Attachment_J.1-SOW_REVISED_082813_(2).pdf

MEDICARE PART A PROVIDER APPEALS (MPAPA)

STATEMENT OF WORK

08/28/13

1. SCOPE

The MPAPA contractor shall perform national coordination of Provider Reimbursement

Review Board [PRRB] appeal functions, intermediary hearing officer appeal functions, and provide other support as needed. The MPAPA contractor will be expected to coordinate

Medicare Part A Cost Report individual and group appeals before the PRRB. Key functions entail effectively managing the appeal workload and cooperatively working with the

Medicare Administrative Contractors [MAC] to process provider appeal requests. Required activities include, but are not limited to, preparing and reviewing jurisdictional briefs, reviewing and approving MAC position papers, and communicating with the provider or provider's representative. In addition to preparing for hearings, providing legal staff for hearings, and filing post hearing briefs, the MPAPA contractor will be responsible for preparing and approving appeal resolutions when issues are resolved prior to a hearing.

When necessary, the MPAPA contractor will be required to work with the Office of General

Counsel.

In addition to coordinating the appeals before the PRRB, the MPAPA contractor will be responsible for managing Medicare Part A Cost Report individual appeals before an intermediary hearing officer. Included in this task is the contractor’s responsibility to appoint one or more qualified intermediary hearing officers.

The MPAPA contract is multi-faceted. In addition to overseeing appeals before the PRRB and intermediary hearing officers, the MPAPA contractor will be responsible for performing other tasks as requested by the Centers for Medicare and Medicaid Services [CMS]. When required the contractor will provide assistance to CMS on related projects, such as supporting Provider and Statistical Reimbursement [PS&R] activities and other Medicare cost reporting tasks and initiatives.

A. Background

Appeal Functions

Section 1878 of the Social Security Act established that providers may request and receive a hearing before the PRRB for a cost reporting period for which a provider filed a cost report.

The contractor’s Notice of Program Reimbursement [NPR] is final and binding unless a timely request for a hearing is filed with the PRRB [see 42 CFR §405.1835] or the

Intermediary Hearing Officer [see 42 CFR §405.1811] and a decision is rendered, or unless one of the provisions for reopening in 42 CFR §405.1885 is exercised. Therefore, the NPR is the base determination for appealing a cost report.

Under 42 CFR §405.1835, individual providers may bring an appeal before the PRRB if the amount in controversy is $10,000 or more. Under 42 CFR §405.1811, providers may request an Intermediary hearing if the amount in controversy is at least $1,000 but less than

$10,000. Under 42 CFR §405.1837, providers may request a group appeal of a single issue involving a question of fact or interpretation of law, regulations, or CMS ruling, which is common to all providers in the appeal as long as the aggregate claims in dispute total at least $50,000. Additionally, providers under common ownership or control which have an issue in common must file a group appeal if the amount in controversy is, in the aggregate, $50,000 or more. A request for hearing must be filed with the Intermediary Hearing Office or the PRRB, as appropriate, within 180 calendar days from the date of receipt of the provider of the NPR.

PRRB instructions are located at: http://www.cms.gov/Regulations-and-Guidance/Review-

Boards/PRRBReview/index.html?redirect=/PRRBReview

B. Purpose

The purpose of this task order is to:

Coordinate Medicare Part A Cost Report individual and group appeals before the

PRRB.

Provide a hearing officer and coordinate Medicare Part A Cost Report intermediary appeals before a hearing officer.

Provide other support to CMS as needed.

2. Requirements:

Independently and not as an agent of the Government, the contractor shall furnish all of the necessary services, qualified personnel, material, equipment, and facilities, not otherwise http://www.cms.gov/Regulations-and-Guidance/Review-Boards/PRRBReview/index.html?redirect=/PRRBReview http://www.cms.gov/Regulations-and-Guidance/Review-Boards/PRRBReview/index.html?redirect=/PRRBReview provided by the Government, to perform the requirements of this task order Statement of

Work.

3. Specific Requirements:

Specific tasks to be performed:

Task 1: Appeal Activities – PRRB Individual and Group Appeals

The contractor shall be responsible for processing PRRB individual and group hearing requests until a decision is rendered by the PRRB [through judicial review] or the provider formally requests closure of the case to the PRRB. In accordance with this SOW, Medicare rules and regulations, CMS instructions, and PRRB Instructions, the contractor shall:

1. Ensure pertinent information [including active and closed issues] related to each case has been accurately included in the System Tracking for Audit and

Reimbursement [STAR] by the servicing Medicare Administrative Contractor [MAC] including status updates as changes occur.

a. The contractor shall reconcile STAR with the PRRB database on an annual basis.

2. Maintain an electronic appeal file for each potential appeal.

a. Maintain a separate hearing file electronically for each potential appeal. The file shall include the provider’s appeal request and supporting documentation. In addition, the file shall contain all evidence used in making the determination including but not limited to a copy of the provider’s cost report [applicable pages], related cost report audit or desk review workpapers, the NPR, and correspondence with the provider.

b. Update the file with correspondence from the PRRB and provider upon receipt of such correspondence.

c. Ensure that the appeal file is accurate and current at all times.

3. Review for Jurisdiction.

a. Determine whether each issue in the appeal is jurisdictionally valid

b. Challenge jurisdiction as necessary.

c. Group jurisdiction: Review a MAC’s group jurisdictional decision prior to the

MAC’s submission to the PRRB once the MAC has completed review of Schedule G, Providers in Group.

d. Forward a copy of the jurisdictional decision to the MAC and CMS Contracting officers Representative [COR] within five days of receipt.

e. Establish and maintain an electronic database of PRRB jurisdiction decisions.

The database shall be available to CMS and MACs.

4. Review provider expedited judicial review [EJR] requests and PRRB own motion considerations.

a. Determine whether there are factual or legal matters in dispute that the

PRRB lacks authority to decide.

b. Provide assistance to OGC in the preparation of cases that are expedited to court.

5. Discovery Requests.

a. Respond to provider discovery requests, as necessary.

b. Request discovery from the provider, as necessary.

6. Position Papers

a. Review the provider’s preliminary position paper to gain an understanding of the provider’s dispute.

b. Review the MAC’s preliminary position paper ensuring its response to the provider’s position is accurate. Revise if necessary.

c. Submit the MAC’s preliminary position paper to the provider in accordance with the PRRB established due dates, and submit a copy of the cover page to the PRRB.

d. Prepare the MAC’s final position paper, addressing all unresolved issues.

Submit the MAC’s final position paper to the provider and PRRB in accordance with the PRRB established due dates.

e. Prepare and submit a supplemental position paper, if necessary.

7. Appeal or issue resolution.

a. The contractor shall formally approve or deny all resolutions of issues when the MAC and provider have agreed to the reversal or modification of the adjustment[s] in dispute. This resolution can occur at any phase of the appeals process once the PRRB acknowledges the case.

b. The contractor shall physically attend and assist the MAC during resolution meetings between the MAC, provider, and PRRB, if necessary, as determined by CMS.

8. PRRB Hearings

a. PRRB Prehearing conference

i. The contractor shall participate in the PRRB prehearing conference.

ii. The contractor shall send five additional copies of the MAC’s final position paper to the PRRB by the PRRB’s deadline, notifying the assigned Board Advisor when copies are sent.

b. The contractor shall prepare MAC witnesses to give testimony.

i. The contractor shall pay the expenses for MAC or other witnesses for a PRRB hearing.

c. The contractor shall provide legal representation in defense of the MAC’s position.

i. Perform direct examination of MAC witnesses and cross-examine provider witnesses.

d. The contractor shall submit a post-hearing brief within the PRRB’s timeframe.

e. PRRB Hearing Decisions

i. Forward a copy of the PRRB hearing decision to the MAC and COR within 5 days of receipt.

ii. Evaluate the need to request Administrator Review on PRRB decisions that reverse or modify the contractor’s adjustment or where the

PRRB’s rationale is inconsistent with Medicare policy. Submit a formal request for review as necessary.

iii. Establish and maintain an electronic database of PRRB decisions. The database shall be available to CMS and MACs. The database shall also include Administrator decisions.

iv. Communicate to MACs the implication of major PRRB decisions.

9. Administrator Decisions

a. Forward a copy of an Administrator hearing decision to the MAC and COR within

5 days of receipt.

10. Judicial Review

a. Assist OGC or other governmental counsel in defending the MAC’s position.

b. Provide staff, if necessary, to support OGC or other governmental counsel in defending the MAC’s position.

Task 2: Appeal Activities – Intermediary Appeals

The contractor shall be responsible for processing intermediary hearing requests until a decision is rendered by an intermediary hearing officer [or CMS reviewing official] or the provider formally requests closure of the case to the intermediary hearing officer in accordance with this SOW, Medicare rules and regulations, and CMS instructions as follows:

1. Maintain a separate hearing file electronically for each potential appeal. The file shall include the provider’s appeal request and supporting documentation. In addition, the file shall contain all evidence used in making the determination including but not limited to a copy of the provider’s cost report [applicable pages], related cost report audit or desk review workpapers, the NPR, and correspondence with the provider.

2. Ensure pertinent information [including active and closed issues] related to each case has been accurately included in STAR by the servicing MAC including status updates as changes occur.

3. The contractor shall appoint a hearing officer or officers in accordance with 42 CFR

§405.1817 to conduct intermediary hearings.

4. Review for Jurisdiction

a. The contractor shall determine if the issue[s] in the appeal is jurisdictionally valid.

5. The hearing officer shall issue a decision within 12 months of receipt of the provider’s appeal request.

a. Forward a copy of the intermediary hearing decision to the MAC, provider, CMS

COR and to the CMS Center for Medicare Management within five days of the decision.

6. A provider’s request for review by a CMS reviewing official must be received by the appropriate CMS component no later than 60 days after the date of receipt by the provider of the intermediary hearing officer decision. The CMS reviewing official can review a hearing officer decision based on its own motion. The contractor shall comply with requests from the CMS reviewing official.

Task 3: Other Requirements

1. Participate in bi-weekly meetings with the CMS COR.

2. Contractor staff assigned to work with MACs on appeal activities shall have a minimum of 20 hours Medicare related continuing education training per contract year.

Documentation to support contractor staff continuing education requirements shall be submitted to the contracting officer no later than September 30th of each contract year.

The documentation shall consist of the following:

o List of contractor staff who were responsible for reviewing and/or modifying contractor position papers, reviewing for jurisdiction and/or preparing jurisdictional challenges, reviewing and/or responding to expedited juridical review requests, preparing, reviewing and/or responding to discovery requests, reviewing, approving, or participating in appeal issue resolution, assisting the lead attorney with witness preparation and/or a PRRB hearing.

o Continuing education classes taken by each staff member. Include the title of the class, date and time of class, location of class, course instructor, and continuing education hours.

4. Provide support to CMS on related projects as requested, such as PS&R and other

Medicare cost reporting activities.

5. A listing of PRRB cases scheduled for hearing shall be submitted to the contracting officer by the 1st of each month during the contract year. The listing shall include all cases scheduled for hearing within 60 days from the date of the report. The report shall include the PRRB case number, fiscal year end, provider number and provider name along with identification of each open issue in the case as of the date of the report, and the status of each issue.

6. Have in place at all times a written Quality Control Plan [QC] describing the methods and procedures used to determine if work performed by staff is accurate, complies with

Medicare Rules, Instructions, and Regulations, and provides for review of a work product of each staff member during a contract year.

7. A report summarizing quality control reviews shall be submitted to the contracting officer every 90 days during the base year with the first report being due on January 1, 2014; due dates of subsequent years’ reports will be determined by October 1st of each option year. The report shall include a listing of all quality control reviews completed during the review period including the work product reviewed, name of staff responsible for the work product and the dates work was performed, name of staff who reviewed the work product, date quality control review was completed, and deficiencies noted.

8. Have a written Implementation/Transition Approach and Plan that will be in place at time of award.

Task 4: Project Management

A. Organizational Structure and Key Personnel

1. General Requirements

The ASC shall maintain a staff of key management personnel and qualified and thoroughly trained employees in order to perform the requirements in this SOW.

2. Key Personnel

The ASC shall maintain a staff of key management positions who are fully dedicated as Full Time Equivalents (FTEs). “Fully dedicated” means that the individual for the position shall only work on the ASC contract and may not perform duties on any

Medicare/non-Medicare contractor or commercial line of business without approval by the Contracting Officer. Key personnel shall not serve dual responsibilities in key functions and shall be located onsite at the place of performance at all times.

Changes in key personnel positions shall be submitted to the Contracting Officer in writing for approval prior to any change. Key personnel are as follows:

a. Program Director

The Program Director is responsible for all phases of performance, including contract management, contract cost control, project management, coordination of resource needs, coordination with corporate resources and management, and has direct accountability for the technical accuracy, timeliness and quality of all deliverables. Additionally, although not all inclusive, the Program Director shall:

Have a thorough knowledge of the contract requirements;

Be totally responsible for all operations;

Provide executive direction for the accomplishment of work under the contract;

Have authority for staffing and operations decisions.

Have authority to bind the entity to contract modifications if not performed by a higher position;

Possess the knowledge/skills/ability to plan, conduct, and supervise work to be completed under this contract;

Possess the knowledge/skills/ability to apply new management practices and innovative methods and procedures for managing all aspects of the contract.

Possess Federal Acquisition Regulation (FAR) knowledge including, but not limited to, contractor types, contract changes/modifications, conducting subcontract surveillance, contract administration policies and procedures to sufficiently monitor and maintain uniform management controls over performance.

i. Work Experience

The Program Director shall possess 10 or more years of professional experience with at least 3 years as a senior manager responsible for managing complex systems and work flow.

ii. Education Requirements

The Program Director shall possess a Bachelor’s degree from an accredited institution, plus a Master’s degree from an accredited institution or an equivalent number of credits in business, management, or law or substitution of 4 additional years of relative work experience in lieu of the Master’s degree.

b. Appeals Manager

The ASC Appeals Manager shall be responsible for the following functions:

Oversee all appeals activities;

Interface with various levels of ASC staff to coordinate work flow.

Act as the central point of contact to communicate with the

CMS COR.

Ensure that all operations under his/her supervision meet and are in conformity with accepted principles of reimbursement under the rules and regulations of Title XVIII and within the framework of contractual commitments with CMS.

Ensure that the MACs position regarding cost report appeals is adequately documented and written in accordance with

Medicare law, regulations, manuals, and PRRB Rules.

Maintains the capability of the ASC to complete its assigned objectives within the limits of established policy, regulations and budget.

Ensures that MACs resolution of issues is in accordance with

Medicare law, regulations, and manuals.

i. Education/Work Requirement

The ASC Manager shall meet the following education, experience and skill requirements:

The Manager shall possess a Bachelor’s degree from an accredited institution in business, management, or law;

Exceptional oral and written communications skills;

Knowledge of Medicare law, regulations, manuals, and

PRRB Rules;

Strong leadership, organizational, and planning skills;

Experience in Medicare cost report auditing, settlement and reimbursement [a minimum of 7 years];

Ability to hand multiple and conflicting priorities.

c. Lead Attorney

The ASC shall have on staff a lead attorney. This person shall, among other things:

Possess a Juris-Doctor from an accredited institution;

Passed a bar exam and is licensed to practice law in a US state;

Minimum of 2 years litigation experience;

Knowledge of Medicare law, regulations, manuals, and PRRB

Rules;

Prepare witness[s] for hearing.

3. Non-Key Personnel Labor Category Descriptions

Although not considered key personnel positions, the following labor category personnel shall be required for this SOW.

a. Appeals Supervisor

Job Description:

Performs supervisory reviews on position papers, issue resolution, and jurisdictional challenges;

Ensuring staff completion of assignments;

Directs staff, approves work plans and programs, and ensures that assignments are carried out in a timely basis;

Assist the lead attorney in preparation for hearing.

Possesses excellent communication and technical skills to provide competent customer service to management, CMS, the PRRB, and the provider community. These functions require the highest performance by the incumbent, ensuring that appeals activities meet CMS’ expectations.

Experience/Education:

Demonstrated management skills (planning, organizing, leading, controlling) and demonstrated ability to lead a team;

Experience in Medicare cost report auditing, settlement and reimbursement [a minimum of 5 years];

Knowledge of Medicare law, regulations, manuals, and PRRB

Rules;

The Supervisor shall possess a Bachelor’s degree from an accredited institution in business, management, or law.

b. Appeals Specialists

Job Description:

Reviews appeal requests to determine if the issue[s] are jurisdictionally valid;

o Consult with the MAC should an issue not be jurisdictionally valid;

o Review the MAC’s jurisdictional challenge prior to submission to the PRRB.

Review the MACs determination of “Providers in Group” for group appeals prior to submission to the PRRB to ensure providers included in the group are jurisdictionally valid;

Review provider expedited judicial review requests to determine if

EJR is appropriate for the issue[s];

Assist MACs with responses to provider discovery requests and preparing contractor discovery requests;

Review MAC position papers to ensure the position paper o Adequately addresses the issue[s] under appeal;

o Disputes provider statements that are incorrect;

o Contains necessary exhibits

Submit MAC position papers to the required parties by the PRRB due dates;

Assist the ASC legal attorney in preparation for hearing;

Assist MACs in issue resolution.