Medical Healthcare Consulting Services RFI.pdf

Medical Healthcare Consulting Services

Part 1 General Overview

1.1. Description of Services/Introduction:

The Healthcare Consultant (Contractor) shall provide services as defined herein.

1.2. Background:

The Employee Benefits Security Administration's (EBSA) Office of Enforcement (OE), is responsible for planning, administering, and developing nationwide enforcement policies and strategies, providing management and technical support and guidance to the field components in support of EBSA’s enforcement program, and evaluating enforcement program effectiveness. The EBSA field organization is comprised of multiple regional offices across the country which are responsible for investigating private-sector employee benefit plans to protect the interests of the plans' participants and beneficiaries. The requirement for services described in this contract will support the Office of Enforcement, Division of Health Investigations. The Division assists the Director of Enforcement in providing oversight and guidance to EBSA Regional Directors.

The Division needs healthcare consulting services to support research on complex policy, program, and case related issues. The Contractor will gather and evaluate data, including medical claims and medical coding data, relevant to specific cases. The Contractor will work on multiple national level cases at the same time. The Contractor performing service will be an expert in health industry operations and administration, and all entities involved in the benefits process.

1.3. Objectives:

To obtain a contract for healthcare consulting services.

1.4. Scope:

The purpose of the work is to conduct research and analyses and provide findings and technical expertise and support related to specific cases and investigative issues and review evidentiary documents to determine whether they support facts and findings in the cases. The scope of the work also includes using pre-existing claims analysis tools, suggesting improvements to pre-existing claims analysis tools, and creating new claims analysis tools, as needed.

1.5. Special Qualifications:

Proposed Contractor personnel shall:

• Have extensive knowledge of medical administration practices including medical coding, claims administration, and medical process audits.

• Be qualified to review coded data and supporting documentation to determining whether the data is in compliance with standards, coding conventions, guidelines, and documentation requirements. Knowledge and experience investigating and analyzing employee benefit plans is beneficial.

• Be required to develop, amend and create medical coding analysis in MS Excel.

• Have knowledge and experience of medical and insurance administrative processes.

• Have experience effectively communicating technical issues, analysis, and recommendations orally and in writing.

Contractor personnel must have demonstrated knowledge and experience as follows. 10 years’ experience:

• Analyzing management processes, statistical methods, and advanced technical and analytical research techniques to determine solutions based on customer’s healthcare requirements with an IT services/solutions-based scope.

• Analyzing organizational healthcare to obtain a quantitative, rational basis for decision making and resource allocation for the development of Health IT systems.

• Employing process improvements and reengineering methodologies and principles for modernization of IT systems and projects.

• Creating project plans to achieve performance-based objectives, enhancing implementation, systems and service.

• Providing integral support in mission requirements determination, conceptualization, design, development, testing, verification and validation, documentation, and implementation of a healthcare organization’s system applications.

• Advanced knowledge of current medical coding classification systems such as ICD, CPT, and HCPCS.

• Three or more years of experience applying ICD-10, CPT, DRG, and HCPCS coding guidelines and practices related to a wide range of healthcare claims

Contract must have one of the following certifications:

• Apprentice/Associate Level Certification through AHIMA or AAPC.

• Mastery Level Certification through AHIMA or AAPC.

• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

• Certified Professional Medical Auditor (CPMA) Certification

Part 2 Specific Tasks

The Contractor will be called upon during investigations to assist with the analysis of medical claims administration and medical coding technical knowledge, such as the processing and coding of mental health and substance use disorder claims and medical/surgical claims across a comprehensive range of medical specialties and facilities. They will work collaboratively with the assigned investigator for the cases as needed. The Contractor will be privy to confidential information about ongoing investigations.

Tasks:

• Independently review and analyze medical data relevant to specific cases and renders advice relating to medical coding and claims administration practices arising in EBSA investigations and litigation.

• Draft interview questions or analyses, as appropriate, concerning medical coding and claims administration questions that come up in health investigations.

• As requested, participate in interviews of plan personnel concerning medical coding and claims administration questions.

• Analyze proposed corrective action plans in investigations to determine if there has been full correction (e.g., that all affected medical claims have been appropriately reprocessed as necessary).

• Uses claims analysis tools. Suggests modifications and improvements to pre-existing claims analysis tools. Brainstorms and creates new claims tools as necessary to complete thorough analysis of medical coding.

• Assists regional and national office personnel in performing medical claims administrative analyses and in the development and implementation of claims analysis tools and other resources. They should have experience with creating and/or using tools for the analysis of data.

• Conducts research and develops data for periodic and special reports required by senior level management on the enforcement program and administrative operations and accomplishments of the regional offices.

• Prepares technical guidance and training materials for enforcement and field office staff.

• Prepares and submits monthly progress report and invoice as a package for review by the Program Officer and COR.

Part 2 Specific Tasks