Amendment 000002 J.15 UPIC Award Fee Plan.docx

UNIFIED PROGRAM INTEGRITY CONTRACTOR

JURISDICTION 1

AWARD FEE PLAN

TABLE OF CONTENTS

PURPOSE/OVERVIEW

This award fee plan sets forth specific criteria and procedures used to evaluate Contractor performance under the Unified Program Integrity Contractor (UPIC). Performance criteria contained in this plan will be used to determine the amount of award fee earned by the Contractor during the performance of the contract for task order awards.

This award fee plan identifies criteria that CMS determines important to the success of program integrity efforts. The evaluation criteria in this Award Fee Plan are linked to the CMS goal of achieving enhanced detection and prevention of fraud, waste, and abuse across the Medicare and Medicaid programs by:

· Consolidating Medicare and Medicaid program integrity activities;

· Sharing and coordinating information across Medicare and Medicaid partners;

· Emphasizing timely administrative actions; and

· Strengthening data matching across programs to expand the view of provider/supplier billing patterns.

The basis for determination of the award fee shall be the evaluation by the Government. CMS will continuously monitor the Contractor during the period of performance, and may review and evaluate performance on any or all activities performed by the Contractor. CMS will provide the Contractor with general information about the review process; however, CMS is not obligated to provide specific details on how the Contractor’s performance evaluation will be conducted.

To be eligible for award fee a Contractor must receive a minimum rating of “Satisfactory” in all CPARs criteria for the period of performance under review.

The amount of fee for this contract/task order will be contained in section B.4 of this contract/task order. The total dollar amount of fee will be broken out as follows:

*The Excellence Award is a portion of the overall Award Fee that will be implemented in Year 2 of the contract.

ROLES AND RESPONSIBILITIES

2.1 Fee Determining Official (FDO)

The Fee Determining Official (FDO) is the Director, Contract Management Group (CMG) in the Center for Program Integrity (CPI), or his/her designee. The FDO shall review the recommendation made by the Performance Evaluation Panel (PEP – see below), in addition to consideration of the Contractor’s Self-Assessment Report. The FDO will, after considering available pertinent information and recommendations, determine the award fee earned and payable to the Contractor in accordance with the provisions of this plan. The FDO may determine a different award fee than the recommendation made by the PEP; it is possible that the Contractor may receive all, part, or no award fee in any given award fee period. The FDO determination shall be made within 150 days of the end of an Award Fee evaluation period. The final determination made by the FDO will be forwarded to the Contracting Officer (CO) for Contractor notification.

2.2 Performance Evaluation Panel (PEP)

The PEP is a panel comprised of the Contracting Officer’s Representative (COR), Alternate COR, Business Function Leads (BFLs), Evaluation Subject Matter Expert (SME) team, CO, Contract Specialist (CS), and any other Government staff as necessary. The PEP will evaluate the Contractor’s performance as it relates to the Award Fee Evaluation Factors listed in Section 5 of this plan; however, CMS reserves the right to monitor any aspect of the Contractor’s operation at any time. The responsibilities of the PEP are as follows:

· Continuously monitor and collect data on the Contractor’s performance during each period of performance;

· Consolidate data and information, and if needed, perform an in-depth review of the Contractor’s performance at the end of each Award Fee Evaluation Period; and

· Prepare a written report of its evaluation. This Award Fee Recommendation Report will include recommendations as to the adjectival rating and numerical score to be assigned to the Contractor for its performance during that evaluation period.

2.3 The Contractor

The Contractor shall submit an Award Fee Performance Evaluation Self-Assessment Report into CMS-ART and notify the CO, CS and COR within fifteen (15) business days following the completion of each Award Fee evaluation period.

The Award Fee Performance Evaluation Self-Assessment Report shall capture a self-assessment of achievements and deficiencies, as well as, at a minimum, the following:

· The self-assessment format, indicating how the Contractor performed broken out by the factors in CPARS;

· Recommendations for areas that could be improved;

· Identification of unanticipated problems encountered in the performance of the USOW and TO SOW;

· Recommendations and insights into resolution of the unanticipated problems; and

· Areas of innovation where the Contractor has gone above and beyond the USOW and TO SOW requirements.

The following are general assumptions and responsibilities for the Contractor during the performance evaluation process:

· If the USOW or the TO SOW does not list specific minimum requirements for the tasks, the basis standard is assumed to be an accurate, timely, and high quality product that effectively performs the intended function.

· When requested by CMS, the Contractor shall provide complete and accurate information in a timely manner.

· The Contractor shall be transparent and pro-active in communicating in a timely and effective manner with CMS about any issues or problems that arise. The Contractor shall be strategic in managing their work to have plans in place to reduce adverse effects of issues or problems that arise.

The Contractor agrees that the Fee Determining Official will make the determination as to the amount of the award fee earned. Such determination concerning the amount of the award fee earned is binding on both parties and shall not be subject to appeal under the “Disputes” clause or any other appeal clause.

Evaluation Periods In general, dates are calculated from one year of the effective date of contract award, and annually thereafter; however, a performance evaluation process can be tailored to the contract. The evaluation periods established and identified in the award fee plan for this task order are as follows:

Evaluation Procedures CMS will continuously evaluate the Contractor and provide feedback. The Contractor is encouraged to reach out to the COR or CO for updates on performance. All award fee determinations will be assessed annually unless changed through contract modification.

a. The Contractor will be apprised by the Contracting Officer’s Representative (COR) of a general assessment of its performance at the mid-point of each evaluation period, and at such other times as deemed appropriate.

b. The Contractor shall submit an Award Fee Performance Evaluation Self-Assessment Report to the PEP within 15 business days of the completion of each Award Fee Evaluation Period. The self-assessment report shall provide the Contractor’s documentation regarding their perspective of performance in each of the evaluation criteria, as well as substantiation for their self-assessment rating.

c. The PEP will meet after the conclusion of each evaluation period to consider all performance information it has obtained, including the Contractor self-assessment report (if received within the allotted time in (b) above). The PEP will summarize its findings and recommendations in the Award Fee Recommendation Report. The Award Fee Recommendation Report will include the Rating; Weight; Available Award Fee; and the recommended Award Fee Earned for each of the Evaluation Factors, as well as supporting documentation.

d. The COR will present the Award Fee Recommendation Report findings to the Fee Determining Official (FDO). The report will include recommended adjectival rating and performance scores with supporting documentation.

e. The Contractor may submit to the Fee Determining Official (FDO) via the COR, a supplement to the self-evaluation report within three (3) business days of receipt of the Award Fee Recommendation Report to provide any additional information to the Fee Determining Official (FDO) and in response to the Award Fee Recommendation Report that the Contractor believes is relevant to its performance and that may affect the Fee Determining Official’s determination.

f. The FDO will consider the PEP recommendation, self-assessment report, and any other pertinent information in determining the performance scores. The FDO’s findings will be stated in the written Award Fee Determination and will be forwarded to the Contracting Officer.

g. The Contracting Officer will provide the Award Fee Determination to the Contractor.

CMS will routinely evaluate the performance measures that are used to evaluate Contractor performance. If it is determined that measures are not achieving their intended purpose or are not meaningful, then CMS will provide the opportunity for Contractor feedback regarding performance measures before revision or implementation.

The majority of the data used to measure the performance of the Contractor will be obtained through the Unified Case Management system (UCM).

5.0 PERFORMANCE criteria, Weights and standards

5.1 Performance Criteria and Weights

The following criteria are to be used to determine the award fee rating for each evaluation period:

The specific elements that will be monitored in each of the three (3) Evaluation Factors noted in the table above include:

1. Quality Overall quality of service performed by the Contractor will be measured by a quality and technical review by the CMS COR/BFL/Evaluation SME team on tasks along the continuum of vulnerability identification, lead prioritization, investigations, data analysis, administrative actions, and medical review, as well as other PI work. This assessment will be based on the evaluation of a sample of PI work to determine whether the appropriate action was performed and completed in a timely manner. This evaluation element includes not only the accuracy of the service, but also the timeliness of the service. Some of the areas evaluated and methods of evaluation may include the following:

· The Contractor’s capability to move quality investigations to the point of administrative action, referral, or closure within 180 calendar days; therefore the average age of investigations (in days) will be calculated.

· The Contractor’s capability to perform quality and timely administrative actions.

· Documentation by the Contractor must be complete and concise so that all activity is transparent to the CMS review team. For example, the plan for the investigation and the prioritization of the investigation must be clearly documented.

· CMS may also consider the percentage of administrative actions recommended compared to administrative actions implemented.

· Out of the PI work selected for evaluation, the PEP will calculate the percentage of agreement with the Contractor’s work based upon the percentages noted in section 5.2.

For example, if 50 open and closed investigations were assessed and the PEP determined agreement in 45 of those investigations, then the Contractor’s score would be 90% (Very Good).

2. Management

a. Exceptional leadership – The Contractor will be evaluated on its ability to maintain highly qualified and high performing staff while ensuring a cohesive team.

b. Exceptional coordination, communication, and relationship with stakeholders, including the MAC, Law Enforcement, the State Medicaid Agencies, and CMS. The Contractor will be evaluated on the ability to communicate professionally and to provide clear, accurate, and reliable information with minimal errors or delays.

· CMS may conduct surveys with stakeholders periodically throughout the contract Period of Performance.

· The effectiveness and adequacy of the JOAs and other agreements may be assessed by CMS.

· Referrals and support to stakeholders will also be assessed.

· All Contractor stakeholder outreach must be communicated with the COR/BFL to mitigate potential stakeholder burden. CMS will assess Contractor’s communication, collaboration and support efforts.

c. Exceptional subcontractor management – The Contractor will be evaluated on the overall effectiveness of managing subcontracts.

d. Exceptional overall program management, including transition and fully functioning tasks and milestones.

3. Other Areas The activities in this section are intended to provide the Contractor an opportunity to receive incentives for innovative ideas identified by the Contractor during performance of the UPIC functional tasks that result in adding value to program integrity processes. If the Contractor chooses to provide any ideas from “a” or “b” below, CMS expects these to be submitted in the Contractor’s Award Fee Performance Evaluation Self-Assessment Report and each idea must meet all of the following criteria:

· The idea must be a major process improvement;

· The idea must be supported by a methodology and metrics; and

· The Contractor must be willing to share this idea with other contractors.

CPI has an internal process for evaluating a proposed innovation and anticipates that the Contractor would not submit more than two proposed innovations in an evaluation period. CPI will not consider submitted ideas unless they meet the criteria noted above. The Contractor will receive credit for the innovation as part of the award fee plan if and when CPI is able to independently evaluate the idea(s) through the CPI internal process.

a. Innovation – An innovation is considered a new or significantly improved practice, process, method, or system that results in measurable efficiencies and/or measurable cost savings. From a business perspective, innovation is a considered a prime resource for organizational success. The Contractor’s day-to-day program integrity work provides an important perspective to enhance or streamline operational processes. Examples of the areas that may be considered for innovation include:

· Actionable innovations to the Fraud Prevention System

· Analysis and recommendations regarding the Appeals process that results in a reduction in overturn of denials. This can be measured by calculating the percentage of ALJ agreements with UPIC findings.

· Development and sharing of innovations in a functional task as noted in the UPIC TO SOW and UPIC USOW.

b. Other specific vulnerabilities, such as electronic health records, high-risk providers, or Contractor recommendations that result in special projects or policy changes.

5.2 Performance Standards

For each evaluation period, and in accordance with the evaluation procedures in Section 4 of this Award Fee Plan, the Government will evaluate the Contractor’s performance and assign a corresponding rating for each of the three (3) proposed factors. The Government will give a score from 0 through 100% to each evaluation factor in accordance with the Award Fee Evaluation Ratings table below.

Award Fee Performance Standards

6.0 EXCELLENCE AWARD

This award fee plan also includes the potential for an “Excellence Award,” that will begin in year 2 of the contract/task order. The Excellence Award is a portion of the award fee that may be earned in addition to the criteria found in Section 5.0 of the Award Fee Plan (Quality, Management, and Other Areas). The criterion for the Excellence Award will be based on CPI reaching its Return on Investment (ROI) goal for its program integrity efforts. CPI will recalculate the ROI annually for each fiscal year and will provide information regarding the ROI calculation. This ROI goal can only be accomplished with the success of multiple PI stakeholders reaching their individual goals and providing open communication, collaboration and support between the stakeholders, including CMS, other UPICs, other CMS contractors, State Medicaid Agencies, and Law Enforcement.

In order to be eligible for the Excellence Award, the Contractor must achieve at least a Very Good in all CPARS evaluation factors.

7.0 AWARD Fee Earnings ranges/DISTRIBUTION

To be eligible for award fee, a Contractor must receive a minimum rating of “Satisfactory” in all CPARs criteria for the period of performance under review.

The amount of fee for this task order will be contained in section B.4 of this contract/task order. The total dollar amount of fee will be broken out into three categories: Base Fee, Award Fee, and Excellence Fee. The fee breakout will be based on the contract percentages established at time of award.

Example 1 In the base year, a Contractor will may propose a base and award fee structure, as follows:

Base Fee Awarded at 20%

Award Fee Awarded at 80%

In years 2-5 of the contract/task order, a separate fee (Excellence Award) will be implemented and the structure will may include the following:

Base Fee Awarded at 20%

Award Fee Awarded at 75%

Excellence Award Awarded at 5%

To be eligible for an award fee, the Contractor must first achieve at least a Satisfactory in all CPARs evaluation factors. To be eligible for the Excellence Award, the Contractor must first achieve at least a Very Good in all CPARS evaluation factors.

Example 2 In the base year, a Contractor may propose a base and award fee structure, as follows:

Base Fee Awarded at 10%

Award Fee Awarded at 90%

In years 2-5 of the contract/task order, a separate fee (Excellence Award) will be implemented and the structure may include the following:

Base Fee Awarded at 10%

Award Fee Awarded at 80%

Excellence Award Awarded at 10%

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