review for new questions) as established in the contract.

Other assigned work For consultation services and special projects, and the services of coding specialists, the work order issued by the COR, after agreement between both parties, will designate the maximum number of hours allowed for the Contractor to complete the work reflecting the hourly consultation/case review rate as established in the contract.

Panel review for any of the above noted types of review and consultation services and special projects OPM may request a panel of two or three reviewers of identical or varied medical specialties who can provide separate simultaneous medical advisory opinions for a disputed claim or consultation request.

Consultant Qualifications The contractor’s medical physician staff and coding specialists performing the work must comply with the following minimum requirements:

Education Coding specialists must have nationally accepted credentials/certifications.

The medical physician staff must have a degree in Doctor of Medicine, Doctor of Osteopathic medicine, Doctor of Dental Surgery, or Doctor of Dental Medicine from an accredited university.

Licensure The medical physician staff must be licensed to practice medicine in a state in the United States of America, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands. A list of all medical doctors who will perform the services, under this contract, must be provided and include at a minimum the medical doctor’s name, specialty/sub-specialty, and professional license renewal certification number, state(s) of issue, and dates of renewal and expiration (for each specialty/subspecialty). Failure to maintain a valid license, free of sanctions, will result in termination of the contract or be reason to disallow exercising an option to extend the term of the contract. The Government will not approve any medical doctor assigned by the Contractor to provide professional services under this contract to work on any Government work whose:

(1) license to provide health care services is revoked or suspended by any State licensing authority, pursuant to adequate due process procedures, for reasons bearing on professional competence, professional conduct, or financial integrity; or

(2) Until a final determination is made, has surrendered such a license while formal disciplinary proceedings involving professional conduct are pending. The parties agree that any exclusion, debarment, or suspensions as mentioned above is cause for the Government to terminate the contract and/or not to exercise the option to extend the term of the contract.

(3) The contract includes clause 1752.209-74, that addresses Organizational Conflicts of Interest (July 2005). The IRO must conduct conflicts of interest screening upon credentialing/recredentialing its physicians and at case recruitment. When cases are assigned by the IRO to a Medical Specialist, the nurse is notified in the FDC system and acknowledges the IRO assignment. Once the Medical Specialist assigned reviewed the member’s file for the Plan the Nurse will request the IRO select a new reviewer.

Both parties recognize that the Government will, when deemed appropriate and necessary and without notice to the Contractor, review the status of the Contractor’s medical staff credentials for the purpose of monitoring any license or program participation restrictions and/or sanctions.

Medical specialties and sub-specialties – The Contractor’s medical staff providing services under this contract will be board certified and represent all medical specialties and sub-specialties recognized by the American Board of Medical Specialists and American Dental Association.

Proficiency in the English Language The Contractor’s medical staff must be capable of providing an acceptable, understandable, typewritten document addressing the issue(s) relative to the work order under review.

Government Furnished Property/Information Government furnished property/information, if applicable, will be identified and provided in individual work orders.

Place of Performance All services will be performed at the Contractor’s facility or other work location managed by the Contractor.

Time of Performance Services will be provided at any time as so designated by the Contractor. However, the Contractor personnel will be available during the hours of 8:15 A.M. – 4:45 P.M., Eastern Standard Time, Monday through Friday, or in accordance with a schedule agreed to by both parties, for communication via telephonic, an established electronic transmission method, electronic mail and/or facsimile methods. When services are requested by the COR, the Contractor will perform the services. In the event the Contractor is unable or unavailable to provide services specified by the Government for a period exceeding one (1) day, without justifiable cause and appropriate notification, this may be cause for termination of the contract for default. Failure of the Contractor to return documentation within the specified time limit, without prior notification, may result in payment reduction for the product by 75% per day the product is past due and may result in termination of the contract.

Transmission of Work Orders Medical review and consultation work orders will be forwarded to the Contractor via a secure electronic transmission method, or overnight mail. Medical case and consultation documents will be forwarded to the Contractor primarily Tuesday through Friday. However, the Contractor will acknowledge receipt of daily work orders submitted by OPM. Cases requiring expedited/priority review will either be forwarded via the secure FEHB Disputed Claims (FDC) system, secure email or sent overnight mail to the Contractor’s office. Completed work orders (medical review analyses and disputed claim case files) will be returned via file manager/ FDC system, secure email, or overnight mail to OPM by the Contractor within seven (7) business days after the date of receipt of work orders from OPM. For cases requiring expedited/priority review, the Contractor will return the advisory medical analysis per an established electronic transmission method, file manager/FDC or overnight mail within three (3) business days after the date of receipt from OPM, and the original analysis and case file via overnight mail. For consultation services or special projects, the COR and Contractor will decide on a reasonable work order pickup and return time. If requested by OPM, the Contractor will submit a paper copy or PDF of all cited references to OPM by the Contractor within one (1) to two (2) business days after OPM receives a completed work order from the Contractor. OPM will have five (5) working days from receipt of the Contractor’s completed work order to review and accept all work products. The Contractor will use OPM’s designated mail account or federal government system (to be provided at time of contract award) to ship completed cases back to OPM.

Deliverables Each work order will specify the deliverable product (medical review analysis, consultation services, special projects), its due date, and payment rate as specified in the contract. For consultation services and special projects, and the services of coding specialists, the work order will designate the number of hours estimated to do the work. The Government will have five business days to review and accept all work products after receipt of the Contractor’s completed case analysis, consultation services, or special projects. Teleconferences are scheduled by the Contractor to review monthly and quarterly reports and document meetings.

Medical Review Analysis For medical and dental claims reviews the COR or designated OPM Nurse will provide individual case files with appropriate supporting documentation to the Contractor. Each case will include the Legal Administrative specialist's (LAS) written medical inquiry fully describing the medical issue for which a review analysis is being sought, relevant information/medical records concerning the member's prior approval request or disputed claim, and specific Health Plan definitions and benefits.

If the Contractor’s case review results in the need for additional clinical information to be submitted by OPM, the Contractor will identify the specific information needed and return the case to the COR. If the requested additional clinical information is received by OPM, the case is returned to the Contractor for re-review by the same medical specialist who conducted the initial review. A typewritten, free of grammatical errors, medical review report addressing the issue relative to the dispute, must include a list of medical records reviewed, reviewers’ assessment of records, summary of review determination, relevant current medical literature cited, reviewers’ summary, analysis and findings, thorough response to questions submitted on OPM’s inquiry.

All reports must be signed by the consultant and the consultant’s qualifications must be listed.

The contractor will return all review responses to OPM via secure email no later than 4:30 P.M., Eastern Standard Time, on the date due. The contractor must be able to complete expedited/priority reviews within three (3) business days and standard case reviews within seven

(7) business days from receipt of the case file. The contractor must have the ability to deliver the product electronically, and in accordance with Executive Order 14028 ‘Improving the Nations’ Cybersecurity’. The contractor must be compliant with HIPPA requirements.

Consultation Services The contractor’s Medical Director must be available as an expert witness or in person to discuss advisory opinions via teleconferences or in person ad hoc when legal suits are addressed with OPM on cases reviewed while under the approved contract. For written reports, each report will accurately reflect the current nationally accepted standards of the clinical practice, provide credible medical/scientific literature and clinical practice guidelines cited to support the determinations. The contractor and COR will decide on a reasonable work order pickup and return time for consultation services.

Special Projects Special project written reports will accurately reflect the current nationally accepted standards of clinical practice credible medical/scientific literature and clinical practice guidelines cited to support determinations. The contractor and COR will decide on a reasonable work order pickup and return time for special projects.

Quality Control Reports The contractor is expected to complete Quality Control Reports that reflect the efforts of the Quality Review Team for each medical/dental case and consultation service/special project and presents the statistics and actions specific to the following parameters; individual medical specialist activity for OPM to include number of cases reviewed by category (routine or expedited/priority), number of cases rejected for quality issues or timeliness issues and corrective action taken for all rejected cases and timeliness issues. The contractor must provide monthly reports and quarterly reports.

Quality Assurance Surveillance Plan The below Quality Assurance Surveillance Plan (QASP) will apply to the overall contract inclusive of individual work orders to be issued per the Performance Work Statement (PWS).