OIG260145-SOO Medical Review.pdf

Medical Record Review and Consultative Services Project ID: OIG260145

Issue Date: June 9, 2020

STATEMENT OF OBJECTIVES

1.0 PURPOSE

The Office of Inspector General (OIG) is pursuing the acquisition of medical review (MR) and consultative services to assist the OIG in conducting its’ oversight responsibilities regarding the programs operated by the Department of Health and Human Services (HHS). The acquisition will primarily result in services that support the OIG’s auditing function and the production of audit reports. The resulting contract will include professional services to determine whether selected medical services and claims pertaining to beneficiaries of Medicare (and occasionally Medicaid) complied with coverage, coding, payment, and billing requirements and to provide medical consultative services to the OIG with respect to such services and claims. The acquisition is primarily to assess services and claims for Medicare fee-for-service payments for Part A and Part B. Other analyses on an infrequent basis may include assessment of services and claims for Medicaid or the Medicare Prescription Drug Plan (Part D). While individual reviews may comprise 100-200 claims, annual volume is expected to be 2,000-3,000 claims.

2.0 BACKGROUND

OIG mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. Since its establishment in 1976, OIG has been at the forefront of the Nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 100 other HHS programs. A majority of OIG's resources goes toward the oversight of Medicare and Medicaid — programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens. Our government oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration.

To carry out this mission, OIG conducts activities, including audits, evaluations, and investigations.

Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These audits help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.

3.0 SCOPE

The scope of the resulting contract will include medical review and consultative services associated with the oversight activities of the OIG primarily involving Medicare fee-for-service payments. Occasionally it may include assessment of services and claims for Medicaid or Medicare Part D.

3.1 Period of Performance

The base period of performance is for 1 year from contract award with four, 1-year options.

4.0 OBJECTIVES

4.1 Medical Review of Claims

The resulting contract will require medical review of claims and the supporting medical record documentation as part of the development of audits and other OIG activities (e.g., evaluations or investigations). Prior to the medical review, the OIG will select the claims for review and in most cases collect the medical documentation. The number of claims and timeframes will vary by review. Claim reviews require, at a minimum, the clinical evaluation of medical records and related documents to determine whether Medicare claims were billed and paid in compliance with Medicare's coding, coverage, billing and payment requirements.

A medical record is the systematic documentation of a single beneficiary's medical history and care across time. Medical record review is the evaluation of the beneficiary's information and medical records to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements. When clinical judgment is needed, a medical record review must be performed by appropriate licensed professionals within the scope of their practice. Occasionally the OIG may request assistance in collecting the records.

The Contractor will perform medical record review and/or support a large volume of claims that are generated from all fifty (50) States and in six (6) territories.

4.2 Consultative Services

Consultative services will primarily consist of assisting the OIG both orally and in writing in responding to auditee comments and other information received by the OIG pertaining to work previously conducted by the awardee. In addition, consultative services may include providing expertise on a wide variety of medical related issues including assistance in assessing risk in designing future oversight activities or in assessing the Medicare program to identify fraud, waste, and abuse vulnerabilities.

5.0 MINIMUM REQUIREMENTS AND QUALIFICATIONS

• The Contractor must have in place adequate facilities, personnel, and equipment to perform medical reviews.

• The Contractor shall provide a secure environment for the transmission of information and adequate protection of all personally identifiable information (PII).

• The Contractor must have professional staff (medical and coding) with thorough knowledge of and extensive expertise in applying requirements for providing and billing services to Medicare beneficiaries.

• The Contractor shall develop medical record review instruments based on the particular review, with detailed knowledge of the Medicare criteria.

• The Contractor shall provide a detailed final review results letter for each sampled claim. The final review results letter must contain enough specific detail, in plain language. The letter should clearly explain the basis for each claim decision.

• The Contractor shall have in place a mechanism to oversee and monitor the progress of all assigned projects and shall be able to provide status updates to OIG at least bi-weekly.

• The Contractor will be available to participate in discussions (in person or via teleconference) with outside entities (including the auditee and Medicare officials) in the event that the OIG requests such assistance.

• The Contractor shall have a robust quality assurance process to maintain accuracy in decision making (inter-reviewer reliability).

• The Contractor shall have programs in place to identify, report, and mitigate actual and potential conflicts of interest for itself, its employees, subcontractors and consultants.

• The Contractor shall have the capacity to review Spanish medical records.