J.6.B_UPIC_J1_Task_Order_SOW.doc

Attachment J.6.B

HHSM-500-2015-RFP-0122

UPIC

UNIFIED PROGRAM INTEGRITY CONTRACTOR (UPIC) TASK ORDER

STATEMENT OF WORK

Jurisdiction 1

I. SCOPE

The UPIC shall perform fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed within Jurisdiction 1 for the states of Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska and Kansas.

A. Background

The Centers for Medicare and Medicaid Services (CMS) currently relies on a network of Contractors to carryout program integrity work in Medicare and Medicaid. The Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) are under contract to perform specific Medicare program integrity functions. The Medicare-Medicaid Data Match (Medi-Medi) program is incorporated under the current ZPIC scope of work. The ZPICs are under contract to conduct Medi-Medi activities including matching Medicare and Medicaid data and investigating potential instances of fraud, waste, and abuse (FWA). The Medicaid Integrity Contractors (MICs) are under contract to perform specific Medicaid program integrity functions, including provider audits for overpayment. The UPIC will combine and integrate these functions into a single contract for each of the five jurisdictions under the UPIC IDIQ contract to perform Medicare and Medicaid program integrity work on behalf of CMS. This Task Order (TO) Statement of Work (SOW) is for all Medicare and Medicaid program integrity work in Jurisdiction 1.

NOTE: Although this contract vehicle combines the Medicare, Medi-Medi and Medicaid work, each are governed under separate and distinct funding appropriations. The UPIC must track all costs incurred under each workload stream and bill to the appropriate contract line item number (CLIN) under this Task Order.

Attachment A provides CMS Medicare and Medicaid claims information by Provider state.

B. Purpose of Task Order

The purpose of this TO SOW is to acquire the services of a UPIC for Jurisdiction 1 to perform FWA prediction, prevention and detection activities for Medicare and Medicaid claims. The UPIC shall perform its responsibilities under the direction of the CMS, while ensuring compliance with all Federal and State(s) regulations and policies.

For purposes of this contract, when differences or conflicts occur, the order of precedence shall be the TO SOW followed by the Indefinite Delivery Indefinite Quality (IDIQ) SOW and then Internet Only Manuals (IOMs) unless otherwise specified. The UPIC shall contact the Contracting Officer (CO) and the Contracting Officer’s Representative (COR) when discrepancies are identified. The UPIC shall identify any budgetary concerns that may occur as a result of the conflict. The UPIC is advised that any and all references in the SOW (including manuals) to “RO-Regional Office” shall also include CPI field offices unless otherwise specified in this SOW. Appendix C of the UPIC SOW contains definitions of all abbreviations used in this SOW.

C. Technical Considerations

· The UPIC shall obtain access to the Fiscal Intermediary Shared System (FISS) and the Multi-Carrier System (MCS). The UPIC shall have read and write access for the VIPS Medicare System (VMS) for DME. The UPIC shall have access to One Program Integrity (One PI)/Integrated Data Repository (IDR).

· As part of this procurement, the UPIC shall enter into a Data Use Agreement (DUA) with CMS. The DUA shall delineate confidentiality requirements of the Privacy Act, implement security safeguards, and explain CMS’ data use policies and procedures. The DUA will serve both as a means of informing the contractor of these requirements and as a means of obtaining the UPIC’s agreement to abide by these requirements. The DUA must be submitted to the COR no later than 30 days prior to the fully operational phase of implementation.

· To create a DUA, the UPIC shall complete the CMS DUA form (Appendix Q). The CMS COR will then coordinate with the CMS Privacy Officer for authorization and assigning of a DUA number. If the COR should require additional data not identified in the DUA, a second DUA may be required to obtain access to that information.

· The UPIC shall provide and use hardware/ software to:

· Communicate efficiently (e.g., e-mail) within its own departments, other specialty contractors (when implemented), CMS, MACs, law enforcement, etc.;

· Receive any applicable Medicare and Medicaid financial reports; and

· View the claims attachment images, if applicable.

II.

REQUIREMENTS

The UPIC SOW is incorporated into this TO with the same force and effect as if it were provided in full text. Independently and not as an agent of the Government, the UPIC shall furnish all of the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform the UPIC SOW requirements and TO SOW requirements for this workload.

For purposes of this TO, the Contractor shall not perform Part C and D audit and investigative activities.

NOTE: This Task Order SOW may be modified to incorporate additional workload not currently identified herein, as well as incorporate SOW section exceptions below. The addition of such workload is in the interest of economy and efficiency and considered a logical follow-on to the work identified herein. Additionally, UPIC workload reconfigurations may be necessary in order to comply with the efficient and effective implementation of programs that may be enacted by legislation.

A. General Requirements Constraints/Assumptions:

· The UPIC shall complete all transition requirements within 90 days of contract award. Transition activities shall be conducted with the understanding that the outgoing contractor will be in place for the initial 45 days of the transition period.

· The UPIC shall use the CMS Unified Case Management system as directed, however, for the Base Year (12 months) of this task order, the UPIC shall also use an internal case management system as referenced in the PIM (IOM 100-08) Section 4.2.2.4.1. The UPIC’s internal case management system shall be accessible to CMS and have reporting and functional capabilities to include, but not be limited to the following:

· Track all UPIC workload information or actions related to potential fraud investigations and administrative actions for a specific provider;

· Compile information for management reports (described in UPIC SOW);

· In the event the Unified Case Management System is not operational at time of the Jurisdiction 1 task order award, the UPIC shall work with CMS and the UCM contractor to transition all workload information and legacy data from the UPIC contractor’s internal system to the UCM when it becomes operational.

· The Joint Operating Agreements (JOA) shall be completed in accordance with the UPIC SOW.

· The UPIC shall begin processing the DUAs immediately upon award of this TO in order to gain access to CMS data systems identified in the UPIC SOW. The DUAs shall be submitted no later than 30 days prior to the fully operational phase of implementation.

· The UPIC role in Medicare and Medicaid managed care FWA will focus on analysis of managed care data and coordination with appropriate Medicare and Medicaid partners for referral and resolution of identified issues.

· The UPIC role in Medicare Part D and Medicaid drug FWA will focus on analysis of Part D and Medicaid pharmacy data and coordination with appropriate Medicare and Medicaid partners for referral and resolution of identified issues.

· The UPIC shall use One Program Integrity (OnePI) and the Integrated Data Repository (IDR) for Medicare and Medicaid data matching, analysis and storage purposes.

· The UPIC shall use the Unified Case Management System (UCM) to gather and submit information for management reports and track workload or actions such as potential fraud investigations and administrative actions for a specific provider.

· Costs associated with Medicare, Medi-Medi and Medicaid shall initially be allocated to the appropriate funding line based on the origination of the lead.

· Costs associated with development of an investigation shall be allocated to the appropriate funding line based on the focus area(s) (Medicare, Medicaid, Medi-Medi) of the investigation.

· In calculation of the Federal Financial Participation (FFP), the UPIC shall consult the following sources for guidance on calculating the FFP (using the Federal Medical Assistance Percentages (FMAP)) and shall monitor any changes to the FMAP as published in the Federal Register on an ongoing basis. The Federal Register adjusts the FMAP for States and territories periodically based on legislation, e.g., the American Recovery and Reinvestment Act (2009) increased the FMAP for certain claims for services on or after October 1, 2008.

· http://aspe.hhs.gov/health/fmap.htm -This chart is the basis for FMAP calculations absent modifying Federal Register notices.

· http://www.gpoaccess.gov/fr/advanced.html -Federal Register notices

B. Specific Requirements

Specific tasks to be performed, which are not identified in the SOW, provide more detail, or are changed from the SOW, are as follows:

1. Transition activities:

The UPIC shall work with the MAC and the outgoing ZPIC to transition all fraud and abuse detection and prevention information, documents, data, and activities. The UPIC shall work with the outgoing MICs to transition all remaining work as directed by CMS. As part of the transition period, the UPIC shall develop a project plan, conduct a kick-off meeting, and submit deliverables in accordance with the UPIC SOW requirements. The UPIC shall lead regular transition meetings with CMS, the outgoing ZPIC, MIC and the appropriate MAC and maintain minutes from those meetings. Meeting minutes shall be provided to CMS within two business days of the meeting date.

Work performed as a UPIC shall occur in two phases: transition and fully operational. The day after the Jurisdiction 1 Task Order award is the first day of the transition period. The transition period will last no longer than 90 calendar days. During this time, the UPIC shall comply with requirements outlined in sections 4.1.1 and 7.6.2 of the UPIC SOW, including but not limited to training its staff and successfully test its access to and ability to use the Unified Case Management (UCM) system. At the conclusion of the transition period, the fully operational period begins.

2. Workload Categories:

The UPIC shall assign the following levels of effort to the workload categories identified in UPIC SOW 5.3.1:

a. Leads prioritized centrally through the Fraud Prevention System: 45%

b. Stakeholder Identified leads: 45%

c. CMS generated leads: 10%

Workload LOE adjustments shall only be made with prior CMS review and approval.

A contract modification is not required for LOE adjustments not exceeding 10%.

3. Law Enforcement Requests:

The UPIC shall provide support to Law Enforcement in accordance with 5.10 of the UPIC USOW. The UPIC shall ensure that the projected level of effort for individual law enforcement support requests (Requests for Information and Requests for Assistance) does not exceed the limits described in the attached draft PIM (Section 4.4.1) without approval from CMS.”

4. Command Center Activities:

The UPIC shall upon request and at a minimum of four times a year, travel to CMS to participate in Command Center missions. As directed by the COR, the UPIC may be required to submit agendas and presentations and take minutes during these missions. These missions may include other UPIC’s, other CMS contractors, states, law enforcement and/or other CMS program stakeholders.

5. Meetings, Workgroups and Conferences:

The UPIC shall attend meetings, workgroups, and conferences as outlined in the UPIC SOW. In addition, the UPIC shall coordinate with CMS to attend or establish regional FWA meetings and other meetings as needed. The UPIC must request and receive authorization from the COR to attend meetings and/or conferences beyond those identified in the SOW.

6. Program Integrity Projects:

The UPIC shall support CMS by conducting projects as outlined in the UPIC SOW Section 5.8.3. The workload associated with these projects shall be further defined by CMS throughout the period of performance of this TO, as required.

7. Healthcare Fraud Prevention Partnership:

The UPIC shall support HFPP activities as outlined in UPIC SOW Section 5.8.1. The workload associated with this work shall be further defined by CMS throughout the period of performance of this TO, as required.

8. Cost Reports The UPIC shall comply with section 7.8 of the UPIC SOW as described, including but not limited to reporting on the following:

· Medi-Medi expenditures by state; and

· Medicaid expenditures by state.

· Costs outlined in Appendix N of the IDIQ SOW.

9. Medicaid Findings Reports

The UPIC shall collaborate with the COR/BFL and the State Medicaid Agency to establish an agreed upon process for conducting Medicaid investigations in the assigned state. Once an agreed upon process has been established, the UPIC shall work with the state to generate a JOA outlining the process and submit a copy to the COR for approval. The process must conclude with a “final report” including, but not limited to the following:

· Summary of overpayment findings as applicable;

· Summary of the federal share of overpayments (FFP)(see Constraints/Assumptions section of Task Order for additional detail);

· Supporting documentation; and

· CMS cover letter notifying the state of the overpayment and requesting repayment of the FFP.

10. UPIC Support of State Medicaid Agency Hearings and Appeals

The UPIC shall, when directed to do so, support the necessary hearings/testimony which may result from the investigations conducted under this contract. The UPIC shall perform functions as defined in the UPIC SOW and as defined more specifically in this TO, in order to support activities that result in challenges which may go before the State administrative hearing process, as well as support activities that may result in appeals which may go through the State/Federal court system. The UPIC shall be prepared to provide support for the following requirements, but not limited to:

· The UPIC shall prepare for depositions, hearings or other related proceedings in order to be able to competently describe all relevant aspects of the audit. The UPIC’s activities may include, but are not limited to, the following:

· Participating in teleconferences with the State;

· Maintaining documents and related work papers in support of the audit findings;

· Providing work papers or documents to support the appeal;

· Cooperate with the State and respond to their request for information to support the appeal;

· Providing required witnesses as necessary for deposition, hearing, explain the findings, subject of the audit or other proceedings; and

· Participating and testifying in the deposition, hearing or other proceedings.

C. Personnel Requirements Key Personnel: In addition to the requirements identified in 7.3 of the IDIQ SOW, the UPIC shall ensure that all identified key personnel positions are full time for the purposes of this TO.