PWS Information for RFI.docx

MEDICAL/TECHNICAL EXPERTS

Part 1 General Overview

Description of Services/Introduction:

The Medical Expert Consultant (Contractor) shall secure Medical and Technical Experts necessary to perform the services as defined herein. The Contractor shall perform to the standards identified herein.

Background:

The Employee Benefits Security Administration's (EBSA) Office of Enforcement (OE) promotes the protection of pension and welfare benefits under the Employee Retirement Income Security Act of 1974 (ERISA) by ensuring a strong and effective national and field office enforcement program through: (1) Policy formulation; (2) Project identification and program planning; (3) Guidance development and implementation; (4) Field liaison; (5) Field and project evaluation; and (6) Coordination of investigations to detect and correct violations of Title I of ERISA and related criminal laws.

OE, with the assistance of the Office of the Solicitor's Plan Benefits Security Division (PBSD), determined the Department of Labor (DOL or the Department) needs a Medical Expert Consultant to assist EBSA with identifying, screening, and securing a variety of Medical and Technical Experts who can consult and assist EBSA with (a) the analysis and review of Coverage Policies and technical medical coding for alignment with generally accepted medical and coding standards and comprehensiveness and (b) analyzing the application of the Coverage Policies, technical medical coding, and benefit contractual provisions to claims determinations, including medical necessity and administrative denials for Employee Welfare Benefit Plans.

To do this, EBSA envisions contracting with a Medical Expert Consultant that can identify, screen, and secure both Medical and Technical Experts that have demonstrated experience with the creation and/or operation of Coverage Policies; determining the medical necessity of claims based upon Coverage Policies, benefit contractual provisions, and technical medical coding; and analyzing Coverage Policies to review alignment with generally accepted medical standards.

Objectives:

Contractor will assist EBSA in identifying, screening, and securing Medical and Technical Experts that must be able to:

· Provide expert analysis regarding alignment and comprehensiveness of Coverage Policies and technical medical coding with generally accepted medical and coding standards.

· Provide expert analysis regarding application of Coverage Policies, technical medical coding, and benefit contractual provisions to benefit determinations, including medical necessity and administrative denials; and

· Assist with EBSA’s investigative process including preparing for interviews, depositions, reviewing documents, and assisting with other investigative activities.

Scope:

The Contractor shall identify, screen, and secure Medical and Technical Experts necessary to perform the scope of services listed herein. The Medical and Technical Experts provided by the Contractor must be able to analyze, evaluate, and opine on the medical basis for and application of approximately 100 Coverage Policies, including associated technical medical coding (procedure and diagnosis codes). These 100 Coverage Policies include a wide range of topic areas including, but not limited, to:

· Testing (e.g., Covid-19, allergy, nucleic acid pathogen, genetic, Vitamin D, etc.)

· Radiology and Ultrasound Services

· Therapies (e.g., Physical, occupational, acupuncture, chiropractic)

· Rehabilitation

· Cardiology, Endocrinology, Gastroenterology, Oncology

· Devices (e.g., compression, orthotic devices, home traction, etc.) (collectively Coverage Topics)

The Contractor must provide EBSA with Medical and Technical Experts that can review the Coverage Policies and technical medical coding to opine on the degree of alignment with generally accepted medical standards and coding conventions and guidelines. The Medical and Technical Experts’ review of the Coverage Policies and technical medical coding will also include an analysis of whether the Coverage Policies are comprehensive for the Coverage Topic.

In addition, the Medical and Technical Experts will assist EBSA in reviewing application of the Coverage Policies and technical medical coding to benefit determinations, including medical necessity and administrative denials, within the Coverage Topics.

The Medical and Technical Experts may also review claims and appeals data associated with the Coverage Policies and technical medical coding to identify any patterns in coverage determinations and opine on the outcomes of these claims and appeals based on generally accepted medical standards.

The Medical and Technical Experts may also be asked to assist EBSA in preparing for or participating in interviews, depositions, reviewing documents, or other investigative activities.

Special Qualifications:

The Contractor shall have the ability to identify, screen, and secure Medical and Technical Experts required pursuant to Part 1, Section 1.4 Scope.

Contractor shall provide Medical Experts with expertise and experience regarding the creation and operation of Coverage Policies, expertise in the Coverage Topics, the ability to assess the alignment of Coverage Policies with generally accepted medical standards, and the ability to assess the application of the Coverage Policies and benefit contractual provisions to benefit determinations, including medical necessity and administrative denials. These experts, hereafter referred to as “Medical Experts” under this contract must have:

1. Current unrestricted medical license in a US state or territory;

2. Current board certification (lifetime certification or certification maintained by Maintenance of Certification (MOC) or other applicable program) in an American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) recognized specialty;

3. Minimum of 10 years of clinical practice experience and/or direct patient care beyond residency;

4. Upstanding medical reputation and undisputable ethical standards;

5. Experience interpreting benefit contractual provisions related to Employee Welfare Benefit Plans;

6. Minimum of 5 years expert or consulting experience; and

7. Previous testifying experience.

The Contractor shall also provide Technical Experts that are experienced Certified Professional Medical Auditors (CPMA) with extensive experience in technical medical coding, claims administration, medical audits, the ability to assess alignment with standard medical coding and industry standards, and to assess the comprehensiveness of the technical medical coding for the Coverage Topics. These experts, hereafter referred to as “Technical Experts” under this contract must have:

1. Current Certified Professional Medical Auditor (CPMA), American Academy of Professional Coders (AAPC), or National Alliance of Medical Auditing Specialist (NAMAS) certification;

2. Minimum of 7 years of experience in medical practice management, technical medical coding, reimbursement revenue cycle management, compliance, or fee analysis in a clinical setting;

3. Minimum of 3 years of consulting or expert experience in technical medical coding, billing, and compliance related to Employee Welfare Benefit Plans; and

4. Previous testifying experience.

The Contractor and all Medical and Technical Experts will also adhere to a Consultant Confidentiality Agreement. The Contractor shall obtain approval from EBSA before securing any Medical or Technical Experts. It is understood that EBSA has final say and authority in the selection of all Medical and Technical Experts.

EBSA anticipates that the successful completion of this project will require the securing of Medical and Technical Experts who will provide, individually or in combination, the following expertise and specialties:

1. Experience in creation, operation, and application of Coverage Policies in benefit determinations related to Employee Welfare Benefit Plans;

2. Expertise in Coverage Topics;

3. Experience in reviewing and analyzing Coverage Policies to determine alignment with medical research, data, and generally accepted medical standards;

4. Experience in assessing the comprehensiveness of a Coverage Policy for the Coverage Topic;

5. Expertise in analyzing and reviewing technical medical coding (e.g., CPT codes, ICD-10 codes, etc.), and assessing alignment with coding standards; and

6. Experience in applying Coverage Policies, benefit contractual provisions, and technical medical coding to benefit determinations.

In addition to the general expertise listed above, the Contractor shall propose a labor category that meets the Medical and Technical Expert criteria. All Contractor-secured Medical and Technical Experts should meet the above qualifications and may use a proprietary labor category title (e.g. Medical and Technical expert, etc.).

Part 2 Specific Tasks

2.1 Task I Work Plan

2.1.1 As soon as possible after the award of the contract the Department and the Contractor will conduct an orientation meeting. This will serve to introduce the main individuals from both sides. It will also serve to answer initial questions the Contractor may have regarding the overall contract intent, present general timelines, and provide general strategy for compliance with the awarded contract.

2.1.2 Within one calendar week of the orientation meeting, the Contractor will provide a more specific strategy regarding securing the Medical and Technical Experts necessary to review approximately 100 Coverage Policies and technical medical coding therein to assess alignment with generally accepted medical standards and comprehensiveness for the Coverage Topic.

2.1.3 Within two calendar weeks from the orientation meeting, the Contractor will identify, screen, and provide the Department with its recommendations for a minimum of one Medical and one Technical Expert. Immediately following Contractor’s receipt of final approval from the Department regarding securing the recommended experts, the Contractor will enter into agreements or arrangements with identified Medical and Technical Experts to provide the services and task included herein. Contractor is also responsible for sharing information and obtaining necessary guarantees from the Medical and Technical Experts to guarantee compliance with all provisions and terms of the awarded contract.

2.1.4. Within two calendar weeks of the orientation meeting, the Contractor shall provide a Quality Assurance Plan (QASP) that provides their approach to deliver to the Department the Medical and Technical Expert opinions or reports. The QASP shall present the Contractor's understanding of the requirements, clarify any residual questions, provide estimated work actions, and estimate lengths of time to fulfill task requirements.

2.2 Task II Review of Coverage Policies and Technical Medical Coding

2.2.1 The primary task of the Medical Expert is to review approximately 100 Coverage Policies and the technical medical coding therein to assess alignment with generally accepted medical standards and comprehensiveness for the Coverage Topic. If instructed, the Medical Expert will also analyze the application of the Coverage Policies, technical medical coding, and benefit contractual provisions to claims determinations, including medical necessity and administrative denials. The Medical Expert will share its findings orally with the Department and may be asked to report its findings in writing regarding this task to the Department.

2.2.2 The primary task of the Technical Expert is to review approximately 100 Coverage Policies and the technical medical coding therein to assess alignment with standard medical coding and industry standards, and to assess the comprehensiveness of the technical medical coding for the Coverage Topic. If instructed, the Technical Expert will also analyze claims data associated with the Coverage Policies and technical medical coding to identify and analyze patterns in benefit determinations. The Technical Expert will share its findings orally with the Department and may be asked to provide a written report of its findings.

2.3 Task III: Identification of Medical Expert with Specialized Expertise

2.3.1 Depending on the Medical and Technical Experts’ findings pursuant to task 2.2.1 and 2.2.2, the Department and Contractor will determine whether any Coverage Policies need further review. After the Department and Contractor identify Coverage Policies that need further review and analysis, if any, the Contractor will identify, seek, and secure additional Medical Experts with specialized expertise in selected Coverage Topics.

2.3.2 Within one calendar week of the Department and Contractor identifying the need to secure additional Medical Expert(s) with specialized expertise in selected Coverage Topics, the Contractor will recommend to the Department the additional Medical Expert(s). Within one calendar week of receiving final approval from the Department, the Contractor will enter into arrangements/contracts with the additional Medical Expert(s).

2.4 Task IV: Specialized Review of Coverage Policies

The primary task of additional Medical Expert(s) will be to use specialized expertise in a Coverage Topic to review selected Coverage Policies to assess the degree of alignment between the Coverage Policies and medical research, data, and generally accepted medical standards. The Medical Expert(s) will also determine whether the selected Coverage Policies are comprehensive and inclusive for the Coverage Topic. The Medical Expert(s) will share their findings orally with the Department and may be asked to provide a report that addresses the analysis of the Coverage Policies.

2.5 Task V: Review of Claims and Appeal Files

Depending on the results of the above tasks, the Medical Expert(s) may be asked to use their expertise to review benefits determinations associated with approximately 100 to 200 claims and/or appeals with supporting documents. If materials provided are insufficient, the Medical Expert shall identify specific areas of insufficiency and suggest specific documents or materials that are typically available or used to make a benefit determination. The Medical Expert(s) will share its findings orally with the Department and may be asked to provide a report that addresses its findings.

2.6 Task VI: Draft Opinion/Report

2.6.1. Draft Opinion

The Medical and Technical Experts shall provide findings to date or draft reports to the Department and the Contractor one week after assignment, to ensure that the Government understands and agrees with the Medical and Technical Experts’ approach to each task. The Medical and Technical Experts will also agree to provide progress reports to the Department and Contractor at intervals determined by the Department. The Department has final authority to determine task assignments, the priority of task assignments, and general time allotments for tasks.

A teleconference will also be arranged to discuss findings and draft reports. The draft report is not expected to be a complete document but should indicate the strategies the Medical and Technical Experts will be using to complete tasks and prepare opinions. The draft report will serve as an extension of the initial assignment meeting and, as the requirement progresses, the Department may waive this task if the Medical or Technical Experts maintain routine delivery of official findings and opinions.

2.6.2. Activity Report

The Contractor shall send a bi-monthly activity report to the Contracting Officer Representative (COR) to provide an explanation of work completed on the assignments for that month. This can be a brief email that describes actions, irrespective of case assignment. The activity report is due on the 30th (or last calendar day) of the month and may accompany the monthly invoice.

2.7 Task VII: Assist with Investigative Activities

The Contractor and/or Medical and Technical Experts may also be required to provide assistance with investigative activities such as preparing for interviews, participating in interviews, reviewing documents, and other investigative activities.

2.8 Task VIII: Meetings

The Contractor and the Medical and Technical Experts shall be available to discuss the investigation and assigned tasks (in person or by phone) with the Department, including but not limited to the following topics: findings, process, actions, reviews, progress, and strategies. These should be scheduled within three days of the Department’s request.

Part 3 Services:

1. Contractor shall identify, screen, and secure such Medical and Technical Experts that are required to complete the tasks and objectives included herein. Such secured Medical and Technical Experts must have the qualifications detailed in “Special Qualifications” and be approved in advance by the Department prior to entering into a contract or arrangement with the Medical and Technical Experts. It is understood that such secured Medical and Technical Experts have the experience and expertise to complete the tasks as outlined above in Part 2 Specific Tasks.

2. If requested by the Department, the Contractor shall identify, screen, and secure additional Medical Expert(s) that have specialized expertise in selected Coverage Topics. Such additional Medical Expert(s) will have the qualifications detailed in “Special Qualifications” and will be approved in advance by the Department prior to entering into a contract or arrangement with the additional Medical Expert(s). It is understood that such secured Medical Expert(s) have the experience and expertise to complete the tasks as outlined above in Part 2 Specific Tasks.

3. If requested by the Department, the Contractor may also be asked to provide general consulting services related to the investigation and advise the Department as to the tasks and services to be provided by the Medical and Technical Experts.

4. Contractor will be responsible for entering into contracts or arrangements with Medical and Technical Experts on behalf of the Department. Contractor is responsible for paying the Medical and Technical Experts for covered labor and approved travel costs. Contractor will also be responsible for monitoring the Medical and Technical Experts’ time allotments for specific tasks to ensure that Medical and Technical Experts are adhering to contracted time allotments. Contractor will notify the Department as soon as practicable if it is anticipated that Medical or Technical Experts will exceed contracted time allotments.

5. The Medical Expert will review approximately 100 Coverage Policies to assess alignment with generally accepted medical standards and comprehensiveness for the Coverage Topic. If instructed, the Medical Expert will also analyze the application of the Coverage Policies, technical medical coding, and benefit contractual provisions to claims determinations, including medical necessity and administrative denials. The Medical Expert will communicate progress in performing tasks at intervals determined by the Department. The Department may also request that the Medical Expert prepare a report.

6. If requested by the Department, additional Medical Expert(s) with specialized expertise in a specific Coverage Topic(s) will review selected Coverage Policies for alignment with medical research, data, and generally accepted medical standards. This Medical Expert(s) will also determine whether the Coverage Policy is comprehensive for the Coverage Topic. The Medical Expert(s) will communicate progress in performing tasks at intervals determined by the Department. The Department may also request that the Medical Expert(s) prepare report(s).

7. If requested by the Department, a Medical Expert may also be asked to review benefits determinations associated with approximately 100 to 200 claims and/or appeals with supporting documents. The Medical Expert will communicate progress in performing this task at intervals determined by the Department. The Department may request that the Medical Expert prepare a report.

8. The Technical Expert will review and analyze approximately 100 Coverage Policies and the technical medical coding therein, and other medical coding data or policies provided by the Department, to assess alignment with standard medical coding or industry standards, and to assess the comprehensiveness of the technical medical coding for the Coverage Topic. The Technical Expert will communicate progress in performing this task at intervals determined by the Department. The Department may also request that the Technical Expert prepare a report.

9. If requested by the Department, the Technical Expert will also review approximately 42,000 lines of claims data and appeals data associated with the Coverage Policies and technical medical coding to identify and analyze patterns in benefit determinations. The Technical Expert will communicate progress in performing this task at intervals determined by the Department. The Department may also request that the Technical Expert prepare a report that outlines findings identified in the review of the claims and appeals data and provides rationale.