E.4_MR_OF_MCOs_Questions_and_Answers.pdf

MEDICAL CLAIMS REVIEW OF MANAGED CARE ORGANIZATIONS - QUESTIONS AND ANSWERS

HHSM-500-2015-RFP-0113

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

Technical Attachment J.1 IV.A.b 3 Please clarify the contractor's responsibility to purchase an Encoder and CMS' expectations of covering that cost.

CMS anticipates this cost will be built into the overall price per claim included with the Offeror’s proposal. As stated in section IV.A of J1 - SOW – Medical Review Contractor, the contractor 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

SOW.

Technical Attachment J.1 IV.A.b 3 Please confirm that CMS expects all of the key personnel called out in Section VI to complete an ICD-10- PM/CMS Train-the-Trainer Certification Program.

CMS expects that the Review Manager, Coding/Claim Review Analyst, and Senior Coding/ Claim Review Analyst will complete the ICD-10-PM/CMS Train-the-trainer Certification Program. CMS has updated the SOW, Section VI to reflect this revision.

Technical Attachment J.1 IV.G 12 How many Cost Audit Contractors (CACs) will the claims review contractor be working with?

CMS is currently in the process of soliciting proposals for the award of audits to Cost Audit Contractors. Therefore, the pool of contractors has not yet been determined. CMS antipates multiple contractors.

Technical Attachment J.1 IV.B.a 6 Will the MRC Contractor be able to recommend the total number of paid claims from which to draw the sample for review?

Per the Statement of Work (SOW), Section IV.B.a, the MRC will be required to sample at least 350 claims. In addition, the MRC must prepare their sampling approach in accordance with the Sampling Guidelines, SOW Appendix C. However, CMS will look to the MRC for feedback regarding sampling approach and extrapolation methodology throughout the contract.

CMS reserves the right to modify the quantity of sampled test items in the option year to this contract. The SOW was updated to reflect this clarification.

General In the RFP MRC is defined as Medical Review Contractor, In the Section J.1 SOW MRC is defined as Medical Record Contractor and in Section J.1.g Appendix G MRC is defined as Medical Review Contractor. What is the definition of MRC?

MRC is defined as Medical Review Contractor. CMS has corrected the error in the Statement of Work.

General Can CMS confirm that the MRC cannot also serve as a Cost Audit Contractor during the same Period of Performance?

The MRC cannot function as both the CAC and MRC during the same Period of Performance (please reference SOW Section IV.A).

General Can Offeror’s submit a proposal to be the MRC and also submit a proposal to be a Cost Audit Contractor for that RFP?

Offerors can submit proposals for both solicitations; however, they cannot be awarded both contracts.

General Can CMS provide a list of all Cost Plans that could be selected to be audited during the Base Year and each Option Year to assist with identifying potential Conflicts of Interest?

CMS has added a list of the entire Cost Plan pool. This will allow Offerors to determine any Conflict of Interest issues for the base year and any option year. Please see Appendix J. Additionally, CMS is providing the final list of cost plans to be reviewed by the MRC during the base year period. Please see Appendix E.

General If the Offeror has a Conflict of Interest with any of the Cost Plans/MCOs that could be selected to be audited, and that Conflict of Interest will not allow the Offeror to serve as the MRC for that Cost Plan/MCO, will that prevent the Offeror from winning the award to serve as the MRC?

Yes, the MRC will potentially audit all cost plans during the base year or option years; therefore, if a conflict of interest exists, this could preclude the Offeror from being awarded the contract, unless the conflict is adequately mitigated. Please reference Appendix J for the complete list of eligible MCOs.

General

Is CMS expecting the Cost Audit Contractor to rely on the Use of a Specialist (the MRC) when issuing the audit report? The Cost Audit Contractor is not involved in engaging the specialist. It would be inappropriate for the Cost Audit Contractor to agree to merely read the Specialist's report solely to describe or repeat the findings, or to take responsibility for all or a portion of any procedures performed by a specialist or the specialist's work product without being in a position to actively plan and supervise the work performed so that the requirements of government auditing standards can be adhered to with regard to the consideration of fraud, abuse and internal control, among other things.

Is CMS expecting the Cost Audit Contractor to take responsibility for all or a portion of any procedures performed by a specialist or the specialist’s work product? Is CMS considering changing the type of attestation report from an examination of Management’s Assertion to Agreed-Upon Procedures?

The Offeror should submit this question in response to the Cost Audit Contractor solicitation.

General Will CMS require that the MRC be capable of performing all audits simultaneously, so that all Cost Audit Contractors are receiving results in the same timeframe?

Yes, CMS expects that all of the MRC’s review will occur within the period of performance (please reference SOW Section IV.C and Appendix H – Overall Review Timeline).

SOW J.1 B - Testing Guidelines

Why isn’t the MRC responsible for all data analysis associated with the reconciled database including removing non-covered services and duplicates? Would it be more uniform for the MRC to perform all data analysis and filtering of reconciled data files for all MCOs selected to be audited?

Per the SOW, Section IV.B, the MRC must verify that analysis for systematic error and non-covered services has been completed by the CAC prior to submitting the reconciled database.

From CMS prior experience auditing cost plans, we have determined this process and division of responsibilities is appropriate and most efficient. Additionally, the CAC may be better equipped to perform the type of analysis required to reconcile the claims database.

SOW J.1

C - Coordination w/MCO Part C, List of Exceptions

8 If the MCO is allowed 60 days to provide medical records when they receive the sample, will the Preliminary List of Exceptions still be due 60 days after the samples are submitted to the MCO?

Per the SOW, Section IV.B.C.c, the Preliminary List of Exceptions is due to CMS and the MCO 60 days after the samples were submitted to the MCO. This is in line with CMS’ expectation that the MRC will review supporting documentation received from the MCO on a rolling basis, i.e. immediately upon receipt, per SOW, Section IV.D.b.

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

SOW J.1

G - Coordination w.

CAC, Part B, Data Requests and Finding Preparation

If the Cost Audit Contractor is to provide a reconciled database of all claims and encounters to the cost report that they receive from the MCO that is being audited, should the MRC remove all non-covered services and duplicates after they receive the reconciled database from the Cost Audit Contractor?

Per the SOW, Section IV.B, the MRC must verify that analysis for systematic error and non-covered services has been completed by the CAC prior to submitting the reconciled database. Per SOW, Section IV.G.b, the MRC should request support of reconciliation from the CAC, and this should be verified prior to sample selection. If non-covered services, duplicates, systematic errors, or other errors of this nature are identified after sample selection, the MRC should make their best effort to identify the exact value of these errors. When this requires additional samples to be selected, the MRC shall notify the COR and confer with CMS on the issue.

Business G Exhibit E1 - Prime Contractor Proposal Checklist

Question states: 2) If a newly formed company, provide name and address of parent companies forming the new entity. 1. Could CMS please define "newly formed." and 2. What if the company is not "newly formed" but has a parent company?

Newly formed is a company that is being created for the purposes of conducting this work. If the company is not considered to be newly formed, question 2 does not need to be filled out.

Business SOW IV.B.a 6

"To assist in future appeals, the Contractor must retain the work papers and the universe used for sample selection for at least 5 years, or until all appeals have been exhausted. The Contractor may contact the servicing auditor to determine if all appeal rights have been exhausted."Will contractor be reimbursed for future appeal support, as requested in the SOW?

Any potential appeal support, as required by the SOW, should be included in the assumptions used to develop the Offeror’s proposal. CMS suggests considering the total population of Cost Plans (Appendix J), as well as the number of Plans to be reviewed in the base year (Appendix E) as a basis for the maximum volume of appeals. Note, CMS cannot anticipate the actual volume of Plans that will appeal Medical Review exceptions.

Business B.2 5 of 76 Is the money allocated for travel in the RFP specifically for the meetings, or for field work indicated in Section G?

Travel should be limited to any fieldwork, and SOW requirements that require the contractor to travel to CMS.

Business

RFP Part III. Section J.1.h Appendix H – Medical Coding Review Steps pg 6 item 8c ii, iii, v, and vi

The text in some of the fields in this file is truncated and the guidance information is not visible. This information may be pertinent to costing. Would CMS please re-issue Appendix H?

CMS has confirmed that no fields are missing from the issued Appendix I – Medical Review Steps. However, minor updates were made to this appendix and the updated version is included with these responses.

Business B.3 6 of 76 Please define the term Fieldwork, as listed in Installment Payment #3

Fieldwork involves traveling to the cost plan under audit to perform the required procedures to obtain sufficient audit/review evidence. CMS does not require fieldwork under this contract; however, if the contractor does perform fieldwork, it must be done prior to the Preliminary List of Exceptions being issued. Upon both of these requirements being completed, the terms of Installment Payment #3 will have been met.

Business L.11 Volume II - Business Proposal Instructions

67 and 71 of 76

According to the instructions, the Business Proposal shall contain the information contained in A, B, C and D on pages 70 & 71 of the RFP. Both sections B and C are asking for the completed Table from Section B.2 of the RFP found on pages 5 & 6. Will CMS please confirm if Agency is requesting that the information contained in Section B.2 of the RFP by included by offerors in both Section B and C of their responses.

The completion of the table in Section B.2 of the RFP should be submitted as part of the contract forms submission requirements in section L.11.C.

Business L.11 Volume II - Business Proposal Instructions

According to the instructions, the Business Proposal shall contain the information contained in A, B, C and D on pages 70 & 71 of the RFP. Section C is asking for signed and dates Standard Form 33 (SF-33) which was not included with the solicitation when the Agency published the opportunity of Fed Biz Opps. Will CMS be providing the SF-33 form(s) directly to the offerors who indicate their intent to submit a proposal or will the SF-33 form(s) be provided on Fed Biz Opps?

Please refer to Amendment 00001.

Business E.3 Business Proposal Spreadsheet

N/A The business proposal template does not appear to include a section where fringe or fee can be included. Please explain where on the business proposal spreadsheet fringe and fee should be included.

The Exhibit E.3 is a template and offeroros should modify the template as necessary to reflect its individual accounting structure.

For example, if the entity charges fringe, it should modify the spreadsheet to identify fringe and apply its calculations. In addition, the template has been modified to include a row for fee.

Business E.3 Business Proposal Spreadsheet

Does FFP per claim include ODCs - indirect labor - appeal support Yes, the Price per Claim should include all contractor direct and indirect costs, including appeal support.

OCI H.1.c.2 23 of 76

"The Medical Review Contractor (MRC) and Cost Audit Contractor (CAC) should not be the same as the entity that certifies or prepares the cost report for the particular cost plan under review/ audit. The MRC and CAC should not be the same contractor. " - Will the agency provide a listing of the current CACs for OCI reference?

CMS is currently in the process of soliciting proposals for the CAC contracts. As such, we cannot provide a listing of CACs that will be in place at time of performance for the MRC contract.

Other L.3.f.1 60 of 76

"(1) The Government intends to award a contract or contracts resulting from this solicitation to the responsible Offeror(s) whose proposal(s) represents the best value after evaluation in accordance with the factors and subfactors in the solicitation." - Please give the scale of evaluation CMS intends to utilize to determine technical competitive range (e.g. Color scale evaluation, point value per section)

IAW FAR 15.304(d) the rating method need not be disclosed in the solicitatoin.

Other Will this be a multiple award IDIQ. If yes, how many awardees does CMS anticipate? This is an ID Requirements to one contractor.

Other Will CMS consider a four(4) week extention on this opportunity, to allow for questions to be answered for accurate bids?

Please refer to Amendment 00002

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

Technical Appendix G 1 Appendix G - Overall Review Timeline - is the "send Data Request and Survey to Plans" - Will CMS please clarify what "to plans" idicates?

The “Plans” referred to in the Overall Review Timeline are the Managed Care Organizations under review (see Appendix J for complete list). Please note, the item referred to in the question is the responsibility of the CAC, and not under the scope of this solicitation.

Technical SOW IV.A.d 4

"The kick-off meeting shall be held no later than 20 calendar days after the contract is awarded. An agenda shall be prepared by the Contractor and submitted to the COR at least 2 business days prior to the kick-off meeting. The kick-off meeting shall include, at a minimum, the following information:

• Discussion of all items from the Schedule of Deliverables and the Contractor’s plan to successfully complete them

• Discussion of expected risks and plan for risk mitigation

• Discussion of the submitted Project Management Plan (see section e below) and of how the plan fulfills all SOW requirements

• Discussion of the Security and Tracking Plan (see section F below)" - Are the PMP and the Security Tracking Plan both due 20 calendar days after award?

Yes, both the Project Management Plan (PMP) and the Security Tracking Plan are due to CMS 20 calendar days after the award (please reference SOW Section IV. A.e and Section IV.A.f).

Technical SOW IV.C.c 8

"The Contractor shall afford the MCO an initial 60 day period to retrieve medical records.

c. List of Exceptions Preliminary List of Exceptions The first phase of medical records review shall be completed 60 days after the samples are submitted to the MCO." - Please clarify that the language shoul state "60 days to complete, upon reciept of the complete records"

The Offeror’s understanding of the SOW is incorrect. The Preliminary List of Exceptions is due to the Plan 60 days after the MRC sends the samples. This is in line with CMS’ expectation that the MRC will review supporting documentation received from the MCO on a rolling basis, i.e. immediately upon receipt, per SOW, Section IV.D.b. Note that this is not a final list of exceptions. The MCO should be provided an additional 30 days to submit documentation and the MRC will have another 30 days after the additional 30 days to complete their review (for a total of 60 following the Preliminary List of Exceptions).

Technical SOW IV.D.b 9 Please confirm the definition of what a "rolling basis" timeline indicates to CMS.

Per SOW, Section IV.D.b, review of support should be performed on a rolling basis, i.e. immediately upon receipt. CMS anticipates this will be necessary for the MRC to meet SOW requirements, and to avoid any backlog developing due to multiple reviews (of various MCOs) occurring concurrently.

Technical SOW IV.F 11

Upon receiving the reconciled claims database from the CAC, the Contractor must prepare sampling plans and submit to CMS within 2 weeks.

• Upon approval of the sampling plan, the Contractor must select samples and send these to the MCO within 10 calendar days. This should generally occur at the same time as the Entrance Conference.

How long does CMS anticipate it will take to approve the sampling plan?

The MRC must prepare the Sampling Plan in accordance with Appendix C to the SOW, and including supplemental stratification details from Appendix D to the SOW. Assuming the sampling parameters required by the SOW are met, and all necessary information is adequately demonstrated, CMS review will not require a protracted amount of time. However, CMS cannot provide an exact time frame. Upon submission of the Sampling Plan, the MRC should discuss review timelines with each servicing auditor to establish expectations of when the MRC will receive feedback.

Technical SOW.IV.K 18

K. Contract End Round Table Discussion At the conclusion of the contract and as the majority of work in completed, CMS will conduct an in-person Round Table Discussion between all contractors. This will be held at the CMS Baltimore offices.

The content of this discussion may vary, but at a minimum, the Contractor may be required to discuss findings from the past year, lessons learned, suggestions to CMS to improve efficiency and coordination among contractors. CMS will notify the Contractor in advance of any materials they must prepare for this discussion. The Contractor shall also expect to present on applicable topics, as notified by CMS. Any presentation materials prepared by the Contractor shall be submitted to the COR at least 5 days prior to the discussion. (Please clarify if the round table will take place at the conclusion of the contract or at the conclusion of each Task Order allowing for the contractor to "discuss findings from the past year".)

The Roundtable discussion will occur at the conclusion of the Base Year and each Option Year (please reference SOW Section V.K.) on the contract (not the task order). The contractor should include any cost associated with the roundtable as part of its price per claim (except for the travel expenses which will be priced from the travel line item). The contractor should expect to travel to CMS at the conclusion of each option year on the base contract to have this “round table” discussion, and costs associated with this should be included in the price per claim, except for the actual travel expenses which will be reimbursed via the travel line item on the task orders.

Technical F.3 10 of 76 "All deliverables shall be submitted via email to the assigned Contracting Officer’s Representative (COR) and/or Servicing Auditor) or as indicated otherwise below." - Can CMS provide the name of the current Servicing Auditor?

Each reviewed cost plan will have a Servicing Auditor assigned. There will also be one COR for the entire contract. The COR will oversee the high level of contractor’s work (i.e. overall priorities, guidance that will impact all reviews), while the Servicing Auditor will interact and oversee the detailed work of the contractor (i.e. reviewing draft reports). CMS will provide the list of Servicing Auditors, along with contact information, upon award of the contract.

Technical F.3 11 of 76 How will the reconciled database be delivered to the winning contractors?

Per the SOW, Section IV.G.a, at the Planning Meeting between the CAC and MRC, the MRC shall provide the CAC with any and all claims database fields that they will require for sample selection. The CAC will incorporate this request into their Document Request to the MCO. The CAC will then reconcile the claims database to the Cost Report. Upon completing these procedures, the CAC will provide the reconciled, clean database, to the MRC. Per SOW, Section IV.G.b, the MRC and CAC shall hold a conference call within 5 days of exchanging the reconciled database to verify the MRC understands the statistical unit and discuss completeness of the reconciliation procedures.

The MRC and CAC will need to agree to logistical aspects of delivering the reconciled database during the Planning meeting.

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

Technical F.3 11 of 76 Within 15 days after the contract award, the Contractor shall work with the COR and each CAC to hold a planning meeting. (Page 12 SOW) - is this one planning meeting with COR and all CACs in attendance or separate meetings

The Contractor will need to hold a separate planning meeting with each CAC, the COR, and the applicable servicing auditors. The MRC will need to schedule separate meetings with each CAC, and invite applicable CORs and Servicing Auditors (please reference SOW Section IV.G.a.). The MRC can discuss any logistical issues that might arise with the COR.

Technical F.3 11 of 76

F. Overall Timing Requirements (Please confirm the agency is referring to Appendix G - Overall Review Timeline) In order to better coordinate with both the CAC and the MCO, the Contractor must adhere to the review timeline as follows, and as described in Appendix H – Overall Review Timeline.

CMS is confirming that Appendix G – Overall Review Timeline is the document referenced in the RFP. The discrepancy has been corrected.

Technical SOW 6, 11

b. Sampling Plan Following the receipt of the reconciled claims database from the CAC, the Contractor shall submit to each Servicing Auditor, the COR, and the CAC a Sampling Plan, specific for each MCO to be reviewed, within 2 weeks. The Sampling Plan must be prepared in accordance with the sampling plan guidance found in Appendix C – MCO Standard Sampling Plan. Along with the Sampling Plan, the contractor shall also submit summary details regarding J.1 Medical Claim Review Contractor (MRC) Statement of Work (SOW) Page 7 stratification. The contractor shall use the first tab (“Universe Statistics”) from the Extrapolation Template (Appendix D) to demonstrate these details. Any revisions to the Sampling Plan must be made within 5 calendar days of receiving CMS guidance. Each Servicing Auditor will be responsible for approving the Sampling Plan for their MCO. (Please clarify - Page 6 of the SOW indicates that the Contractor shall submit to each Servicing Auditor, the COR, and the CAC a Sampling Plan, specific for each MCO to be reviewed, within 2 weeks. However, Page 11 states Upon receiving the reconciled claims database from the CAC, the Contractor must prepare sampling plans and submit to CMS within 2 weeks. - Is the Contractor to send the Sampling plan to CMS first for approval - then make any revisions to the Sampling Plan within 5 calendar days of receiving CMS guidance. Then send the Approved Sampling Plan to the COR, CAC and Servicing Auditor? In addition the SOW states Each Servicing Auditor will be responsible for approving the Sampling Plan for their MCO. When does the Servicing Auditor approve the Sampling Plan? Before the Contractor sends the selected samples to the MCOs?

Upon receipt of the clean, reconciled database, the MRC must submit the Draft Sampling Plan to the COR, Servicing Auditor and the CAC within 2 weeks. CMS may solicit input from the CAC on the Sampling Plan; however, approval and feedback will only be received from the Servicing Auditor. Assuming the sampling parameters required by the SOW are met, and all necessary information is adequately demonstrated, CMS review will not require a protracted amount of time. However, CMS cannot provide an exact time frame. Upon submission of the Sampling Plan, the MRC should discuss review timelines with each servicing auditor to establish expectations of when the MRC will receive feedback.

Technical L.9.(c) 66 of 76 "The technical must be 12 point font and 1 1/2 line spacing." Can tables and charts be in a smaller font provided they are legible?

Section L.9.(c) has been updated to include the following statement, "Charts, graphs, and tables may be no less than 9-point font Times New Roman."

Technical L.9.(c) & L.10.(b) 66-67 L.9.(c) stipulates that resumes are limited to 3 pages each. L.10.(b) stipulates that resumes are limited to 2 pages each. Please clarify.

Section L..9.(c) & L.10.(b) has been updated in the RFP. The resumes are limited to 3 pages each.

Technical L.10.(d) 68-69 In the Past Performance section, is the requirement for simply a listing of contracts with all of the specified information or is CMS also requesting that a narrative be provided summarizing experience and past performance in addition to the requested table/listing.

CMS is requesting that a narrative be provided summarizing experience and past performance in addition to the requested table/listing.

RFP N/A H.1.C.2 24 of 77

The RFP states: "The Medical Review Contractor (MRC) and Cost Audit Contractor (CAC) should not be the same as the entity that certifies or prepares the cost report for the particular cost plan under review/ audit. The MRC and CAC should not be the same contractor." Can the MRC have a subcontractor that is also a CAC?

The MRC shall not have a subcontractor that is also a CAC on the same audit.

SOW 4.A.c. 4

Under Request for Information, CMS references the servicing auditor. This is referenced additional places in the SOW. Please define who the servicing auditor for the MCOs are? It is not the Contractor, the CAC, CMS. Who is it? The financial statement auditor? The cost report certification auditor?

CMS's A-76 contractor? The CMS auditor internally assigned?

Each reviewed cost plan will have a Servicing Auditor assigned. This individual is a CMS employee. There will also be one COR for the entire contract. The COR will oversee the high level of contractor’s work (i.e. overall priorities, guidance that will impact all reviews), while the Servicing Auditor will interact and oversee the detailed work of the contractor (i.e. reviewing draft reports).

CMS will provide the list of Servicing Auditors, along with contact information, upon award of the contract.

SOW 4.A.f. 5 We assume that the responsibility for security over the transfer of data on the part of the MCO or the providers will be their responsibility and our responsibility is limited to the methodology we provide for the secure transfer only (to and from us only). Please confirm.

The offerors understanding is correct.

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

SOW 4.B. 6

Please define the reconciliation that will be provided by the CAC. Will they be required to provide the detail of the claims, encounters, etc. that tie to each statistic so that no adjustments need to be made, except stratification, by the Contractor? Or will it be a general reconciliation to the entire database?

If the reconciliation is not complete or accurate, how will this be handled and how will it affect the timeline?

Per the SOW, Section IV.G.a, at the Planning Meeting between the CAC and MRC, the MRC shall provide the CAC with any and all claims database fields that they will require for sample selection. The CAC will incorporate this request into their Document Request to the MCO. The CAC will then reconcile the claims database to the Cost Report. Upon completing these procedures, the CAC will provide the reconciled, clean database, to the MRC. Per SOW, Section IV.G.b, the MRC and CAC shall hold a conference call within 5 days of exchanging the reconciled database to verify the MRC understands the statistical unit and discuss completeness of the reconciliation procedures.

If the MRC identifies any errors or omissions in the reconciled database, the COR and Servicing Auditor should be notified immediately to remedy the situations between the two contractors. As necessary, the CAC will be responsible for obtaining and preparing a revised database and reconciliation. The MRC should confer with the servicing auditor and COR to determine how the timeline will be adjusted for delays.

SOW 4.B. 6

Please clarify how the systematic errors and analysis to remove non-covered services by the CAC will be incorporated into the adjustments to the statistics based on the medical claims or medical costs review done by the Contractor. The SOW says the Contractor shall "verify any systemic errors and analysis to removed non-covered services has been completed by the CAC". Who will be responsible for the final adjustment to the medical service costs or the statistics since both of these adjust the same line items but are being reviewed and evaluated by two different contractors?

Per the SOW, Section IV.G.b, the CAC will rely upon the Contractor’s work to prepare their finding. The MRC is responsible for calculating the adjustment to the medical service costs and statistics; however, because the CAC is responsible for preparing the Final Audited Cost Report, the CAC will input the MRC’s adjustment into the cost report. The CAC will also input any adjustments they identify related to systematic errors, non-covered services, etc.

If the CAC identifies any systematic errors, non-covered services, etc., these claims will have been removed from the claims database prior to the MRC selecting samples. Therefore, these adjustments do not need to be incorporated into the MRC’s adjustment, as they are the exact value.

SOW 4.B.a 6 Please verify how the sample or minimum sample will be determined if the MCO uses RVU for pricing medical service costs or building their statistic. Will the sample still be 350 if the MCO only has an RVU study of several thousand claims?

The statistical unit, in most cases, will be the basis for the MRC’s sample. The sample will consist of 350 test items. In many cases, this means 350 claims. However, for certain statistical units, such as RVUs, this will result in more than 350 medical records being requested, as several records may be necessary to review to support one unit. Offerors should consider the complexity of certain statistical units when developing their proposals. CMS is requiring a minimum of 350 samples, regardless of the population size.

However, we reserve the right to modify the sample size in future option years.

Also note, per the SOW, Section IV.B.a, there are certain circumstances where statistics cannot be tested in conjunction with costs, and a separate, additional sample of 100 test items may be required for attribute sampling of statistics (ex. Visits), in addition to a sample of 350 claims to test costs.

At the end of each period of performance, the MRC will have the opportunity to provide recommendations and insight to improve the medical review process in the Self-Assessment/Lessons Learned Report, per the SOW, Section V.J.

SOW 4.B.a 6 Is the 350 claims to be sampled on EACH statistic (or the 100 additional if the medical service costs and statistics can not be sampled together) and medical service cost type (E&M, non-E&M, etc.) or 350 in total?

The MRC shall select 350 samples, total. Also note, per the SOW, Section IV.B.a, there are certain circumstances where statistics cannot be tested in conjunction with costs, and a separate, additional sample of 100 test items may be required for attribute sampling of statistics (ex. Visits), in addition to a sample of 350 claims to test costs.

However, the MRC will need to consult with each Servicing Auditor and CAC to determine how this sample is broken down. This is particularly important when considering MCOs that utilize several different statistical methodologies, or when the majority of the MCO’s costs are in one cost center. The MRC will need to consider how to apply stratification in each unique situation.

SOW 4.B.a 6 Since the results will be extrapolated, is it up to the Contractor contractor to stratify the 350 items in the sample amongst the various statistics and medical service cost types?

Yes; however, the MRC must prepare the Sampling Plan in accordance with Appendix C to the SOW, and including supplemental stratification details from Appendix D to the SOW. This includes stratification of the sample.

SOW 4.B.a 6 Are Non Medicare medical service costs, included in the statistics denominator, also to be sampled and tested?

CMS does not intend to review non-Medicare items; however, CMS reserves the right to revise this policy, in the future.

SOW 4.B.b 7 Can you clarify the timeline? Sample plan within 5 days. CMS to approve in ?? Days. Revisions within 5 days of CMS request for revisions. CMS to approved revision within ?? Days?

The Offeror should reference the SOW, Section IV.B. The MRC’s Sampling Plan is due to CMS two (2) weeks after the reconciled database is received from the CAC. Any revisions to the Sampling Plan must be made within 5 calendar days of receiving CMS guidance. Upon CMS approval of the Sampling Plan, the MRC shall complete sampling selection and submit the samples to the MCO within 10 calendar days.

Assuming the sampling parameters required by the SOW are met, and all necessary information is adequately demonstrated, CMS review will not require a protracted amount of time. However, CMS cannot provide an exact time frame. Upon submission of the Sampling Plan, the MRC should discuss review timelines with each servicing auditor to establish expectations of when the MRC will receive feedback.

Amendment 00001

Document Title (i.e. SOW) Attachment or Exhibit Section Page # Question Response

SOW 4.C.b and 4.F 8

The Contractor shall afford the MCO an initial 60 days to retrieve the medical records. However, the first phase of the medical records review is also required to be completed 60 days after the samples are submitted. Please clarify how the review of the records can be due the same day as the MCO is allowed to submit the records? Our experience has been the MCO waits until the last day to submit the entire sample.

The Preliminary List of Exceptions is due to the Plan 60 days after the MRC sends the samples. This is in line with CMS’ expectation that the MRC will review supporting documentation received from the MCO on a rolling basis, i.e. immediately upon receipt, per SOW, Section IV.D.b. Note that this is not a final list of exceptions. The MCO should be provided an additional 30 days to submit documentation and the MRC will have another 30 days after the additional 30 days to complete their review (for a total of 60 following the Preliminary List of Exceptions). In the case where an MCO waits until the last day of the 60 day period, the Preliminary List of Exceptions should reflect that it is based on incomplete information. In extreme cases, the Servicing Auditor should be notify and they will determine whether any modifications to the review timeline are necessary.

Please note that the MRC is required to issue a Memorandum of Understanding (MOU)(SOW, Section IV.C) to each MCO. The main goal of the MOU is to notify the MCO of CMS’s and the MRC’s expectations and deadlines for providing supporting documentation. The MOU shall also document the timeline of the MRC’s medical review.

SOW 4.C.c 8 Does the Contractor need to submit the Final List of Exceptions to the MCO for review and additional comment? What is the timeline for this process?

Per the SOW, Section IV.C, following the Preliminary Exit Conference, the MCO shall be afforded an additional 30 days to provide supporting documentation. Upon the additional 30 day window closing, MRC shall have 30 days to finalize their Final List of Exceptions. At a maximum, 60 days following the Preliminary Exit Conference, the MRC shall provide a Final List of Exceptions to the MCO, the Servicing Auditor, and COR. The MCO should be made aware that this “final list” is subject to CMS review. Please reference the SOW, Section IV.C.d, for treatment of late documentation.

Approximately 60 days following the submission of the Final List of Exceptions to the MCO, the Agree/ Disagree letter will be submitted for the MCO’s review and comment. CMS anticipates their response to the Agree/Disagree letter and comment will be received following 2 weeks.

SOW 4.C.d. 8 What is the timeline for submitting the Draft Report Package to the CAC?

The submission of the Final List of Exceptions to the MCO shall coincide with the MRC’s submission of the Draft Report Package to CMS and the CAC, per the SOW, Section V.D. The MRC will receive feedback from CMS, and at times, the CAC. As indicated by CMS, revisions to the Draft must be implemented within 5 business days and a revised draft shall be submitted.

SOW 4.D 9

The SOW references the "indirect operating costs" are apportioned using the statistics. This does not appear to be accurate. Indirect operating expenses should be ALLOCATED using the A&G or included in Plan Administration. Please clarify CMS" expectations for this contract and "indirect operating expenses"?

The Medical Review Contractor is responsible for the medical review of each MCO. This will include medical expenses as well as apportionment statistics. In some cases, an MCO may “pool” their indirect costs based on the balance of each cost center. In that vein, testing medical service costs could impact Administrative and General allocation. However, this contract’s scope does not include review of indirect operating expenses.

SOW 4.D 9

When the statistic or medical service costs are based on capitation agreements and not on claims for service, what does CMS anticipate the apportionment statistic sample for covered medical services and proper coding will consist of?

CMS has observed that an individual MCO could utilize several different payment methodologies and several apportionment statistics. If medical service costs are based on capitated payments, and there are no other cost centers with different payment methodologies, CMS anticipates that the apportionment statistic will be Visits, or some other utilization statistic that will require attribute sampling. However, the Offeror should be aware that the parameters in this example represent one unique circumstance, and may not be reflective of any existing MCO.

SOW 4.D 9

Will pricing under the provider agreements for services (negotiated rates) be the responsibility of the CAC or the Contractor contractor? For example, the medical service may be covered and the medical records support the coding of the service. But the pricing is not in accordance with the provider agreement. Who is responsible for that testing, determination and effect on the medical service costs, statistics and the extrapolations?

Please reference step 6e in Appendix I – Medical Review Steps. The MRC is responsible for verifying sampled claims are paid in accordance with that provider’s contract.

SOW 4.D.c 10

Under Unsupported Services, claims processed with Medicare as primary and beneficiary not enrolled will not be information that is in the Medical record. Who is responsible for determining this information? How is it to be obtained? These exceptions are not medical in nature and should be included with the analysis by the CAC.

CMS adjusted Appendix I – Medical Review Steps and the SOW, Section IV.B.c to clarify the MRC and CAC responsibilities for enrollment confirmation. The MRC shall identify each unique beneficiary and the sampled date of service, and send this listing to the CAC for confirmation of cost plan enrollment at the time of service. The listing shall be sent to the CAC at the same time the samples are sent to the MCO. In addition, the CAC will confirm the beneficiary had no other insurance primary to Medicare at the date of service.

SOW 4.D.c 10 For unsupported services, does CMS expect that the denominator to the statistic be reduced (Medicare and non-Medicare) or only the numerator (Medicare).

When the MRC identifies medical review exceptions, CMS expects that both the numerator and denominator to the statistic will be reduced. However, there are certain exceptions where only the numerator will be adjusted. The MRC shall confer with CMS when these distinctions are not obvious or when some ambiguity exists. CMS added this clarification to the SOW. CMS would like to note that adjustments to the medical service cost are also often necessary.

SOW J.1 IV Requirements 9

The SOW states that in the case of exceptions, a second level review by another credentialed coder shall take place. What about exceptions that are not based on a coding error but rather due to a failure to meet coverage criteria or lack of medical necessity? This type of analysis is not normally performed by coders. Is a second review required for these types of exceptions?

CMS expects that exceptions identified during the medical record review process are confirmed by a second level reviewer, see SOW, Section IV.D.b. This second level review should occur regardless of the exception type. CMS has clarified the SOW to better define our expectations of who is performing the review and how to handle exceptions.

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SOW J.1 VI Key Personnel

In general, the SOW appears very coding focused (for example, the list of key personnel included 2 coders and no medical trained personnel). However, the determination of whether claims are supported by the medical record often requires extensive familiarity with Medicare coverage rules and regulations and/or medical knowledge. Is it the client’s expectation that both coding review and medical review will be performed by coders?

CMS corrected the inconsistent terminology, i.e. medical coding vs medical review. To meet the scope of the MRC’s SOW, medical record review must be performed. This includes review of coding, coverage and billing rules, including coding and medical necessity. As per the SOW, the MRC must perform their medical review in accordance with the Medicare Program Integrity Manual. This includes having appropriately credentialed reviewers. CMS has adjusted the Key Personnel section, as well as other references throughout the SOW to better reflect the intention of the medical review. CMS does not require that a Coder perform medical review; however, complete medical review must be performed by members of the Key Personnel.

SOW 4.E.c 11

Please expand on Pattern Errors and removing items from a statistical sample extrapolation when the items are identified after the sample has already been selected from the universe that included those items, has been tested as part of the statistical sample, but needs to be excluded from the extrapolation?

Please see Section IV.E.c of the SOW for discussion of Pattern Errors. Whenever possible, the MRC should identify the exact value of systematic or pattern errors in the entire universe. Alternatively, the MRC may consult directly with the MCO to calculate the exact value. In either situation, the MRC shall consult with CMS to determine their approach to resolving the situation. Please note, CMS does not anticipate this situation regularly occurring. Each MCO’s circumstance shall be resolved on a case-by-case basis. Additionally, the MRC shall notify CMS immediately when they believe the situation could be resolved with an expanded sample.

SOW 4.F 12 The timeline does not appear to be consistent. If the MCO gets 60 days. This now says the Contractor gets 30 days. Most 120 days. The timeline is unclear. Please clarify.

The Overall Timing Requirements in Section IV.F, and Appendix H of the SOW serves to provide a broad look at the contract’s deadlines. The Preliminary List of Exceptions is due to the Plan 60 days after the MRC sends the samples. Note that this is not a final list of exceptions. The MCO should be provided an additional 30 days to submit documentation and the MRC will have another 30 days after the additional 30 days to complete their review (for a total of 60 following the Preliminary List of Exceptions). Therefore, at most, 120 days will pass between the sample being sent to the MCO and the MRC providing a Final List of Exceptions (60, 30, 30).

SOW 4.G 12 In order to anticipate the level of effort, please clarify the information that the CAC may request to incorporate information into their opinion, how often, the timeline, etc.

For every MCO cost plan under review, the CAC may request copies of all documentation, up to and including what is submitted to CMS (please reference SOW Section IV.C, SOW Section IV.E, SOW Section IV.F and Appendix H - Overall Review Timeline for specific timeline of when this may occur). Additionally, this may include personnel credential information and resumes. CMS suggests the MRC discuss expectations for information requests with the CAC during the Planning Meeting.

SOW 4.G 12

How will the Contractor know the fields required without first seeing the statistic, the data collected by the MCO, the fields in the database? Can prior data bases, collection templates or some other information be provided as a basis for this determination? Do we just assume ICD-9 or ICD-10 fields?

CMS included the complete list of MCOs, including the primary statistical unit and payment methodology, at Appendix J. For the initial contract year, CMS expects claims data will include ICD-9 fields, based on the years going into review. In later review periods, claims will include ICD-10 fields. However, each plan has its own system for claims collection, and so there is no standard template. The MRC is responsible for determining what information they need in the claims database in order to perform sample selection, see SOW, Section IV.G.a. Nonetheless, the MRC should be aware that each MCO may have limitations on how claims information is generated.

SOW 4.G.b 13

Are you expecting a separate "Agree Disagree Letter" from this review or is this the same one the CAC is obtaining? If the CAC does not complete its work timely, and the Agree Disagree letter becomes untimely, who is responsible for obtaining updates? Also, is the letter solely associated with the medical claims and statistics review? If other adjustments to these costs or statistics are necessary due to work by the CAC, who will be responsible for obtaining the new Agree Disagree Letter?

There will only be one Agree/Disagree Letter for each MCO (per year) under review. The CAC will obtain the agree/disagree letter, and the MRC’s findings will be incorporated. The MRC's findings will also be incorporated into the CAC's report (see SOW, Section IV.G.b). When notified of any disagreements, the MRC is responsible for responding to those in a timely manner and per the SOW requirements. If there are any adjustments to the agree/disagree letter, in most cases, the revisions will be coordinated through the CAC; however, CMS will determine responsibility on a case-by-case basis. CMS anticipates that the MRC will be aware of any items or issues the MCO plans to disagree with prior to receiving a formal agree/disagree letter.

SOW 4>h 14 To anticipate and propose a realistic LOE, what percent of MCOs appeal and to what level of detail?

What is the LOE typically associated with testifying, responding to appeals, reviewing appeals documents, etc.

CMS cannot anticipate the number of medical review findings that will be appealed. However, the Offeror should reference the SOW requirements for potential level of effort.

SOW VII 23 What is the role of the A-76 Contractor as it pertains to this RFP? What coordination with them is expected?

CMS may consult with the A-76 contractor on certain issues; however, the A-76 contractor has no direct role in this contract. If CMS requests a conference call, per SOW Section VII.b, it is possible the A-76 contractor would attend to provide clarification on a topic, for example.

Proposal Instructions E.3 L.11.B 70 There is no instruction to include any profit or fee in the price buildup for the FFP per claim. Where is this to be included or proposed?

Exhibit E.3 has been amended (also see answer to question 22).

Proposal Instructions L.11.A 70

Please clarify this table with the sample MCO and claims. If the number of claims to be sampled is 350, and if the data is not the same for the statistic then another 100 should be sampled per the SOW Section 4, then is this table simply showing 350 times the number of cost report years? And if there are 10 MCOs to audit, why does the table only include 5 MCOs for the pricing assumption? The table only equals 4,550 claims. This affects pricing and economies of scale.

CMS has added the complete list of MCOs eligible for review under this SOW, Appendix J. When CMS selects an MCO for review, we also determine the number of years to be reviewed. For example, Plan H-1234, 2011 – 2013. Within the same option year, we may also review H-9999, 2012-2014. In this example, we are only reviewing two MCOs, but we are reviewing six years. Typically, for each year, the MRC will review 350 samples. The number of MCOs and number of years will vary for each option year. For the base period, CMS expects a total of 4,550 samples, but in other options years, the total number of samples may be up to 10,000.

Note, CMS reserves the right to modify the number of samples per year.

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Proposal Instructions L.11.A 70

The table shows various methodologies. Is determining the acceptability of, CMS approval for , and…