Attachment_J-19,_Quality_Assurance_Surveillance_Plan.docx

Section J Attachment J-19 Draft Quality Assurance Surveillance Plan (QASP)

TRICARE Overseas Program (TOP) 2021 Contract

Quality Assurance Surveillance Plan (QASP)

HT940219R0001 Page 1 of 9

1. INTRODUCTION

1.1. Purpose

The purpose of the Quality Assurance Surveillance Plan (QASP) is to ensure that the contractor satisfactorily performs the TRICARE Overseas Program (TOP) contract requirements, to ensure the Government receives the quality of service defined in the contract and applicable Defense Health Agency (DHA) manuals, and to establish a planned process for assessing the contractor’s performance in a systematic manner. Performance assessment will be accomplished in accordance with DHA PD 42-02, DHA Performance, Guidance, and Instruction (PGI) 242, DHA PGI 246, terms of the contract, and the QASP.

The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. The QASP is a “living” document that can be revised or modified by the Government as circumstances warrant. The contractor is responsible for managing and ensuring that contract requirements are met and ensuring internal quality controls meet the terms and conditions of the contract. However, it is incumbent on the Government to independently verify that the contractor meets all contract requirements.

The surveillance/evaluation methods identified in the QASP, in concert with the contractor’s quality management and quality improvement procedures, provide a comprehensive approach to contract performance assessment. Following contract award, this document will be reviewed by the Program Manager/Contracting Officer Representative (COR) to ensure that it works in concert with the contractor’s Quality Management/Quality Improvement (QM/QI) Plan. In areas where gaps are identified in quality assessment or increased surveillance is warranted, adjustments may be made to the QASP and/or the QM/QI Plan.

The QASP covers the period from the start of transition through the last day of the awarded contract.

1.2. Intent

The intent of the QASP is to ensure the contractor performs contract requirements satisfactorily. As necessary, the Government will adjust its level of oversight to maintain assurance of satisfactory contractor performance. The role of the Government in contract surveillance is to ensure contract requirements are met by the contractor such that contract objectives are achieved.

2. ROLES AND RESPONSIBILITIES

The following positions are responsible for monitoring contractor performance:

2.1. Contracting Officer (CO)

The individual(s) with a prescribed sole authority to enter into, administer, and/or terminate contracts. CO responsibilities include:

· The oversight of contractor performance to include ensuring the appropriate quality assurance and performance assessment tools and methods are implemented.

· Ensure that appropriate contractual remedies and solutions are applied when contractors fail to meet contract requirements

· Serve as final determination authority of the adequacy of the contractor’s performance in accordance with the Federal Acquisition Regulation (FAR), Defense Federal Acquisition Regulation Supplement (DFARS), DoD directives/instructions, DHA procurement directives, and the TRICARE Acquisition Manuals

· Sole authority to issue a Contract Action Report (CAR) to the contractor

· Sole authority for modifying the contract

2.2. Contracting Officer’s Representative (COR)

The individual(s) designated and authorized in writing by the CO to perform specific technical or administrative functions. The COR is the senior technical expert responsible for surveillance of contractor performance. The COR does not have the authority to direct the contractor or change the contract terms and conditions. COR responsibilities include:

· Serve as the primary monitor of contractor performance and delivery in accordance with the contract and QASP.

· Define, guide, and coordinate contract surveillance activities to ensure satisfactory contractor performance of contract requirements

· Ensure adequate resolution of contractor technical performance issues

· Perform Subject Matter Expert (SME) duties in designated areas

· Review contract performance documentation submitted by SMEs

· Review the contractor’s QM/QI Program, in coordination with SMEs, to ensure provision of acceptable quality level in all areas of the contract

· Promptly report any suspected fraud/abuse or aberrant trends or practices in accordance with established Program Integrity guidance

· Collate performance observations of contractor performance from all sources

· Design and implement contractor audit/review tools that identify specific areas for on-site surveillance (in coordination with the Program Manager, SMEs, and TAOs)

· Ensure audit tools are made available to the contractor prior to on-site performance reviews

· Review contractor deliverables and other reports for adequacy, accuracy, adverse performance trends, and assurance of requirement accomplishment

· Use the PAT, or other tool/method, to monitor and document contractor performance, and to access contract deliverables.

· Recommend to the CO, in instances of nonconformance, whether corrective action is required.

· Assist the CO with review of Corrective Action Plans (CAP) and contractor progress against approved plans.

· Document contractor performance utilizing the annual Contractor Performance Assessment Reporting System (CPARS)

2.3. Program Manager, TRICARE Overseas Program

The individual responsible for ensuring all contract surveillance activities are performed in a consistent and appropriate manner. Program Manager responsibilities include:

· Provides primary program oversight

· Nominates and ensures that the COR is trained in accordance with DHA directives.

· Ensure procedures for documenting contractor performance are executed

· Ensure audit tools are designed and implemented

· Ensure contractor performance audits/reviews are conducted in accordance with the QASP

· Assign Subject Matter Experts (SME) to perform surveillance on important contract requirements

2.4. Subject Matter Experts (SMEs)

Personnel with in-depth knowledge of contract performance requirements. SMEs are the “eyes and ears” of the Government with respect to the actual performance of the contract. SMEs do not have the authority to direct the contractor or change the contract terms and conditions. SME responsibilities include:

· Serve as an expert on the technical requirements of the contract in designated area(s)

· Perform contractor performance surveillance and assessment activities in accordance with the QASP and its attachments

· Review assigned contractor deliverables and other reports for adequacy, accuracy, adverse performance trends, and assurance of mission accomplishment

· Promptly report any suspected fraud/abuse or aberrant trends or practices in accordance with established Program Integrity guidance

2.5. TRICARE Area Offices (TAOs)

TAOs are responsible for planning and delivering services to meet the healthcare needs of beneficiaries within their area of responsibility (AOR) to include oversight and surveillance of the TOP contract with respect to their specific AOR.. As an integral part of the TOP surveillance team, TAOs serve as primary points of contact for the TOP contractor/Military Treatment Facilities (MTFs) with respect to the TOP Contract. TAOs do not have the authority to direct the contractor or change the contract terms and conditions. TAOs’ responsibilities include:

· Perform regional contract surveillance as directed by the Program Manager

· Serve as an expert in the technical requirements of the contract in their AOR

· Facilitate the identification and resolution of AOR contract issues

· Know and apply the procedures for documenting contractor performance surveillance and assessment

· Review contractor deliverables and other reports for adequacy, accuracy, adverse performance trends, and assurance of requirement accomplishment

· Assist TRIACE Overseas Program Office (TOPO) in ensuring contractor’s adherence to its internal QM/QI plan requirements, policies and procedures

· Notify the COR of any performance concern/issue that cannot be resolved at the local level, regardless of how the issue was identified

· Submit performance issues to the COR for input into the annual CPARS

· Report any suspected fraud/abuse or aberrant trends or practices to the COR

2.6. Other Government Resources

Other DHA employees and Service representatives may be called upon to provide feedback relative to contractor performance. These individuals will help facilitate the execution of the QASP by providing critical feedback on the contractor’s performance to the Program Office.

3. Contract Requirements Evaluated

The contract requirements applicable to this QASP are listed in Section C of the contract and the TRICARE Manuals. The Government is not limited to conducting contract surveillance for the specific contract requirements identified in the QASP. The Government will modify surveillance methodologies and approaches as necessary to ensure the Government is receiving the level and quality of services as set forth in the contract.

4. Contract Deliverables (Reports and Plans)

The contract deliverables applicable to this QASP are identified/included in Section F, and Section J, Exhibit A of the contract.

5. Contract Quality Requirement Roles

The contractor is responsible for the satisfactory performance of all contract requirements and for developing and managing an internal quality control program in accordance with contract requirements (see Section C.8.4 of the contract). The Government will design, implement, and conduct adequate contract surveillance and quality assurance to ensure contract requirements are performed and Government standards met.

6. Fraud/Abuse Prevention and Detection

The potential for health care fraud and abuse is higher in an overseas setting since U.S. laws and controls do not apply. The TOP contractor is responsible for the appropriate identification and referral of potential cases of fraud and/or abuse, and for supporting the Government’s investigation and resolution of potential fraud and/or abuse cases, including provider exclusions, suspensions, termination, and reinstatements. Members of the surveillance team (Program Manager, COR, TAOs, SMEs) assist in this effort by reporting any suspected cases of fraud and/or abuse in accordance with the provisions of the TRICARE Operations Manual (TOM), Chapters 13 and 24, Section 14. Additional surveillance may be required/implemented whenever fraudulent or abusive practices are suspected, or if aberrant trends or practices are identified.

7. Quality Assurance Surveillance Methods

The method for evaluating contractor compliance varies by contract requirement. The Program Manager/COR is responsible for selecting the evaluation method(s) used in the surveillance process. In determining the appropriate evaluation method, the Program Manager/COR consider the specific contract requirement, how performance can be observed/measured, and whether the method of surveillance is adequate to ascertain the required level of performance has been achieved. In making this determination, the Program Manager/COR will consider the contractor’s QM/QI Plan.

This section describes the available methods which can be used to verify the contractor’s compliance with the contract requirements. Periodic (scheduled or non-scheduled) performance assessments will be accomplished utilizing a combination of assessment methods and metrics to include:

7.1. Random Sampling

Random sampling is a statistically based method that assumes the contractor provided acceptable performance if a given percentage or number of sample size is found acceptable.

7.2. 100% Inspection

This surveillance/assessment type may be used for tasks which:

· Occur infrequently

· Have a small lot size

· Have very stringent performance requirements

7.3. Contractor Self Reporting

This surveillance methodology uses self-reporting by the contractor to determine compliance with contract requirements.

7.4. Government Reports

As part of the Government assessment process, DHA will use internal reports (e.g., reports extracted from the TRICARE Encounter Data (TED) Database, MHS Data Repository (MDR), and MHS Mart (M2)) to verify and validate Contractor submitted reports.

7.5. Customer Feedback

The Program Manager, CO, COR, or SMEs may receive customer (e.g., beneficiaries, MTF staff) feedback relative to the quality of services performed under the contract. These inputs maximize Government surveillance resources and are considered as part of the assessment process. Customer feedback may identify contractor process improvement opportunities or areas requiring corrective action. Customer input will be verified and validated by the Program Manager/COR prior to requesting formal corrective action on the part of the contractor.

7.6. Periodic Performance Audits/Reviews

Performance audits/reviews will be employed as a tool for evaluating performance, measuring performance levels, and implementing service-level/performance adjustments as necessary. Details on the performance audits/reviews process is provided in paragraph 8 of the QASP.

7.7. Review/Audit Activities by Other Government Contractors or External Agencies

DHA will use the results of review/audit activities conducted by other Government contractors or external agencies to assist in monitoring contractor performance. These review/audit activities may include, but are not limited to, the TRICARE Claims Review Services (TCRS) Contract. The TCRS contractor provides results of audits conducted on claims processed by the TOP contractor. The audits identify the number of claims with payment errors and other types of processing or reporting errors.

7.8. CDRL Surveillance

The TOPO uses CDRLs to monitor performance of the contractor against the contract requirements and standards. The Program Manager assigns TOPO SMEs to compare CDRL reports/plans to requirements and results are documented in the Performance Assessment Tool (PAT).

8. Performance Audits/Reviews

8.1. Transition-in: Prior to the start of health care delivery, the Government will conduct a Performance Readiness Assessment and Verification (PRAV) to assess and verify the contractor’s readiness to perform in the key contract areas. PRAV activities will be conducted by Government transition teams via onsite testing/inspection at one or more contractor locations. Section C.26.4. of the contract provides details on the process.

8.2. Comprehensive On-site Audit: During each option period of the contract, the Government will perform two comprehensive on-site performance audits to ensure compliance with contract requirements. The Program Manager will notify the contractor 2-3 months prior to the audit and all audit tools will be provided to the contractor at least one month in advance. The Government may adjust the number of on-site performance audits at its discretion.

The Comprehensive On-site Audit includes the following areas (The Program Manager may change audit areas at his/her discretion).

· Aeromedical Evacuations

· Provider Credential Files

· Inpatient Medical Management

· Referral and Authorizations

· Grievances

· Potential Quality Issues (PQIs)

· Customer Service Calls

· Priority Written Correspondence

· Translations

· Medical Management of TOP Prime Remote Enrollees

· Other areas as identified

8.3. Claims Audit: The Government will conduct an on-site claims audit at the contractor’s claims processing center semi-annually. The Program Manager will notify the contractor 2-3 months prior to the audit and all audit tools will be provided to the contractor at least one month in advance.

8.4. Regional Contract Surveillance Reviews: If the contractor structures its operations across multiple regions (i.e. aligns operation centers with overseas TRICARE regions), the Government may perform annual on-site regional contract surveillance reviews. The Program Manager will notify the contractor 2-3 months prior to the review and all review tools will be provided to the contractor at least one month in advance. The regional contract surveillance reviews include the following areas (The Program Manager may change review areas at his/her discretion).

· Network Provider Education Program

· Customer Service Education Program

· Network Adequacy

· Online Provider Site Directory Accuracy

· Network Onsite Evaluation Reviews

· Routine Written Inquiries

· Process for calculating self-reported standards

· Prime/Prime Remote ADSMs not receiving cashless/claimless service

· Applied Behavior Analysis (ABA) Therapy Management

· Aeromedical Evacuation Block Overflight Permit usage

· Other areas as identified

8.5. Desktop Audits. The Government will conduct desktop audits of the contractor to include CDRLs, invoices, and other documents as requested. Recurring desktop audits include:

· 100% monthly audit of the transient case fee invoices

· Other areas as identified

8.6. The above is the minimum surveillance required for normal operations, however the Government retains its rights under the Inspection of Services Clause (FAR 52.246-4) which states in part, "The Government has the right to inspect and test all services called for by the contract, to the extent practicable at all times and places during the term of the contract."

9. DOCUMENTATION PROCEDURES

9.1. CDRL Review: The Program Manager, COR, TAOs, and SME(s) review contractor deliverables (reports and plans) or any other information available, and document evaluations in the Performance Assessment Tool (PAT) in accordance with DHA established policies, DHA PGI 242.15. When performance does not meet standards, the CO, COR(s) and SME(s) shall follow the performance assessment processes outlined in DHA PGI 246, DHA PD 42-02, and any established business procedures for the TOPO.

9.2. Audits/Reviews: The results of all audits and reviews will be documented by the TOPO though the PAT and findings provided to the contractor.

9.3. Self Reported (by contractor): The contractor will notify the Government of self-identified areas of improvement and provide improvement plans. Contractor improvement plans should consist of a description of the process requiring improvement, identification of the causes or circumstances leading to the nonconformance, specific actions that will or have been undertaken to improve performance, and an estimate of when the improvements will be implemented.

9.4. CPARS:

The COR will complete the CPAR annually using available documentation and his/her observations of the contractor’s performance. If necessary, the CPAR will include information on nonconformance and resolution. If the contractor self-identifies the nonconformance and executes an acceptable CAP, then inclusion of the nonconformance information may be included in the CPAR at the CO’s discretion

10. ACCEPTANCE OF SERVICES

Services will be accepted as cited in Section E of the contract (Inspection and Acceptance).

Approved: ___________________ Date: _____________________

Program Manager, TRICARE Overseas Program HT940219R0001 Page 2 of 9