TDEFIC_Pre-Proposal_Conference_4-26-13.pdf

TRICARE Dual-Eligible Fiscal Intermediary Contract (TDEFIC)

Solicitation HT9402-12-R-0005 Pre-Proposal Conference

April 26, 2013

TRICARE Management Activity 16401 East Centretech Parkway Aurora, Colorado 80011-9066

TDEFIC Pre-Proposal Conference:

Agenda

• Welcome/Introductions.

• Overview of the TDEFIC Requirement.

• Proposal Preparation.

• Conclusion.

Introductions

• Mr. Scott Lamond, Contracting Officer, Contract Operations Division, Aurora.

• Ms. Cheryl Griffing, Program Analyst, Policy and Benefits Branch.

• Ms. Laura Johnson, Program Analyst, Policy and Benefits Branch.

Introductions

Primary Point of Contact:

Ms. Margaret Zancanella Contract Specialist margaret.zancanella@tma.osd.mil Phone: (303) 676-3451

Secondary Point of Contact:

Mr. Scott Lamond Contracting Officer scott.lamond@tma.osd.mil Phone: (303) 676-3649 mailto:margaret.zancanella@tma.osd.mil mailto:scott.lamond@tma.osd.mil

• This TDEFIC acquisition is for a new contract for the continuation of comprehensive health care claims processing, customer support and other associated administrative services on behalf of dual-eligible Medicare/ TRICARE beneficiaries.

• Adds a requirement for limited targeted education for beneficiaries and providers.

• Information Assurance requirements are governed by National Institute of Science and Technology (NIST) standards rather than the Defense Information Assurance Certification and Accreditation Process (DIACAP).

Program Overview

• Contract Goal: Furnish high quality health care in a manner that protects the fiscal and other interest of the US Government (Chapter 55, Title 10).

• Contract Objectives:

• Provide timely and accurate delivery of health care claims processing and customer services;

• Establish and maintain beneficiary and provider satisfaction at the highest level possible throughout the period of performance, through the delivery of a claims processing system as well as customer friendly program services;

• Use an effective management approach to provide the necessary services, incorporating best business practices when practicable; and

• Ensure all services and systems are fully operational at the start of health care claims processing (Beginning Option Year 1) with minimal disruption of services to beneficiaries.

• Claims processing, Customer Service and administrative functions for dual-eligible Medicare and TRICARE beneficiaries.

• Eligible Beneficiaries noted in TRICARE

Operations Manual (TOM), Chapter 20, Section 1.

• Current Dual-Eligible Population: 2.1 million covered lives.

• Jurisdiction: Services received in the United States and its territories.

• TDEFIC Claims (See HT9402-12-R-0005 Exhibit L-2, Workload Volumes)

• Estimated 48 million claims processed annually (approximately 4 million per month).

• 98% of claims received are 2nd pay to Medicare.

• 2% TRICARE Primary Pay.

• 88% of claims are electronic.

• 12% of claims are paper.

• Reimbursement

• Primary reimbursement guidance TRICARE Reimbursement Manual

(TRM), Chapter 4 Section 4 (See HT9402-12-R-0005 Attachment J-6, TRM, Chap 4, Section 4, Specific Double Coverage Actions).

• Primary Pay Examples

• Medicare benefits are exhausted.

• Part B claims for Active Duty Family Members w/o Part B.

• Service is not a Medicare benefit.

• TRICARE Encounter Data (TED) Records

• Vehicle by which the Military Health System (MHS) Obtains & Tracks Purchased-care Processed Claims & Encounter Data.

• Provides Detailed Information for Each Treatment Encounter.

• Reflects the Government’s Need for Complete Health Care Records with

Minimum Data Sets.

• Incorporates Health Insurance Portability and Accountability Act (HIPAA)

Requirements and Data Element Code Sets.

• Invoices that are the Basis for TRICARE Management Activity Financial

Systems to:

• Approve the Release of Non-financially Underwritten Healthcare

Dollars.

• Pay Electronic & Paper Administrative Claim Rates.

• Collect Interest.

• TED (continued)

• Captures

• Sponsor/Beneficiary Information.

• Rendering Provider’s Identification & Specialty.

• Healthcare Data.

• Financial Amounts.

• TRICARE Special Processing Information.

**Specific TED data requirements are found in the TRICARE System Manual, Chapter 2.

TED processing standards = TOM Chapter 1, Section 3.

• Centers for Medicare and Medicaid Services (CMS)

Coordination of Benefits Contractor (COBC)

• Single contractor established by CMS.

• Automatically transfers adjudicated Medicare Part

A & B claims data to secondary payers via trading partner agreements.

CMS Coordination of Benefits Contractor (COBC) cont:

• Defense Enrollment Eligibility Reporting System (DEERS)

• Performs a data match with CMS to obtain Medicare data.

• This Medicare data is incorporated into the DEERS database with noted effective dates.

• DEERS also provides the TDEFIC with a monthly eligibility file based on the Medicare Parts A and B information to utilize as part of their coordination with the COBC (See HT9402-12-R-0005 Attachment J-7, DMDC Eligibility File Layout).

• Seamless process for TRICARE Providers and Beneficiaries.

• Crossover fees paid to the COBC cover the transmission of Medicare claims data. These are submitted via a non-Ted voucher. Instructions are noted in Section G.11.3

• Customer Service

• Explanation of Benefits format and clarity of actions.

• Accuracy of Responses.

• HIPAA and Privacy Requirements, including email.

• Relationship/Coordination with the Managed Care Support

Contractors (MCSCs).

TOM Chapter 11, Section 7, paragraph 5.0 real time remote call monitoring N/A (real time on-site call monitoring applicable)

• Skilled Nursing Facility (SNF) Preauthorization.

• The TRICARE SNF benefit structure and reimbursement methodology follows Medicare with the exception of Medicare’s 100 day limitation (See TRM Chapter 8, Section 2).

• Preauthorization Requirements when TRICARE becomes primary payer for TDEFIC beneficiaries (Effective with dates of service 6/1/2010).

• Challenges

• SNF care not covered beyond Medicare’s day limitation under most insurance.

• Provider belief that TRICARE will continue to pay.

• TRICARE becoming primary payer in the middle of the episode.

• Timing of claim receipt and documentation.

• Uncertainty of needed documentation.

• The successful offeror is not responsible for the following (MCSCs functions):

• Enrollment

• Networks

• Referrals

• TRICARE Service Centers (TSCs) and Military

Treatment Facilities (MTF)

**Benchmark testing will not occur.

Proposal Preparation

• Solicitation HT9402-12-R-0005

• Also known as a request for proposals (RFP).

• Posted on Federal Business Opportunities (fbo.gov.).

• Proposals & Past Performance Questionnaires are due

1200 Noon (Mountain), June 3, 2013.

• Late proposals will not be considered for award.

• The TDEFIC solicitation:

• Is a full and open competition using tradeoff best-value source selection procedures.

• Will result in the award of a single requirements contract with fixed unit prices.

• The period of performance includes:

• A 10-month transition-in period, plus six 1-year option periods.

• Transition-out will occur concurrently with the last option period exercised.

• Read entire Solicitation, including all amendments, sections, attachments and background information carefully.

• Pay special attention to Sections L and M.

• Failure to comply with the RFP instructions could result in the proposal being ineligible for award.

• It is the offeror's responsibility to ensure its proposal meets the solicitation requirements.

• Government will not provide a hard copy of solicitation.

• The Government will post any subsequent revision to the solicitation requirements as an amendment to the solicitation.

• As of today, there is one amendment to the solicitation.

• Summary of Changes:

• Amendment 1, dated Apr 11, 13:

• Deleted requirement for benchmark testing

• Updated the paper claims estimated quantities

• Other minor revisions

• Any changes are posted to fbo.gov.

• L.2.2.3.1. In the Government’s opinion, the following companies represent an actual conflict of interest and, unless demonstrated otherwise, may not serve as a prime contractor, subcontractor, or in any advisory capacity to any offeror of this solicitation and the resulting contract:

• Axiom

• Kennell and Associates

• Keystone Peer Review Organization (KePRO)

• Lockheed-Martin

• National Government Services (NGS)

• SofTec Solutions

• Cherokee Information Services

• ThinkQ

• OST Global Solutions, Inc.

Organizational Conflicts of Interest (OCI)

• Paragraph L.2.2.3.2. “Potential” or “actual” OCIs may exist with TMA contractors who currently perform logistical, program, operational, data management support for TMA Aurora, CO; TMA Falls Church, VA; and Defense Manpower Data Center. The following may fall into the “potential” or “actual” category:

• HP Enterprise Services (formerly EDS), IntelliDyne LLC, CTA Inc., E.R. Williams, Bearing Point, the Lewin Group, Ingenix, Delmarva Foundation, Quintiles Pharma Inc., and Quintiles Transnational Group.

Former DoD officials/employees OCIs:

• Paragraph L.2.2.4. “Potential” or “actual” OCIs may exist with former DoD officials/employees that have served in positions such as TRICARE acquisitions, program management, finance, in an executive position or participated in a TRICARE source selection evaluation board as the source selection authority, an advisor or an evaluator (See DFARS 252.203-7000 (Ref 203.171-4)).

• It is incumbent on each offeror to use sound business judgment and determine the significance of any conflict of interest.

Contract Award

• The Government intends to evaluate offers and award a contract without discussions with offerors.

• The offeror’s initial offer should contain the offeror’s best terms from a price and technical standpoint.

• Award will be made on a competitive best value basis using the Tradeoff approach.

Tradeoff Source Selection Procedures (see FAR 15.101-1).

• Allow for a tradeoff between non-cost factors and cost/price.

• Allow the Government to accept other than the lowest priced proposal or other than the highest technically rated proposal to achieve a best-value contract award.

• Factors (in order of importance).

• Factor 3, Price.

• Factor 1, Technical Approach.

• Factor 2, Past Performance.

• The non-price factors, when combined, are significantly more important than price (FAR 15.101).

Factor 1, Technical Approach

• 5 Subfactors:

• Subfactor 1, Claims Processing

• Subfactor 2, Beneficiary and Provider Customer Service and

Satisfaction

• Subfactor 3, Management Functions

• Subfactor 4, Transition Activities

• Subfactor 5, Small Business Subcontracting Participation

• Subfactor 1, Claims Processing, and Subfactor 2, Beneficiary and Provider Customer Service and Satisfaction, are of equal importance and the most important subfactors.

• Subfactor 3, Management Functions, and Subfactor 4, Transition Activities, are of equal importance and less important than Subfactors 1 and 2.

• Subfactors 3 and 4 are more important than Subfactor 5.

• Subfactor 5, Small Business Subcontracting Participation, is the least important subfactor.

Factor 2, Past Performance:

• 5 contracts for offeror and each first-tier subcontractor

• Recency: Within the 3 years prior to June 3, 2013.

• Relevancy: See paragraphs L.7.3 and M.5.3 of the Solicitation.

• Quality: See paragraph M.5.4.: Government will use Past Performance

Questionnaires, CPARS reports, other past performance information.

• Performance Confidence Assessment: See paragraph M.5.5. Based on the recency, relevancy, and quality, the Government will assess a performance confidence assessment rating relative to the offeror’s ability to successfully perform the requirements of this solicitation.

• One performance confidence assessment rating will be assigned for each offeror after evaluating the offeror’s past performance in total.

• Sources of Past Performance Information:

• May be provided by the offeror as stated in the solicitation.

• May be obtained from questionnaires tailored to the circumstances of the acquisition (See Exhibit L-5, Past Performance Questionnaire).

• Shall be obtained from any other sources available to the Government to include, but not limited to, PPIRS or other databases; interviews with Program Managers, Contracting Officers, and Fee-Determining Officials;

and the Defense Contract Management Agency.

• The past performance evaluation team will review this past performance information and determine the quality and usefulness as it applies to performance competence assessment.

Past Performance Questionnaires (PPQs) (Exhibit L-5):

• Use Exhibit L-5 posted as part of the TDEFIC Solicitation on

FBO on April 5, 2013.

• The PPQ states “* To facilitate proposal evaluation, the offeror or its first-tier subcontractor/teaming partner shall CLEARLY state the offeror’s name under which the proposal is submitted to the Government. The past performance questionnaire will not be considered if the Government cannot determine whose past performance or the offeror team to which the past performance belongs.”

• TMA encourages the offeror to complete the following items on the PPQ before sending it to the customer:

• Contractor/Subcontractor Name

• Customer/Account Name, Address

• Period of Performance (month/year): From ________ to ________

• Annual Contract Value:

• Number of Beneficiaries/Customers Served:

• Annual Number of Claims Processed (if applicable):

• Contract Summary (to include type and scope of services provided):

Factor 3, Price

• Options: The price evaluation is inclusive of the evaluation of options.

• Total evaluated price: The sum of all priced Contract Line Item

Numbers (CLINs )and Sub-line Item Numbers in Section B, Supplies or Services and Prices/Costs, for the Transition Base Period and each of the six option periods. Since Transition-out will occur only once during the contract Period of Performance, the offeror’s highest priced Transition-out CLIN will be included and used in calculating the total evaluated price.

• Reasonableness. The Government will use the proposal analysis techniques discussed in FAR § 15.404-1 in determining reasonableness.

Price analysis will be the primary technique used in the government’s price evaluation.

• Unbalanced Pricing. The Government will evaluate each offeror’s price proposal for unbalanced pricing per FAR 15.404-1(g).

TDEFIC Pre-Proposal Conference :

• The Government strongly encourages offerors to read the Government’s Responses to Vendors’ Questions.

• Where any response indicates a change to a solicitation document or section, those will be incorporated into a future amendment to the solicitation.

• Offerors shall proceed with their proposal preparation based on the information in the RFP, as supplemented by the Government’s Responses to Vendors’ Questions

TDEFIC Pre-Proposal Conference

Thank you for attending