Amendment_000007_-_Second_Round_Qs-As_Exhibit_E_2_-_RAC.docx

Exhibit E.2 – Second Round Questions and Answers – HHSM-500-2016-RFP-0003

REQUEST FOR QUOTE QUESTIONS (RFP):

Question # 1 Section/ Page Number: E.6, Proposal Organization, page 53 Question: Please confirm that Microsoft (MS) Office 2013 is the correct version for compatibility of files.

CMS Answer: Yes, Microsoft Office 2013 is the correct version.

Question # 2 Section/ Page Number: E.2, 52.212-1 Instructions to Offerors – Commercial Items (Apr 2014) – Addendum, page 50 Question: What is the address of the place for submission of proposals? Can the Offeror submit their proposal in person to the 7111 Security Boulevard, Baltimore (Woodlawn), Maryland address, on the day before the due date of the proposal?

CMS Answer: Yes, an Offeror may drop off their proposal in person to 7111 Security Boulevard. Once you enter the building and approach security, please contact Justin Menefee at 410-786-7629. Prior to drop-off, please contact Justin Menefee to set up a time for arrival.

Question # 3 Section/ Page Number: B, Business Proposal Instructions, page 61 Question: What is required for item (a) Completed Sections E.5 and E.6?

CMS Answer: The solicitation has been amended to reflect sections E.9 and E.10.

Question # 4 Section/ Page Number: A. Technical Proposal Instructions, Factor 8: Section 508 Compliance Question: The Technical Proposal volume list Factor 8: Section 508 Compliance as a section in the Technical Proposal, and it does not count toward page count. In addition, there is a separate volume, Volume IV, Section 508 Proposal, that requires the completion of the Section 508 Product Assessment Template. Should information on 508 Compliance be included in the Technical Proposal and Volume IV?

CMS Answer: The submission of an Offeror’s Section 508 proposal shall be submitted in Volume IV separate from Volume I. However, the Section 508 proposal submission will be included in the technical evaluation as evaluation factor 8.

Question # 5 Section/ Page Number: E.2, 52.212-1 Instructions to Offerors – Commercial Items (Apr 2014) – Addendum, page 51, (8) and E.9, page 66 Question: Item (8) states that the offeror must show “a completed copy of the representations and certifications at FAR 52.212-3(see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically.” What volume should the Offeror provide a completed copy of the representations and certifications?

CMS Answer: Please include a completed copy of the representations and Certifications in Volume II – Business Proposal.

Question # 6 In Section B of the RFP amendment 000005 released on April 22nd, CMS revised the schedule of services to include 4 different categories of recovery types with the offeror expected to provide a proposed contingency fee for each category as part of the business proposal. In practice, we anticipate that the volume of recovery types will vary significantly between these 4 defined categories, however the government is planning on a simple average among the 4 proposed contingency fees to evaluate the offeror’s price. Would the government consider changing the formula utilized in the evaluation (Section E.7) with unequal weights among the 4 defined categories based on the historical distribution of recovery types experienced over the prior contracting period? We believe that this would provide a more realistic estimate of the total cost of this contracting activity to the government, and result in an improved selection process.

CMS Answer: CMS believes weighting by historical distribution would not be relevant to this contract due to the previous high focus on complex patient status review, and low focus on CMS referrals and extrapolation. No changes will be made to this section.

Question # 7 Section/ Page Number: Section B.1 Schedule of Supplies/Services, p. 5 Question: CMS differentiates between four categories of proposed contingency fee percentages: automated, complex, referral, and extrapolation. Please confirm that CMS will reimburse the contractor at the individual rates by review type and not at the overall average contingency fee.

CMS Answer: CMS will reimburse the contractor at the individual rates by review type as specified. The overall average is for the purpose of rating/evaluation to determine lowest price/technically acceptable proposals.

Question # 8 Section/ Page Number: C.3, page 12 Question: This contract is paid by contingency fee and, as there will be no value stated in the contract, we request that HHSAR # 352.203-70 be removed. This section refers to using contract funds for lobbying.

CMS Answer: Although there is not a dollar amount obligated to the RAC contacts, the RACs are still paid based on Government funds and invoices issued against the contract. CMS believes this clause is appropriate.

Question # 9 Section/ Page Number: E. 6, page 52-53, E.6.A, page 54, E.6.D, page 62 Question: Under the Proposal Organization section, Section 508 Compliance is shown as a separate volume, Volume IV. However the Technical Proposal Instructions seem to indicate that the offeror’s Section 508 Compliance Proposal should be included with the offeror’s Technical Proposal, Volume I (although not subject to 50 page limit). Would you please confirm whether the offeror’s Section 508 Compliance Proposal should be incorporated into Volume I, or be submitted as a separate volume, Volume IV.

CMS Answer: The submission of an Offeror’s Section 508 proposal shall be submitted in Volume IV separate from Volume I. However, the Section 508 proposal submission will be included in the technical evaluation as evaluation factor 8.

Question # 10 Section/ Page Number: Factor 7 Past Performance, page 59 Question: Does an Offeror who is a current Recovery Auditor for the Agency need to complete the summary spreadsheet with Agency and contact information?

CMS Answer: Yes, incumbents should provide a completed summary spreadsheet with agency and contact information.

Question # 11 Section/ Page Number: Factor 7 Past Performance, page 59 Question: If the Offeror has experience as a CMS Recovery Auditor contractor do they also need to supply PPQ’s for non-government contractors?

CMS Answer: No, only Offerors and proposed significant subcontractors without relevant Federal government past performance experience in the CPARS/PPIRS System shall submit no more than three (3) Past Performance Questionnaires (PPQ) for the same or similar work.

Question # 12 Section/ Page Number: Factor 8, Section 508 Compliance, p. 59 – 60 Question: Please confirm that, per the statute and regulations, 508 compliance requirements only apply to a contractor’s public-facing RAC-related websites, such as the Provider Portal, RAC page, and Approved New Issues.

CMS Answer: Section C.23, HHSAR 352.239-74 Electronic Information and Technology Accessibility Notice lists the items that need to be 508 Compliant.

Question # 13 Section/ Page Number: Section B.1 Schedule of Supplies/Services, p. 5 Question: CMS differentiates between four categories of proposed contingency fee percentages: automated, complex, referral, and extrapolation. Please confirm that, for any claim where the recovery auditor is required to review medical records, the complex or extrapolation rates will apply.

CMS Answer: Claims actually requested and reviewed would be paid the complex fee; the rest of the claims universe would be paid the extrapolation fee. Medical records reviewed based on a CMS referral are paid the referral fee.

Question # 14 Section/ Page Number: Section B.1 Schedule of Supplies/Services, p. 5 Question: CMS differentiates between four categories of proposed contingency fee percentages: automated, complex, referral, and extrapolation. Please explain how CMS will classify QIO referrals for short stay cases. Will these be considered complex, extrapolation, or referral?

CMS Answer: QIO referrals will be categorized and paid as complex.

Question # 15 Section/ Page Number: E.6 Proposal Organization/page 59

Question: The response to Question #50 indicated all offerors are to submit Past Performance Questionnaires, “Are all offerors required to submit past performance questionnaires, or only offerors who do not have the relevant experience as described in Sub-Factor 1, Legislative Requirement?

CMS Answer: Yes, all offerors are required to submit past performance questionnaires.”

The proposal instructions did not change from, “offeror’s without relevant Federal government past performance experience may ask customers to submit no more than 3 PPQs…”.

Please confirm the “requirement” identified in the Q&A response is for offerors without Federal government past performance to submit up to 3 non-Federal government past performance experience.

CMS Answer: Yes, only Offerors and proposed significant subcontractors without relevant Federal government past performance experience in the CPARS/PPIRS System shall submit no more than three (3) Past Performance Questionnaires (PPQ) for the same or similar work.

Question # 16 Section/ Page Number: SF1449, Solicitation/Contract/Order for Commercial Items and revised RFP.

Question: The initial contract was issued as a negotiated solicitation under FAR Part 15 using SF33. Pursuant to Amendment 5, offeror understands that CMS has revised the solicitation so that services will be procured under FAR Part 12, Acquisition of Commercial Items and governed by FAR Clause 52.212-4 along with other agency specific terms and conditions included in the solicitation.

Please confirm that our understanding that this RFP is now governed by FAR Part 12 is correct.

Please also confirm that offerors should ignore any information provided in the initial solicitation through Amendment 4 and base their response only on the revised RFP provided in Amendment 5.

CMS Answer: This solicitation is a FAR Part 12 acquisition and Offerors should submit proposals in accordance with the information found in amendment 000005 and any subsequent amendments.

Question # 17 Section/ Page Number: Section B.1 Schedule of Supplies/Services / p.5 (follow-up to RFP Question #2) Question: In the case of a future modification to extend the awarded contracts or that significantly impacts the awardee’s ability to recover their costs (e.g. an adjustment in workload or an addition of a new requirement), will awardees be offered an opportunity to update their proposed contingency fees?

CMS Answer: CMS will review the situation and coordinate with the Recovery Auditor to determine appropriate steps in accordance with the terms of the contract.

Question # 18 Section/ Page Number: Section B.1 Schedule of Supplies/Services / p.5 (follow-up to RFP Question #5) Question: We strongly suggest that CMS reconsider implementing price realism as a key criteria in determining whether an offerors proposal is technically acceptable. Specifically, there are many aspects of the statement of work that require significant administrative and operational support – from outstanding customer service for providers, external facing websites, tracking of claims review activities, appeals support, and many others. These requirements, coupled with the fact that these are contingency fee contracts, could leave the Recovery Audit program with uneven support and performance across the various regions if price realism is not considered. Considering the technical aspects along with the offerors ability to achieve them based on their proposed contingency fee would seem to be a significant factor in evaluating an offeror’s technical acceptability. Please explain why price realism will not be applied.

CMS Answer: CMS found LPTA to be the most appropriate source selection for this acquisition.

Question # 19 Section/ Page Number: Section B.2 Schedule of Payments / p.10 (follow-up to RFP Question #11) Question: Often voluntary refunds are triggered by RA activities and do not contain a list of claims. Instead, Providers submit an estimate following RA activities. How does CMS intend to identify whether or not a voluntary refund is associated with RA activities, in these cases?

Also, will CMS provide Recovery Auditors a list of voluntary refunds, since Recovery Auditors often do not know when a provider voluntarily returns money to CMS?

CMS Answer: CMS will review each case independently with the Medicare Administrative Contractor to determine whether a voluntary refund was made based on Recovery Audit activities.

CMS does not currently plan on providing a list of voluntary refunds.

Question # 20 Section/ Page Number: Section B.2 Schedule of Payments / p.10 (follow-up to RFP Question # 14) Question: Can CMS assure Recovery Auditors that, even if appeals increase these timeframes will be met?

CMS Answer: CMS cannot guarantee appeal timeframes, however, CMS will closely monitor appeal contractor timelines, communicate with the respective Contractor Officer Representative(s) and/or oversight component, and intervene where necessary.

Question # 21 Section/ Page Number: Section E.6 Proposal Organization, A. Factor 7 Past Performance / p. 58 (follow-up to RFP Question #47) Question: Does this answer also to apply to past performance for offerors that have never performed under a contingency fee structured contract? As you know, contingency fee contracts require substantial up-front investment in operational infrastructure which generally take longer to recoup thus the contractor assumes more risk than usual in providing serves on a contingency fee basis. Understanding how a contractor performs under this type of contract is key when assessing past performance. We cannot imagine another type of activity that is comparable. Since offerors without contingency fee past performance would have no reasonable expectation to successfully perform the required effort, we recommend CMS consider all non-contingency fee past performance as Unacceptable.

CMS Answer: Each offeror shall submit the required information requested in the solicitation.

Question # 22 Section/ Page Number: RFP Section E.6 Proposal Organization, A. Factor 7, Page 59 and Attachment D.3, Past Performance Questionnaire (follow-up to RFP Question 50) Question: The RFP instructions for past performance only mention Past Performance Questionnaires in the context of offerors without federal past performance, and in that context, PPQs are limited to 3. The answer to RFP Question 50 indicates that all offerors should submit Past Performance Questionnaires. Please confirm that offerors with CMS and/or other federal contracts with performance information in CPARS are not required to submit Past Performance Questionnaires.

CMS Answer: Yes, only Offerors and proposed significant subcontractors without relevant Federal government past performance experience in the CPARS/PPIRS System shall submit no more than three (3) Past Performance Questionnaires (PPQ) for the same or similar work.

Question # 23 Section/ Page Number: RFP Section E.6.B. Business Proposal Instructions, Page 61 Question: The revised Business Proposal instructions direct offerors to include the completed Sections E.5 and E.6. Are these references meant to be Sections B.1 and E.9, or is CMS asking for the Intent to Bid and Proposal Organization to be included in the business volume?

CMS Answer: The solicitation has been amended to reflect sections E.9 and E.10.

Question # 24 Section/ Page Number: E.6, Organization/Page 52 Question: May offerors provide a table of contents to help the evaluators better navigate the proposals? And if so, will the table of contents count against the page limit?

CMS Answer: Yes, Offerors may provide a table of contents and it will not count against the page limit.

Question # 25 Section/ Page Number: Factor 1, Key Personnel and Staffing Plan/Page 55 Question: Factor 1 states that offerors are to employ a Chief Information Officer as well as a Systems Security Officer. Many organizations have this as a combined role for a Chief Information and Security Officer. Will CMS accept this as a combined role, or are these positions required to be filled by two separate personnel?

CMS Answer: The CMS Business Partners System Security Manual in relevant part requires the Systems Security Officer and Chief Information and Security Officer to be separate positions to be filled by two separate personnel. (See language in bold, bullets number 1 and 2.)

· “The contractor shall appoint a Chief Information Officer (CIO) to oversee its compliance with the CMS information security requirements. The contractor’s principal System Security Officer (SSO) shall be a full-time position dedicated to assisting the CIO in fulfilling these requirements.” (Centers for Medicare & Medicaid Services (CMS) Business Partners Systems Security Manual, Rev. 12, Issued: 11-15-13, ,Section 1.1, Additional Requirements for MACs)

· “Business partners shall designate a principal (i.e., primary) SSO qualified to manage the Medicare information security program and ensure the implementation of necessary safeguards. The SSO shall be organizationally independent of IT operations. The SSO can be within the CIO organizational domain, but cannot have responsibility for operation, maintenance, or development.” (Centers for Medicare & Medicaid Services (CMS) Business Partners Systems Security Manual, Rev. 12, Issued 11/15/13, Section 2.2, Principal System Security Officer (SSO))

Question # 26 Section/ Page Number: Section E.2.b, Page 50-51 Question: The RFP states that at a minimum, offers must show the 11 items listed at the end of page 50 and extending onto page 51. Some of these items are not included in Section E.6, Proposal Organization.

· Would CMS like each of these items summarized in a cover letter or executive summary?

· If not, will CMS please clarify which proposal organization offerors are supposed to follow and/or where CMS would like each of these 11 items included in each of the volumes outlined in Section E.6?

CMS Answer: The solicitation has been amended to remove the 11 items listed under section E.2 as section E.6 explains where each document should be provided.

Question # 27 Section/ Page Number: Section E.2.b, Page 50 Question: The RFP states, “The offeror would submit four (4) copies of this proposal as identified below in section 4.” Section E.4 addresses the solicitation questions. Would CMS please clarify?

CMS Answer: The solicitation has been amended to reflect E.6 instead of E.4

MISCELLANEOUS:

Question # 1 Section/ Page Number: Standard Form 1449 Question: What volume should the completed SF 1449 be included in?

CMS Answer: Please include the SF 1449 in the Business Proposal submission – Volume II Question # 2 Section/Page Number: Attachment D.7, Part I of the Contractor Personal Conflicts of Interest Financial Disclosure Form, page 3 of 9 Question:

1. Part I of the Contractor Personal Conflicts of Interest form requires disclosure by the reporter of the dollar amount of each healthcare related asset (e.g., stock, bond, sector mutual fund, etc.). Reporters who complete this form may have investments in medical device and pharmaceutical manufacturers, commercial healthcare insurers or other entities that would not constitute healthcare providers (i.e., entities that could be audited under the RAC contract). To the extent these entities do not submit reimbursement claims to CMS that might be the subject of a recovery audit under the RFP, an investment in these entities would not appear to pose any actual, apparent or potential conflict of interest. Consequently, would it be acceptable not to require disclosure of these investments in the form?

CMS Answer: No, this information must be submitted. However it should be understood that the personal conflict of interest information is submitted to the offeror’s Compliance Officer and not to the Government.

1. Alternatively, if CMS concludes that the investments described above must be disclosed, would it be acceptable not to require disclosure of the dollar amount of each of these investments, which would in many cases be an onerous requirement for reporters?

CMS Answer: No, the dollar amount must be included. However it should be understood that the personal conflict of interest information is submitted to the offeror’s Compliance Officer and not to the Government.

1. As a further alternative, if CMS concludes that the investments described above and the dollar amount of each of those investments must be disclosed, would it be acceptable to allow the reporter to make disclose the dollar values based on reasonable dollar ranges, rather than specific dollar amounts for each investment (e.g., disclose if an investment value is (i) under $10,000; (ii) $10,000 or more but less than $75,000, or (iii) $75,000 or more)?

CMS Answer: Yes, this would be acceptable. However it should be understood that the personal conflict of interest information is submitted to the offeror’s Compliance Officer and not to the Government.

Question # 3 Section/ Page Number: Q&A, p.25 Question: CMS plans to provide several pre-approved issues for review. As our fee bid will depend on what those issues are, please list the pre-approved issues.

CMS Answer: CMS will not provide a list of pre-approved issues.

Question # 4 Section/ Page Number: Q&A, p.25 Question: CMS plans to provide several pre-approved issues for review. Will pre-approved issues be considered referrals for purposes of the contingency fee?

CMS Answer: CMS Pre-approved issues are considered recommendations only, not referrals. The decision to review a pre-approved issue is at the discretion of the Recovery Auditor.

Question # 5 Section/ Page Number: Q&A, p.39 Question: What will ADR limits be at the start of the contract? Will they be equal to, or greater than, the ADR limits outlined in the chart in the original Q&A?

CMS Answer: As of January 1, 2015, CMS has revised the ADR limits. Guidelines and the new adjustment methodology can be found at:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Institutional-Provider-Facilities-ADR-Limits-May-2016.pdf.

Question # 6 Section/ Page Number: Amendment_000005_RAC_AB_QA, Question #35, Page 12 Question: May offerors also include items such as a detailed work plan, transition plan, company’s security plan, etc. as an appendix? Or are the items listed in response to question #35 the only items that may be included as an appendix?

CMS Answer: A detailed work plan, transition plan, company’s security plan should not be included as an appendix. Appendices should only include resumes, organizational charts, letters of intent, past performance disclosures, and any relevant financial information.

Question # 7 Section/ Page Number: Amendment_000005_RAC_AB_QA, Question #35, Page 12 Question: May offerors include resumes for the essential personnel, such as the Chief Information Officer, Systems Security Officer, Customer Service Manager, and any other personnel that are essential to the success of the program? Or are offerors only to include resumes for the key personnel.

CMS Answer: Offerors should only include resumes for the key personnel as instructed.

Question # 8 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question 14, Page 6 Question: We understand that “CMS is unable to control or direct providers on the frequency or appropriateness of appealing”. However, to ensure balance between the provider community and the Recovery Auditors, will CMS consider allowing the RACs to audit more claims for providers found to be arbitrarily and inappropriately appealing claims without cause, so as to artificially and purposely “clog the system”?

CMS Answer: CMS is unable to determine with any degree of certainty that a provider is arbitrarily appealing claims to clog the system as characterized in the question. CMS will not adjust a provider’s ADR limits and/or increase the volume of claims available for Recovery Audit review based on these or similar assumptions.

Question # 9 Section/ Page Number: Amendment_000005_RAC_AB_QA, Question #3, Page 25 Question: Will the two awards be one DME and one non-DME award, or does CMS foresee allowing one offeror to be awarded two non-DME contracts?

CMS Answer: The two awards may be a combination of one DME and one Part A/B award, or two Part A/B awards.

Question # 10 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #5, Page 30 Question: Would CMS consider the short term establishment of a workgroup which could include a RAC representative and be chartered with evaluating the current review process and recommending potential approaches for streamlining the review and decision process?

CMS Answer: No response is being provided to this question. The question has no bearing on the solicitation and evaluation of proposals.

Question # 11 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #10, Page 32 Question: Under this continued practice would CMS consider paying the applicable RAC(s) a one-time fee based upon the original RAC review topic, which was recommended and implemented by the RAC(s) but has now been retired or become obsolete because of the implementation of the MAC edit? This process is disadvantageous to the RAC(s) by the practice of CMS implementing an edit for a review topic that originated with the RAC(s).

CMS Answer: CMS will not pay a one-time fee based on an established review topic as characterized in the question. MAC edits are an anticipated part of CMS program safeguard measures and coincide with the overall goal of the Recovery Audit Program to ensure claims are paid correctly and to protect the Medicare Trust Funds.

Question # 12 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #19, Page 35 Question: For financial planning purposes, can CMS provide a “not to exceed” amount for this expense?

CMS Answer: CMS is unable to establish the costs involved and will not establish a “not to exceed” cost threshold.

Question # 13 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #32, Page 40 Question: Will CMS reconsider this decision in light of Section 638 of the American Taxpayer Relief Act of 2012 which appears to have extended the look back period to five years by amending the last sentence of two subsections of a section of the Social Security Act:

SEC. 638. REMOVING OBSTACLES TO COLLECTION OF OVERPAYMENTS. (a) IN GENERAL.—The last sentence of subsections (b) and (c) of section 1870 of the Social Security Act (42 U.S.C. 1395gg) are each amended— (1) by striking ‘‘third year’’ and inserting ‘‘fifth year’’; and (2) by striking ‘‘three-year’’ and inserting ‘‘five-year’’. (b) EFFECTIVE DATE.—The amendments made by subsection (a) shall take effect on the date of the enactment of this Act.

This extension to five years is also consistent with an OIG recommendation for a longer look back period, see OIG report: http://oig.hhs.gov/oas/reports/region4/41003059.pdf , which CMS concurred with.

CMS Answer: As stated in the initial response to Question #32, no changes will be made to the look-back period at the current time.

Question # 14 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #33; Page 40 Question: Will CMS please provide additional background and/or information for the types of hardware/software expected/required to support esMD so that RAs can better determine what the true costs will be associated with this requirement? If CMS cannot provide this, please provide further justification for the determination that the expected costs will be minimal.

CMS Answer: CMS believes the expected costs will be minimal based primarily on the following factors:

· esMD utlizies the existing CMS Managed File Transfer for exchange of files/documents to/from contractors,

· esMD provides a Java and .Net version of ‘RC Client’ that is developed and maintained by esMD for the contractor to use directly as is, or they have the option of using a customized version using the esMD services,

· esMD provides support to on-boarding and assisting on issues via the esMD support team.

Question # 15 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question 50, Page 47 Question: Has CMS ever approved a Recovery Auditor initiated extrapolation? If yes, will CMS provide the parameters of this approved extrapolation with all new Recovery Auditor contract awardees?

CMS Answer: CMS has not approved any extrapolation reviews as of the release of the solicitation.

Question # 16 Section/ Page Number: Amendment_000005_RAC_AB_QA; Question #79; Page 58 Question: Will CMS please provide additional background and/or information for the types of hardware/software expected/required to support the web-based, referral tracking system so that RAs can better determine what the true costs will be associated with this requirement? If CMS cannot provide this, please provide further justification for the determination that the expected costs will be minimal.

CMS Answer: CMS expects minimal costs as we anticipate using a system already in existence for the current Recovery Audit Program (e.g., Recovery Audit Data Warehouse, CMSnet).

STATEMENT OF WORK QUESTIONS (SOW):

Question # 1 Section/ Page Number: CMS responses; Question 59, page 50 Question: Since CMS will provide the awardee with both the New Issues and the Preapproved Issues, would CMS also provide the appeal rate of the Preapproved Issues?

CMS Answer: Appeal rates vary among contractors who may review the same issue. CMS will not provide the individual appeal rates of these contractors.

Question # 2 Section/ Page Number: Section H Recovery Auditor Staff, p. 10 Question: The Project Manager is required to have a master’s degree from an accredited institution or substitution of four (4) additional years of related work experience in lieu of the master’s degree. Please confirm whether a J.D. would be acceptable in lieu of a master’s degree.

CMS Answer: A J.D. is acceptable in lieu of a Master’s degree.

Question # 3 Section/ Page Number: Task 1, p. 14 Question: At its discretion, CMS may impose minimum percentage review requirements by claim type. Please provide more details and the percentages here as this could significantly impact our costs.

CMS Answer: CMS would only consider adding percentage minimums if the Recovery Auditor(s) was not reviewing all claim/provider types as required. It is not possible to anticipate the related percentages.

Question # 4 Section/ Page Number: Task 1, p. 14 Question: At its discretion, CMS may impose minimum percentage review requirements by claim type. Where CMS imposes review requirements, will these reviews be considered referrals?

CMS Answer: No.

Question # 5 Section/ Page Number: Purpose /Pages 1-2 (follow-up to SOW Questions #2, #4, and #37) Question: The Recovery Audit Program continues to have significant workload volume uncertainty, as exhibited in CMS’ response to the “STATEMENT OF WORK QUESTIONS (SOW): Sections and Page Numbers refer to Region 5 SOW” Questions #2, #4, and #37. In CMS responses to these questions, it appears that a risk-based Provider ADR adjustment process has not been fully developed, and is unavailable for contractors to use in their evaluation and consideration of this solicitation – as CMS has not provided any specificity and is only referencing a range of ADR limits (0-100%) based on “low” and “high denial rates”.

Offerors require more details regarding CMS’ risk-based Recovery Audit Program in order to effectively proposal a firm fixed contingency fee. Without this vital information, offerors may wildly underbid or overbid a firm fixed contingency fee that is inconsistent with the future expected workload volume. As a result, offerors may not be able to recover the costs of performing the RA contract, or, conversely, CMS may over compensate offerors. Either outcome will have a negative impact to the RA program, and ultimately the Medicare Trust Fund.

In order to avoid this pitfall, we respectfully request that CMS provide offerors with CMS’ risk-based Recovery Audit Program, and future expected workload volumes in order to adequately evaluate and propose a firm fixed contingency fee price.

In addition, we request CMS share the process and timeline for evaluating and adjusting providers’ ADR limits – i.e. when will providers’ error rates be initially evaluated, how frequently will providers’ error rates be evaluated throughout the contract, and how quickly will RAs be able to implement these changes in ADR limits.

Additionally, under the current ADR model, many providers are excluded from audit because the calculation of their ADR limits are less than zero every 45 days. How does CMS intend to evaluate these providers, or will they be excluded from RA reviews indefinitely?

CMS Answer: Guidelines and the adjustment methodology can be found at the following link:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Institutional-Provider-Facilities-ADR-Limits-May-2016.pdf.___ Providers with zero (0) ADR limits are low billers and do not represent a significant arisk to Medicare Trust Funds. Baseline ADR limits will be calculated annually to ensure providers whose limit is more than zero (0) are available for review.

Question # 6 Section/ Page Number: Task 1, F. Website and Provider Portal / p.26-28 (follow-up to SOW Question #43) Question: Does CMS know what uniform requirements are planned and will be required for offerors and can CMS provide this information as part of the SOW?

CMS Answer: These requirements have not yet been fully established and will be published for Recovery Auditors upon completion. Once established, the requirements may be subject to change throughout the Program and CMS will use Technical Direction Letters (TDLs) to indicate these changes. TDLs provide instruction and direction to contractors without altering the SOW.

Question # 7 Section/ Page Number: Task 1- Identification of Improper Payments on Postpayment Review; G. Activities Following Review; L. Compromise and/or Settlement of Overpayment/ page 34 (follow-up to SOW Question #53) Question: Understanding CMS is retaining this clause; there are many reasons why CMS may choose to enter into a settlement or compromise, including the financial health of a provider or litigative risk to CMS regarding its payment policies. These examples show settlements and compromises that CMS enters into often are not be related to whether the RA made the correct determination and correctly applied CMS’s payment policies. Additionally, in these cases the RA has reviewed the claim and the issue as directed by CMS. Assuming the RA made the correct determination and applied CMS’ payment policy accurately, would CMS consider those situations as unique and not recoup contingency fees?

CMS Answer: Similar to if a claim is overturned on appeal, the amount of recoupment is reduced in the case of a settlement and contingency fee will be adjusted accordingly.

Question # 8 Section/ Page Number : Task 3, B. Accuracy Reviews / p.38 (follow-up to SOW Question # 61) Question: Will RAs have an opportunity to review the accuracy rate information prior to CMS recalculating their fees?

CMS Answer: Recovery Auditors have the opportunity to dispute accuracy decisions and discuss results with CMS and the Validation Contractor.

Question # 9 Section/ Page Number: Administrative and Misc. Issues, A. Payment Methodology / p. 48 (follow-up to SOW Question #88) Question: If CMS will not consider excluding ALJ appeal overturns from reducing contingency fees; will CMS allow RAs discretion when reviewing claims? Specifically, will CMS consider allowing RAs to base their denial determinations following documentation requirements that ALJs must follow such as, NCDs, legislation, and statute? Aligning review requirements with the way ALJs apply discretion to documentation requirements contained in LCDs and manual instructions could reduce the number of provider appeals, as well as the overturn rate. Also, will CMS consider aligning or revising review criteria at some point in the future?

CMS Answer: Recovery Auditors shall review in accordance with all applicable policies and should reference the hierarchy of authorities when reviewing claims: Program Integrity Manual, Chapter 3.3. Recovery Auditors have discretion to limit reviews to those authorities that are applicable to ALJs (except in the case of CMS referrals). The Statement of Work also references this in Task 1.3.E.a.