J.7 UPIC Technical Evaluation Scenarios.docx

Attachment J.7 HHSM-500-2015-RFP-0122 UPIC Unified Program Integrity Contractor (UPIC) Technical Evaluation Scenarios Technical Understanding and Approach:

· The Offeror will provide responses to the scenarios that follow to demonstrate technical understanding of the work required under the UPIC Umbrella Statement of Work (SOW) and Task Order SOW. The Offeror’s response should address its approach for providing the services to CMS and its understanding of the task, as well as how and when the task will be performed; which personnel will be involved throughout the process; and any process performed by the Offeror to ensure that the service provided to CMS or other stakeholders is complete, accurate, effective, and timely, as well as promoting proper stewardship of the Medicare and Medicaid programs.

· The Offeror’s response to each scenario should be no more than 3 pages in length and should fully defend the response. The Offeror must include the assumptions used in developing the response.

· The Offeror’s responses to the scenarios must demonstrate:

1. The ability to conduct lead prioritization, data analysis, investigative activities, review of medical documentation, and other activities required for successful program integrity outcomes;

2. Relevant knowledge of Federal/State laws and regulations that relate to Medicare and Medicaid program integrity; and

3. The ability to interface and build successful partnerships with CMS, law enforcement, Medicare and Medicaid partners, and other stakeholders, as well as find situations that promote the efficiencies of unifying Medicare and Medicaid program integrity.

Scenarios:

1. “Pills4All” is enrolled in the Nebraska Medicaid program as a pharmacy. During the period from March 1, 2012 through April 30, 2013, Pills4All was reimbursed $5,994,450 for 51,106 claims. The State Medicaid department noted both duplicate claims and services billed after death during initial data analysis of this provider.

a) Describe how you would proceed with this analysis.

b) What sources of data would you use and how would you use them?

c) With whom and how would you interact and/or coordinate the analysis?

2. The UPIC received an OIG Hotline complaint. M.B. is a former employee of Dr. Z., an internal medicine physician, and has reported that Dr. Z. has opened a second office and hired a new doctor. M.B. says that Dr. Z. provided the new doctor with prescription pads and other medical documents that were pre-signed by Dr. Z. M.B. also reports that the new doctor introduces himself to patients as Dr. Z. and provides them with business cards containing Dr. Z.’s name and medical credentials. M.B. indicated that the services provided by this new doctor are billed to Medicare and other payors under Dr. Z.’s name.

a) Based upon this information, would you need to open an investigation, or would you need to perform some additional information gathering before you open an investigation? Justify your answer.

b) Take this scenario and describe the actions that you would perform as you follow this to conclusion and a general timeline to complete the associated tasks. Include a list of all the tasks you would perform, who on your team would perform the task(s), and the rationale for performing those tasks.

3. Multiple articles in the news media have noted that there have been several neurosurgeons throughout the country that have billed for spinal fusion surgeries that were based upon false diagnoses and were not needed; in several cases, patients died as a result of these procedures. While performing data analysis on spinal procedures, you find that a neurosurgeon in Ohio performs spinal fusion surgeries at a rate that far exceeds any other physician. This neurosurgeon treats both Medicare and Medicaid patients.

a) Would you open an investigation on this provider, would you refer this provider to another entity, or would you do something else? Justify your answer.

b) If you would refer the provider to another entity, describe which entity you would refer the provider to and why, as well as what information you would provide to them.

c) If you would proceed to open an investigation, describe step-by-step how you would conduct the investigation and provide a general timeline to complete the associated tasks.

d) If you would do something other than an investigation or referral to another entity, describe your action and why you are taking this action.

e) If you determine that you would take no action, describe why.

4. The movement toward managed care is playing an increasing role in both Medicaid and Medicare programs. Vulnerability and risk identification regarding fraud, waste, and abuse in the managed care environment is providing additional challenges to program integrity.

a) Describe your process for addressing program integrity in the managed care environment and how you would be able to efficiently and effectively work in a situation that involved fraud, waste, and abuse investigation that deals with fee-for-service and managed care from both the Medicare and Medicaid perspectives.

5. J.J. is a patient of Dr. P., a podiatrist and is the source of the complaint for this scenario. In April 2014, J.J. complained of pain in the heels of both feet. Dr. P. recommended a nerve test to both feet. In April 2014, the nerve test was conducted in Dr. P.’s second office using equipment and staff provided by a neurologist, Dr. N. J.J. was concerned because it appeared that the staff did not appear to be adequately trained to operate the equipment they were using to perform the test. The staff had to start and stop the test several times. When the test was complete, the office receptionist told J.J. that the results would be given to Dr. N. for interpretation. J.J. did not see either Dr. P. or Dr. N. at the time of the test. The events described in this scenario occurred in your jurisdiction, as well as a neighboring UPIC’s jurisdiction.

a) Would you pursue this lead? If so, describe your complete plan of action regarding this lead and provide a general timeline to complete the associated tasks.

b) If data analysis is part of your plan, describe what data you would pull and what you would be looking for in terms of aberrancies.

6. As the UPIC, you are involved in an active investigation from the Medi-Medi perspective in one of the states in your jurisdiction. A thorough data analysis has generated several home health agencies that appear to be in violation of certain Federal and State laws. The home health agencies identified are Medicare and Medicaid providers. After some preliminary investigation and during a collaborative discussion, it was mentioned that medical review was the best course for the next action.

a) Is medical review the most appropriate remedy in this situation? Is medical review the first action that should be taken? Are there other tactics that could be used? Justify your answer and explain your investigative steps.

b) If Medical Review is conducted, would it be prepay or postpay? Describe in detail how you would proceed to perform medical review from both the Medicare and Medicaid perspectives, including your proposed workflow to final report, including timeline of events and action on any findings.

UPIC Technical Evaluation Scenarios Page 1