ESBD_370759_1722625043991_HHS0015278 - RFI_SUR Claims Review Management and Tracking System.pdf

RFI HHS0015278 1

CECILE E. YOUNG, Executive Commissioner

Request for Information (RFI) for

Surveillance Utilization Review (SUR) Claims Review Management and Tracking System

RFI No. HHS0015278

Date of Release: August 2, 2024

Responses Due by: August 28, 2024, by 10:30 a.m. Central Time

NIGP Class/Item Codes

Class/ Item Code AIS Description

208-11* Yes Application Software, (Not Otherwise Classified), Microcomputer

920-07* Yes Applications Software for Microcomputer Systems: Business, Mathematical and Statistical, Medical, Scientific, etc.

920-39* Yes Processing System Services, Data (Not Otherwise Classified)

952-15 No Case Management

*The State of Texas has marked certain codes for information technology and related commodities and services as Automated Information System (AIS).

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Table of Contents

1. INTRODUCTION

1.1 AGENCY LIABILITY

1.2 OBJECTIVE/ PURPOSE

1.3 BACKGROUND

1.4 SUR PROGRAM OVERVIEW

1.4.1 NURSE FACILITY UTILIZATION REVIEW

1.4.2 HOSPITAL UTILIZATION REVIEW

1.4.3 ACUTE CARE SURVEILLANCE

1.4.4 NON-CLINICAL PROGRAM SUPPORT

1.5 CURRENT SYSTEMS

1.6 STATUTORY AUTHORITY

2. GENERAL INSTRUCTIONS AND RESPONSE REQUIREMENTS

2.1 REQUIREMENTS

2.2 QUESTIONS

2.2.1 CLAIMS REVIEW MANAGEMENT SOLUTION

2.2.2 SERVICES

2.2.3 ADVANCEMENTS

2.2.4 PROJECT DEVELOPMENT AND COMPANY QUALIFICATIONS

2.3 PRESENTATIONS/DISCUSSIONS

2.4 GENERAL INFORMATION

2.5 RESPONSE SUBMISSION, DATE, TIME, AND LOCATION

2.6 DESIGNATED POINT OF CONTACT

2.7 RESPONSE FORMAT

2.8 TEXAS PUBLIC INFORMATION ACT

2.9 DISCLAIMERS

2.10 ACCEPTANCE OF TERMS AND CONDITIONS

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1. INTRODUCTION

The Texas Health and Human Services Commission (HHSC) is the state agency responsible for administration and coordination of health and human service programs in the State of Texas.

HHSC, on behalf of the Office of Inspector General (OIG), seeks information from qualified Respondents regarding a claims review management and tracking system for its SUR unit. This RFI is not a procurement opportunity, and no contract will be developed as a result of the submission of a response.

1.1 AGENCY LIABILITY

HHSC is requesting written responses from qualified Respondents with experience providing design, development, and implementation of claims review management and tracking software solutions (the “Services”).

This RFI is issued solely for information-gathering and planning purposes and does not constitute a Request for Proposal (RFP), Request for Offer (RFO), Invitation for Bid (IFB) or any other solicitation, nor does it constitute a commitment on the part of HHSC to issue any solicitation for any of the services described herein. Those Respondents choosing to respond to this RFI will, merely by virtue of submitting a response, NOT be deemed to be “bidders” in any sense, and no such respondent will have any preference, special designation, advantage or disadvantage whatsoever in any subsequent procurement process related to this RFI.

HHSC will not pay for information submitted in response to this RFI, nor will it compensate a Respondent for any costs incurred in the development/furnishing of a response. It is the responsibility of the potential respondent to monitor the Electronic State Business Daily (ESBD) for additional information pertaining to this RFI.

1.2 OBJECTIVE/ PURPOSE

The SUR unit conducts retrospective claim and medical reviews in various health and human services programs, including acute care, hospital, and nursing facility utilization. In fiscal year 2023, SUR reviewed 23,457 hospital claims, 264 acute care cases, and performed 412 nursing home reviews, bringing in $18,012,570.00 in recoveries.

Currently, OIG UR activities are supported by multiple applications across different data platforms. These systems have limited functionality and cannot be integrated, complicating reporting and limiting data analysis.

The high-level goals of this RFI are:

A. Discover best-in-class claims review management and tracking solutions that will centralize all SUR activities into one (1) platform.

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B. Discover solutions that will increase operational efficiencies and promote innovation and prioritization of UR activities.

1.3 BACKGROUND

The OIG's mission, as prescribed by statute, is the "prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of these services.” SUR contributes to the mission by conducting utilization review (UR) of paid claims and encounters for inpatient hospital stays, nursing facilities, and acute care services.

1.4 SUR PROGRAM OVERVIEW

The OIG SUR program is composed of 70 nurses, coders, program specialists, and administrative support staff that comprise five teams:

A. Nursing Facility Utilization Reviews;

B. Hospital Utilization Reviews;

C. Acute Care Surveillance

D. Non-Clinical Support

E. Lock-In (not included in the scope of this RFI)

1.4.1 NURSE FACILITY UTILIZATION REVIEW

Nurses perform retrospective onsite and desk reviews of nursing facility records to evaluate whether:

A. Facilities correctly assessed and documented residents’ needs;

B. Medicaid reimbursements were appropriate for the level of care provided; and

C. Care provided was medically necessary.

1.4.2 HOSPITAL UTILIZATION REVIEW

Nurses perform retrospective utilization reviews of paid inpatient hospital claims for services provided to Medicaid recipients to assess:

A. Medical necessity for inpatient care;

B. Appropriateness of the Diagnosis Related Group (DRG) assignment, including consistency with federal coding guidelines; and https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm#531.102

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C. Quality of care provided during the inpatient stay.

1.4.3 ACUTE CARE SURVEILLANCE

A team of registered nurses:

A. Perform acute care claims reviews initiated by independent data queries, analysis, and receipt of referrals;

B. Conduct medical record reviews for special projects and initiatives in collaboration with OIG Fraud Analytics and Data Operations; and

C. Provide support to other OIG divisions when clinical expertise is needed for an investigation, audit, or inspection activity.

1.4.4 NON-CLINICAL PROGRAM SUPPORT

SUR solutions team support clinical staff via operational functions and project management, including process improvements, report and template development, and research.

Regional administrative assistants support regional management and staff by initiating and maintaining processes for Hospital Utilization Review (HUR) and Nursing Facility Utilization Review (NFUR) reviews.

1.5 CURRENT SYSTEMS

The SUR team’s current activities are supported by multiple applications on several data platforms, including the Medicaid Fraud and Abuse Detection System (MFADS), which is supported by the Texas Medicaid and Healthcare Partnership (TMHP), and Microsoft SharePoint.

The 70 users on the SUR team currently use MFADS and SharePoint applications for the following:

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Application Description MFADS SURProfiler+ SURProfiler+ is an integrated query, reporting, and analysis system which aggregates information from the MFADS Data Warehouse into a data mart for SUR sampling.

Creates specialized reports on groupings of peers (similar providers or clients) and case types (service groups) to perform comparison and exception ranking reporting of services. These reports provide service-based statistics and peer comparisons to identify areas of risk. Nurse managers use these risk determinations to identify cases for review, which are then assigned to the SUR nurse reviewers in the Program Integrity Case Tracker (PICT) system for processing.

MFADS PICT PICT is a centralized web-based application built using the Microsoft.net framework technology with a table-driven design.

A case management system used to monitor and track the progress of OIG activities and recoupment, and store case notes, documentation, correspondence, claims details spreadsheets, and other information. This system cannot track the progress and status of claims reviews.

PICT has interfaces to Provider Enrollment Management System (PEMS), MFADS Data Warehouse, and Business Objects.

MFADS Business Objects SAP BusinessObjects (BO) Web Intelligence is a business intelligence platform that accesses MFADS claims repository data warehouse and allows SUR staff to develop customized reports from PICT case management activities, ACS, HUR (Client and Quality) and NFUR reviews and recoveries.

BO provides a drag-and-drop interface so users can create, update, schedule, and export reports.

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Application Description MFADS HUR Microsoft Access Database – Remote Desktop Client that interfaces with a centralized HUR repository database and Business Objects.

Provides workflow and documentation management functionality to support HUR Fee for Service (FFS) inpatient claims review activities.

Facilitates automatic generation of hospital notices and contains detailed claims data that can be used to track the progress of claims reviews as well as outcomes for analysis to inform future work.

MFADS HUR Quality Microsoft Access Database – Remote Desktop Client that interfaces with centralized HUR repository database and Business Objects.

Provides workflow and documentation management functionality to support HUR FFS claims quality reviews. It possesses similar functionality to the MFADS HUR system.

MFADS NFUR The NFUR portal is a web-based application that is considered part of MFADS, but it is developed, administered, and managed by HHSC IT.

Provides workflow and documentation management functionality to support NFUR activities. Houses Minimum Data Set (MDS) assessments selected for review.

The separate NFUR modules are web-based applications that allow users to look up vendors by region; see vendor reviews;

view previous owners by vendor; view and modify override addresses; and print available notification letters.

SharePoint HUR Managed Care Provides limited workflow and management functionality in

SharePoint to support HUR managed care claims review activities.

1.6 STATUTORY AUTHORITY

HHSC is authorized to engage with Respondents through this RFI under Texas Government Code Section 2155.090(b). HHSC will conduct this RFI and engage with the Respondent community in accordance with the Health and Human Services (HHS) Vendor Interaction

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Policy, available on the HHS website at the following URL: HHS Vendor Interaction Policy (texas.gov).

2. GENERAL INSTRUCTIONS AND RESPONSE REQUIREMENTS

Respondents should respond in writing to this RFI explaining how they meet the requirements in Section 2.1 (Requirements) and questions/prompts outlined in Section 2.2 (Questions).

2.1 REQUIREMENTS

A. Ability to pull samples of provider claim/MCO encounter data based on desired criteria that can be customized by staff.

B. Ability to sort and categorize samples by program, funding source, provider type, geographic area, risk criteria, etc.

C. Ability to display, track, analyze, and report detailed real-time individual review progress, status, and outcomes. A review can be a claim, a provider, and/or an MDS assessment, etc.

D. Timekeeping functionality to track individual user hours spent on reviews.

E. A centralized location for users to access and pull ad-hoc and standard reports of current and historical data. Output must be in a Microsoft Excel compatible format.

F. Ability to store and review PHI information, including medical records, MDS assessments, and other documentation submitted by providers to the OIG.

G. Support for a tiered user base with role designations for varying levels of staff (i.e., nurse reviewers, supervisors, data users, etc.).

H. Ability to calculate overpayment amounts based on review findings, including the ability to recalculate nursing facility overpayments based on the Texas HHS-approved Medicaid reimbursement methodology.

I. Ability to customize and amend review criteria fields for acute care, nursing facility, and hospital reviews.

J. Ability to differentiate preliminary data from finalized data and incorporate a mechanism for a super user to review and “finalize” data.

K. Ability to automatically generate provider notices based on review findings.

L. Ability to customize and automatically generate notices and letters requesting records to conduct reviews, notifying providers of overpayments based on review findings, and other correspondence.

https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/vendor-contract-information/vendor-interaction-policy.pdf https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/vendor-contract-information/vendor-interaction-policy.pdf

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M. Updates and changes can be reasonably maintained within HHSC and the OIG.

N. Dedicated ongoing support (as needed).

2.2 QUESTIONS

Respondents shall respond in writing to all of the following questions and/or prompts:

2.2.1 CLAIMS REVIEW MANAGEMENT SOLUTION

A. How would the solution increase operational efficiencies?

B. How would the solution contribute to increasing the accuracy of reporting?

C. What analytics and intelligent features would your solution offer?

2.2.2 SERVICES

A. Describe support services offered, including maintenance, change orders, updates, and troubleshooting.

B. Describe the training and materials that would be offered to SUR staff.

2.2.3 ADVANCEMENTS

A. What advancements in tools and technologies have there been in claims review management software over the last three (3) years?

B. Have there been any significant advancements specific to claims review management solutions for the healthcare domain?

C. Provide insight into projected trends and developments in claims review management software.

2.2.4 PROJECT DEVELOPMENT AND COMPANY QUALIFICATIONS

A. Describe how Respondent determines the level of effort required for a project (e.g., size, scope, time-to-implement, etc.).

B. Provide three examples of successful deployments of similar solutions within the last three (3) years.

2.3 PRESENTATIONS/DISCUSSIONS

HHSC, at its sole discretion, may contact a Respondent after reviewing the information provided in response to the RFI for clarifications, and/or request a demonstration of the Respondent’s potential solution. Any contact or communication by HHSC does not indicate a preference towards a Respondent, constitute an offer of any type, or provide a Respondent an advanced standing on any project related to this RFI or any future solicitation, plan or project.

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HHSC will not accept or respond to telephone calls, e-mails, or questions regarding this RFI.

2.4 GENERAL INFORMATION

This RFI is issued for the purpose of obtaining information on solutions for claims review management services. All interested parties are encouraged to respond to this RFI.

All materials received by HHSC become the property of HHSC and will not be returned to the sender. There will be no acknowledgment by HHSC of receipt of the information. Acceptance of responses to this RFI places no obligation of any kind upon HHSC. Any information or ideas received from a Respondent to the RFI, in any form, may be used by HHSC, without restriction, for any purpose determined by HHSC.

It is not the intent of HHSC to provide answers, but if additional information is issued relating to the RFI, it will be made available on the Electronic State Business Daily (ESBD), located at the following URL: https://www.txsmartbuy.com/esbd.

2.5 RESPONSE SUBMISSION, DATE, TIME, AND LOCATION

Written responses and comments related to this RFI are requested by August 28, 2024, by 10:30 a.m. Central Standard Time. Any response received after this date may not be reviewed by HHSC. Responses must be submitted via e-mail to HHSC’s designated point-of-contact, as identified in Section 2.6 (Designated Point of Contact). A Respondent may not respond via fax or United States mail. Additionally, verbal inquiries by a Respondent will not be accepted.

2.6 DESIGNATED POINT OF CONTACT

HHSC’s official single point-of-contact for this RFI and the delivery point for all responses and correspondence is:

Name: Fernando Garcia, CTCD, CTCM

E-mail Address: Fernando.garcia03@hhs.texas.gov

All communications relating to this RFI must be directed to the HHSC point-of-contact named above. All communications between a Respondent and any other HHSC staff members concerning this RFI are strictly prohibited.

2.7 RESPONSE FORMAT

All responses must be:

A. Clearly legible;

B. Sequentially page-numbered and include the Respondent’s name at the top of each page;

https://www.txsmartbuy.com/esbd mailto:Fernando.garcia03@hhs.texas.gov

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C. Correctly identified with the RFI number and RFI title in either the footer or header of each page;

D. Presented using font type Verdana, font size 12 pt. for normal text and no less than size 10 pt. for tables, graphs, and appendices;

E. Limited to fifteen (15) pages, NOT including attachments and/or reference material;

F. Submitted by Respondent via e-mail;

G. In searchable pdf format; and

H. Submitted without any portion of the submission containing a copyright.

Respondent should submit supporting material, if any, as attachments along with its RFI responses. All proposals become the property of HHSC after submission.

2.8 TEXAS PUBLIC INFORMATION ACT

Responses to this RFI are subject to the Texas Public Information Act (the “PIA”), Texas Government Code Chapter 552, and may be disclosed to the public upon request. Subject to the PIA, a Respondent may protect trade secrets and confidential information from public release. If the Respondent asserts that information provided in the response includes trade secrets or other confidential information, materials containing such information must be clearly marked in large, boldface type and include the words “Confidential” or “Trade Secret” at the top of each page where such designation is applicable. Furthermore, the Respondent must identify the trade secret or confidential information and provide an explanation of why the information is excepted from public disclosure on a separate document that Respondent will attach to its RFI response.

Marking information as “Confidential” or “Trade Secret” does not guarantee or ensure that the Texas Attorney General will except such information from public disclosure under the PIA.

HHSC shall have no liability to any Respondent for complying with the PIA.

HHSC will strictly adhere to the requirements of the PIA regarding the disclosure of public information. Respondents should consult the Texas Attorney General’s website (www.oag.state.tx.us) for information concerning the PIA’s procedures and application to proprietary information and potential exceptions to public disclosure that may be available to the Respondent.

2.9 DISCLAIMERS

Responding to this RFI is not a condition for eligibility to respond to any subsequent solicitation.

A Respondent that submits a response to this RFI may also submit a bid in response to any future solicitation for similar services.

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Responses to this RFI will not have any bearing, positive or negative, on the evaluation and respondent selection resulting from any proposals that may be received in response to any subsequent solicitation. By issuing this RFI and receiving responses, HHSC does not commit to issue a future solicitation regarding the subject matter of this RFI. HHSC may, at its sole discretion, withdraw or cancel this RFI at any time.

2.10 ACCEPTANCE OF TERMS AND CONDITIONS

By submitting a response to this RFI, Respondent indicates its agreement with the terms and conditions contained in this RFI. If a Respondent does not agree to the terms and conditions in this RFI, the Respondent should not submit a response.

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