Part_B_North_QIC_fair_opportunity_document_-_FBO.pdf

Justification for an Exception to Fair Opportunity Pursuant to FAR 16.505(b)(2)(i)(c)

1. Identification of the Agency and the Contracting Activity

Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS)

Contracting Officer’s Representative: Cyqwenthia Boyd (410) 786-5875 Center for Medicare (CM)

Contracting Officer: Matthew Waskiewicz (410) 786-0253 Office of Acquisition and Grants Management (OAGM)

2. Nature and/or Description of Action Being Approved

This justification for an Exception to Fair Opportunity supports a logical follow-on task order award to C2C Innovative Solutions, Inc. on a sole-source basis to provide adjudication services in support of the of the Medicare, Medicaid, and State Children’s Health Insurance Program Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554, Subtitle C – Changes in Medicare Coverage and Appeals Process, Section 521 Revisions to Medicare Appeals Process.

More specifically, the Contractor shall act as a Qualified Independent Contractor (QIC) responsible for conducting reconsiderations of initial Medicare claims determinations in the Part B North jurisdiction. The Part B workload includes, at a minimum, processing reconsideration requests for doctors’ services, outpatient medical and surgical services, diagnostic tests, and ambulatory surgery. It also includes outpatient mental health care, and outpatient physical and occupational therapy.

The original task order (HHSM-500-2004-00005I/HHSM-500-T0004) was competed amongst CMS’ Qualified Independent Contractor (QIC) Indefinite Delivery Indefinite Quantity (IDIQ) contract holders and awarded to C2C in September 2012.

The period of performance for the original task order is September 1, 2012 through December 31, 2018 (inclusive of option periods), with a total value of $61,928,128.

The period of performance for the proposed logical follow-on task order will be January 1, 2019 through April 30, 2020 (inclusive of one option period), with an estimated value of $11,054,917.95 total for both periods.

3. Description of the Supplies or Services Required to Meet the Agency's Needs (including the estimated value)

Under this logical follow-on task order, C2C’s primary responsibility shall be to adjudicate standard and expedited reconsiderations in an accurate, efficient, timely, and consistent manner.

The Part B workload includes, at a minimum, processing reconsideration requests for doctors’ services, outpatient medical and surgical services, diagnostic tests, and ambulatory surgery. It also includes outpatient mental health care, and outpatient physical and occupational therapy.

The claims estimates in Section B of this task order include all reconsideration activities under this task order, including Medicare Secondary Payer (MSP), Program Safety Contractor (PSC)/Zone Program Integrity Contractor (ZPIC), and Recovery Audit Contractor (RAC) appeals.

The outcomes of this TO shall include:

Timely adjudication of reconsiderations of redeterminations using established protocols;

Case management and documentation;

Communication of decisions about appeals with appellants and other parties to the appeal;

Timely collection and transmission of information regarding the receipt, workflow, and disposition of reconsiderations via the Medicare Appeals System (MAS); and, Participation and coordination with other entities in the Medicare appeals process including CMS, the Administrative QIC (AdQIC), other QICs, MACs, the Office of Medicare Hearings and Appeals (OMHA), and the Medicare Appeals Council (herein referred to as Appeals Council) located at the Departmental Appeals Board (DAB).

4. Identification of the Exception to Fair Opportunity and the Supporting Rationale

FAR 16.505(b)(2)(i)(C) allows for a task order to be issued on a sole-source basis under an IDIQ contract in the interest of economy and efficiency because it is a logical follow-on to an order already issued under the contract, provided that all awardees were given a fair opportunity to be considered for the original order. The existing Part B North QIC task order was competed amongst all the QIC IDIQ holders. Additionally, the scope of work for the proposed logical follow-on is identical to the existing Part B North QIC task order scope of work. The purpose of the existing Part B North QIC task order scope of work is to perform all of the tasks associated with the receipt, processing and disposition of reconsiderations of Medicare Administrative Contractor (MAC) redeterminations.

The scope of work for the proposed logical follow-on is nearly identical.

The following paragraphs detail how issuing this logical follow-on task order is in the government’s best interest in terms of economy and efficiency.

Cost Savings to the Government

Transitioning the entire Part B North reconsideration workload in the event the incumbent was not awarded the contract following a re-competition via the acquisition process would involve a number of expensive and time consuming activities, including transferring case files and reconsideration requests from one contractor operation to another, and educating the beneficiary, health plan, and provider communities about the change in contractors. In addition, the government would need to pay the incoming contractor transition-in costs estimated to be between $240,000 and $900,000, based on the historical data.

Exercising a LFO for this jurisdiction benefits the government by saving both the time and money associated with transitioning this workload.

Part B North Program Stability and Continuity

If CMS was to transition the work under the Part B North task order from one contractor to another, it may pose a significant and unnecessary risk for disruption to the continuity and efficient operation of the Medicare Part B North program and the administrative appeals process.

The chart below depicts overall reconsideration receipts in recent calendar years.

Overall, the Part B North program has been successfully maintained, but changing the reconsideration contractor at this time may compromise the current success as a new contractor gets its operations established and learns the Part B reconsideration workload.

Benefit to Stakeholders

A LFO also benefits Medicare beneficiaries, Part B health plans, and providers.

Transitioning appeals contractors can often lead to confusion for beneficiaries, as well as the health plan and provider communities. For example, health plans have to change their decision notices and forms, and beneficiaries must acquaint themselves with the new contractor and associated contact information. CMS takes steps to minimize this confusion by issuing memoranda and modifying relevant beneficiary materials/publications, but these activities require an expenditure of time, resources and effort that would be saved if a LFO is granted.

Staff Resources

Another benefit of allowing the LFO is that it will save scarce staff resources, which are necessary to re-compete this task order. Significant amounts of staff time are devoted to developing the request for proposal, reviewing proposals, answering questions posed by the bidders, and evaluating and scoring business and technical proposals. This time can be saved by allowing an extension in the re-competition of the Part B North QIC task order and granting the LFO request.

Calendar Year Reconsideration Volume (processed cases)

2013 174,500 2014 174,500 2015 174,500 2016 174,500 2017 174,500 2018 174,500

Therefore, in accordance with FAR 16.504(b)(2)(iii), a logical follow-on for this effort is in the best interest of the Government based on the economies and efficiencies that will be realized. Additionally, as stated previously, all QIC IDIQ contract holders were given a fair opportunity to be considered for the original task order.

5. A Determination by the Ordering Activity Contracting Officer that the Anticipated

Cost to the Government will be Fair and Reasonable

The QIC IDIQ was awarded in 2004. CMS has generated a strong base of knowledge in regard to fair and reasonable pricing under the IDIQ based upon the experience with this type of work. The proposal submitted by C2C will be evaluated against both the pricing that was determined to be fair and reasonable under the existing Part B North Task Order and the Government Cost Estimate the program staff will produce. The evaluation of the proposal against those items will enable CMS to make a fair and reasonable determination of the contractor’s price.

Taking into account the information provided in the paragraph above, the Contracting Officer has determined that the anticipated cost to the Government on the Part B North logical follow-on task order will be fair and reasonable.

6. Any Other Facts Supporting the Justification

N/A. Please see Sections 3 and 4 above.

7. Actions the Agency May Take to Remove or Overcome Any Barriers that led to the

Exception to Fair Opportunity

In planning for the continuation of this work after this one (1) year contract period, CMS intends to compete this requirement under the CMS QIC IDIQ. The planning for this competition will start in FY 2019. CMS intends to release a request for proposal at some point of during the second quarter of FY 2019 with award to most likely occur during the fourth quarter of FY 2019.