38_TCRS_Sec_L_Exhibit_L-10_Draft_QASP_11-7.16.pdf

Exhibit L-10 Draft Quality Assurance Surveillance Plan (QASP)

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 1 of 9

QUALITY ASSURANCE SURVEILLANCE PLAN

TRICARE CLAIMS REVIEW SERVICES (TCRS)

Contract Number: HT9402-16-D-XXXX

Contract Description: The purpose of the TCRS contract is to assist the Improper Payment Evaluation and Transition Branch (IPE&TB), DHA Budget & Resource Management Division, Business Support Directorate, in identifying and reporting improper payments. This contract provides independent impartial review of claims processing procedures, reimbursement determinations, and purchased-care contractor compliance with TRICARE policy and directives.

The TCRS contractor shall evaluate the accuracy of claims payment and payment record coding for the MCSCs, TDEFIC, TPharm, TOP, and the ADDP contracts. This contract also supports IPE&TB’s requirement to assess the potential risk of improper payments and to identify, recover, and report improper payments to the Office of Management and Budget (OMB) for publication in the Department of Defense (DoD), Agency Financial Report (AFR) pursuant to Public Laws 107-300, Improper Payment Information Act (IPIA) of 2002, and 111-204, Improper Payment Elimination and Recovery Act (IPERA) of 2010.

Contractor’s Name: (hereafter referred to as the contractor)

1.0 PURPOSE

1.1 This Quality Assurance Surveillance Plan (QASP) provides a systematic method for the Government to evaluate the contractor’s performance for the stated contract. The QASP explains the following:

• What will be monitored

• How monitoring will take place

• Who will conduct the monitoring

• How monitoring efforts and results will be documented

1.2 The contractor is responsible for implementing and delivering performance that meets contract standards using its Internal Quality Management Program (IQMP) Plan (CDRL AP030).

The QASP provides the structure for the government's surveillance of the contractor's performance to assure that it meets contract standards. It is the Government's responsibility to be objective, fair and consistent in evaluating contractor performance.

1.3 The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

1.4 The Government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor. The QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

1.5 Authority: Authority for issuance of this QASP is provided under Federal Acquisition Regulation (FAR) 46, Quality Assurance; which provides for inspection, acceptance and documentation of the service called for in the contract or order.

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 2 of 9

2.0 GOVERNMENT ROLES AND RESPONSIBILITIES:

The following personnel shall oversee and coordinate surveillance activities:

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract.

The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Contracting Officer: Todd Young Organization or Agency: Defense Health Agency/COD-A, Aurora, CO Telephone: (303) 676-3675 Email: Todd.M.Young.civ@mail.mil

b. Contracting Officer’s Representative (COR) - The COR is responsible for the technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. At the conclusion of the contract or when requested by the CO, the COR shall provide documentation to the CO. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf. The contractor shall refer any changes it deems may affect contract price, terms, or conditions to the CO for action:

Assigned COR: TBD Organization or Agency: Defense Health Agency/IPE&TS, Aurora, CO Telephone Number:

Email:

c. Other Key Government Personnel Title: Program Manager, TBD Telephone:

Email:

3.0 CONTRACTOR REPRESENTATIVES:

The following TCRS employees are the contractor’s designated point(s) of contact for contract performance:

a. Program Manager:

Telephone Number:

Email:

b. Task Manager:

Telephone Number:

Email:

mailto:Margaret.A.Zancanella.civ@mail.mil

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 3 of 9

c. Other Contract Personne:

Title:

Telephone Number:

Email:

4.0 PERFORMANCE STANDARDS:

4.1 The performance standards define the level of service required under the contract for the contractor to meet each performance objective in Section C, TCRS Performance Work Statement (PWS). The contract and task orders will specify quality performance metrics and the Acceptable Quality Levels (AQLs) as the standards the Government requires from the contractor’s performance of services. The Government will perform surveillance to determine if the contractor exceeds, meets or does not meet these standards.

4.2 The Government shall compare the contractor’s performance to the minimum Acceptable Quality Levels (AQLs) in the Performance Standards Summary Matrix below.

Table 1, Performance Standards Summary Matrix

Performance Objective

Standard Acceptable Quality Level

Method of Surveillance

Performance Standards:

Compliance Reviews Compliance Reviews – Initial:

The contractor shall complete all quarterly, semiannual and annual payment and occurrence compliance reviews as required by Section C, paragraphs 6.4.2.1.4–6.4.2.1.7.1

The contractor shall complete initial compliance reviews within 60 days from the date the contractor receives claims documentation from purchased-care contractor(s). The contractor shall provide the following CDRL deliverables: R011 thru

R015, DRG/OPPS

Calculation Worksheets.

100% of initial compliance reviews shall completed within 60 days of receipt of claims documentation and DRG/OPPS calculation worksheet shall be submitted to the COR within 2 days following the completion of the initial compliance review process.

Random monitoring of IPE&TS internal Compliance Review Tracking Log

Compliance Reviews – Rebuttal:

The contractor shall complete all quarterly, semiannual and annual payment and occurrence rebuttal

The contractor shall complete rebuttal reviews within 30 days from the date the contractor receives rebuttal comments from the purchased-care contractor(s). The

100% of initial compliance reviews shall completed within 30 days from receipt of rebuttal comments and rebuttal comments shall be submitted to the COR within 2 days following

Random monitoring of IPE&TS internal Compliance Review Tracking Log

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 4 of 9 reviews as required by Section C, paragraphs 6.4.2.1.8 and 6.4.2.1.8.1.1 contractor shall provide the following CDRL deliverables: R160 thru R220, Compliance Review – First Rebuttal Response Report (by purchased care contract).

the completion of the rebuttal review process.

Compliance Reviews. Second Rebuttal: The contractor shall complete all quarterly, semiannual and annual payment and occurrence second rebuttal reviews as required by Section C, paragraph 6.4.2.1.8.2.

The contractor shall complete second rebuttal reviews within 15 days from the date the contractor receives second rebuttal comments from the purchased-care contractor(s). The contractor shall provide the following CDRL deliverables: R230 thru R290, Compliance Review – Second Rebuttal Response (by purchased care contract).

100% of initial compliance reviews shall completed within 15 days from receipt of second rebuttal comments and second rebuttal comments shall be submitted to the COR within 2 days following the completion of the second rebuttal review process.

Random monitoring of IPE&TS internal Compliance Review Tracking Log

Performance Standards: Report Submission The contractor shall complete an Analysis of Errors report as required by Section C, paragraph 6.1.3.2

The contractor shall provide CDRL deliverables R020 through R080, Analysis of Errors Report (by purchased care contract)

100% of the analysis of errors reports shall be completed within 5 days after the end of each claims review cycle

100% Inspection

The contractor shall submit weekly status reports detailing all compliance review activities (i.e. initial, rebuttal, second rebuttal, and error report) as required by Section C paragraph 6.1.3

The contractor shall provide CDRL deliverables W030, Claims Review Workload Status Report and W040, Weekly Activity Status Report

100% of reports shall be submitted to the COR on time with no more than 1 correctable error per submission and no more than 2 rejected items per 100 submissions

100% Inspection

The contractor shall submit results of its

The contractor shall provide CDRL

100% of reports shall be submitted to the COR

100% Inspection

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 5 of 9

Internal Quality Assurance (QA) Reviews as required by Section C paragraph 6.2.2 deliverables R090 thru R150, Internal Quality Assurance Reviews (by purchased care contract and compliance review cycle reviewed).

on time with no more than 1 correctable error per submission and no more than 2 rejected items per 100 submissions

Performance Standards: Focus Studies / Medical Record Reviews The contractor shall submit written results of completed focus studies as required by Section C, paragraph 6.5.1.5

The contractor provides CDRL deliverable R330, Focus Study Analysis Report

100% of studies shall be submitted to the COR on time with no more than 1 correctable error per submission and no more than 2 rejected items per submission

100% Inspection

The contractor shall submit written results of completed medical record reviews as required by Section C, paragraph 6.5.2.8

The contractor provides deliverable CDRL R340, Medical Record Review Analysis Report

100% of medical record reviews submitted to the COR on time with no more than 1 correctable error per submission and no more than 2 rejected items per submission

100% Inspection

Performance Standards:

Government QA Reviews The contractor shall participate in the Government External QA reviews by submitting requested documentation as required by Section C, paragraph 6.2.3.2

– 6.2.3.4

The contractor provides claims documentation within 7 days from the date of the COR’s QA notification letter.

100% of all QA claims review documentation submitted to the COR on time with no more than 1 missing document per submission

100% Inspection

The contractor shall evaluate and respond to Government External QA review findings as required by Section C, paragraph 6.2.3.5

The contractor provides rebuttal comments within 5 days of receipt of the COR’s QA report.

100% of all contractor rebuttal comments submitted to the COR on time with no more than 1 missed rebuttal response.

100% Inspection

The contractor’s The Government will The contractor’s 100% Inspection

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 6 of 9 payment and occurrence error rates performance shall meet the Acceptable Quality Levels as stipulated to the right with performance calculations provided in Section C, paragraphs

6.2.3.6 and 6.2.3.7 conduct ongoing evaluations of finalized contractor reviewed claims.

payment and occurrence error rate performance for Option Period One shall not exceed 1%, and shall not exceed .5% for the subsequent option periods

5.0 METHODOLOGIES OF QA SURVEILLANCE:

5.1. Various methods exist to monitor performance. The COR may use the surveillance methods listed below in the administration of this QASP.

5.2 Regardless of the surveillance method, the COR will contact the contractor’s designated point of contract when a defect is identified and inform the manager of the specifics of the problem. The COR shall be responsible for monitoring the contractor’s performance in meeting a specific performance standard or acceptable quality level (AQL).

a. Direct Observations: Can be performed periodically or through 100% surveillance.

• Compliance reviews (i.e., initial, rebuttal, second rebuttal) findings and analysis reports provided in complete and timely manner.

• Focus studies and medical record reviews are complete, thorough and clearly address topical issues.

• Internal quality assurance reviews identify issues with review procedures and identified issues are thoroughly addressed in timely manner.

b. Management Information Systems (MIS): Evaluates outputs through the use of management information reports. Best used for general surveillance and may need to be supplemented by periodic inspections. DHA E-Commerce Extranet Performance Assessment Tool (PAT).

• Study work products including methodology, Data Use Agreement, Memorandums of Understanding are complete and provided in a timely manner.

c. Periodic Inspection: Uses a comprehensive evaluation of selected outputs. Inspections may be scheduled Daily, Weekly, Monthly, Quarterly, or annually or unscheduled as required.

• Availability and utilization of Document Management System is appropriate.

• QA results meet contract performance standards.

• Medical record reviews performed by certified or otherwise qualified auditor and in an appropriate manner.

6.1.2. Customer Input. The SME may receive customer (e.g. internal Government staff) input about the quality of services performed under the contract. These inputs maximize the Government’s resource potential and are considered in regular assessments as they may identify contractor process improvement opportunities or required corrective actions. The SME will validate any input before corrective action is required by the contractor.

6.1.3. Periodic Inspection:. Performance reviews are an effective tool for keeping performance on course, measuring performance levels, and making adjustments as necessary.

More frequent opportunities than the required contract briefings with the contractor are essential in maintaining focus on critical program areas and may occur as deemed necessary. The SME will identify the specific review items to the contractor in writing. The contractor will provide the SME with written documentation of their internal processes of the specified review items.

The SME will review this documentation and perform an onsite review if deemed necessary.

The SME may be accompanied on the site visit by other Government employees when warranted.

7.0 RATINGS:

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and AQL. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

Table 2, Performance Ratings Rating Definition Exceptional Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor was effective.

Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

8.0 DOCUMENTING PERFORMANCE: TCRS

HT9402-17-R-0002, Section L, Exhibit L-10

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 8 of 9

a. Acceptable Performance: The Government shall document positive performance as part of its ongoing surveillance.

b. Unacceptable Performance: Unacceptable performance is contractor performance that is less than satisfactory or fails to meet the stated AQLs or other contract requirements. When unacceptable performance occurs, the COR shall notify the contractor in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion of unacceptable performance with a courtesy copy to the CO and place it in the COR file.

The COR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence.

The COR will also state how long after receipt the contractor has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

The contractor shall acknowledge receipt in writing of the COR’s notification of unacceptable performance. Any COR notifications of unacceptable performance may become a part of the supporting documentation for contract payment deductions, or other actions deemed necessary by the CO.

c. The COR and CO will use all performance documentation to complete the annual contractor’s performance evaluation in the Contractor Performance Assessment Report System (CPARS) per FAR 42.15, Contractor Performance Information.

9.0 FREQUENCY OF MEASUREMENT:

a. Frequency of Measurement:

During contract/task order performance, the COR shall take periodic measurements, as specified in the AQL column of the Performance Standards Summary Matrix, and shall analyze whether the negotiated frequency of measurement is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings:

The COR shall meet with the contractor as often as necessary to assess performance. If performance is less than satisfactory, the COR shall meet more frequently until the contractor’s performance is at least satisfactory. The COR shall document all performance assessment meetings, including the topics discussed, action items and their status until closed. The COR shall provide a copy of performance meetings to the CO

Prepared by:

TCRS HT9402-17-R-0002, Section L, Exhibit L-10 Page 9 of 9

Signature – Contracting Officer’s Representative

PERFORMANCE REPORT

1. CONTRACT NUMBER:

2. Prepared by: (Name of COR)

3. Date and time of observation:

4. Observation:

Prepared by:

Signature – Contracting Officer’s Representative Date