Pricing Approach and Rationale.pdf

Pricing Approach & Rationale

Prepared by Talisman Solutions Inc.

Contents Pricing

Assumptions

Pricing Approach

Pricing

Assumptions

Please see below the assumptions for the Pricing Proposal

Scope of Services:

• The services requested encompass the full lifecycle of Section 111 reporting, including monthly

Medicare eligibility queries, quarterly claim data submissions (including "empty files" when no payments are made), and ongoing error management and compliance oversight.

• This includes reporting for Liability, No-Fault, and Workers’ Compensation claims (collectively referred to as Non-Group Health Plans or NGHP).

• The service will manage the Responsible Reporting Entity (RRE) Profile Report annual recertification to ensure active RRE ID status.

• The service includes reporting of Ongoing Responsibility for Medicals (ORM), Total Payment

Obligation to Claimant (TPOC) events, ORM terminations, and all necessary updates or corrections to reported claims.

Data Volume and Complexity:

• The ICA's claims volume will influence the effort involved; we are assuming medium volume and proposing a flat fee structure.

• The pricing structure needs to account for the new requirement to report Workers' Compensation

Medicare Set-Aside (WCMSA) data fields for TPOCs on or after April 4, 2025, including MSA Amount, MSA Period, Payout Indicator, Initial Deposit, Annual Deposit, and optional Case Control Number and Professional Administrator EIN.

• The proposal anticipates the need for robust processes to manage the new policy regarding $0

WCMSA proposals, which will no longer be accepted for review by CMS starting July 17, 2025, but still require internal documentation.

System Integration and Data Exchange:

• Talisman Solutions shall interface with ICA’s current Special Fund Claims System (File Handler) through flat file import/export or API calls.

• Data will be exchanged in a secure and compliant manner, as CMS mandates electronic and secure reporting of protected health information.

Compliance and Risk Mitigation:

• The proposal assumes the need for proactive measures to avoid Civil Money Penalties (CMPs), which became applicable on October 11, 2024, and can be levied by CMS starting October 2025, for untimely ORM and TPOC reporting.

• The service will assist ICA in adhering to the "good faith" compliance safe harbor criteria for obtaining "Big Five" data points (SSN/MBI/HICN, first name, last name, date of birth, gender), which requires documenting at least three attempts to obtain this information.

• The proposal includes mechanisms for timely error identification, reporting, and correction, given that uncorrected errors can lead to penalties.

• The service will leverage PAID Act data to identify Medicare Part C (Medicare Advantage) and Part D

(prescription drug) enrollment for proactive lien resolution, mitigating the risk of double damages lawsuits from these private plans.

Training and Support:

• The proposal acknowledges the value of providing training for ICA claims handlers, paralegals, and compliance officers on MSP reporting best practices and evolving CMS guidance.

• Customer service and expert assistance for reviewing and resolving identified errors is a core component.

• The pricing is based on a level of service that includes self-service web-based portals for management reports and compliance oversight.

Financial Terms:

• All pricing will be fixed and firm, and invoices will be submitted on a quarterly basis.

• The total aggregate spend for the initial contract term of 12 months will not exceed $100,000, with a maximum aggregate term of five years if extensions are granted. This overall contract value will guide the component pricing.

• Initial setup fees will be incurred for integration and system configuration and shall be invoiced at the beginning of the contract.

• Medicare eligibility query files may be an additional charge.

• In case additional services are required, such as comprehensive training programs, extensive data cleanup, or advanced analytics, these would be quoted separately on a variable or as-needed basis.

Pricing Approach

This proposal outlines the pricing structure for delivering the required services, drawing on industry standards and the information provided in the BPM007093 solicitation. The pricing structure will be influenced by several variables, including the volume of reported claims, the level of training provided, the amount of customer service required, and the initial data set-up.

To meet the requirements of the BPM007093 solicitation, our pricing proposal is structured to offer comprehensive support while acknowledging the specific needs of the ICA and the scale of reporting activities.

Initial Setup and Implementation Fee

This one-time fee covers the initial integration with ICA's current Special Fund Claims System (File

Handler), data mapping, system configuration, and establishment of secure data exchange. It includes the effort required for initial RRE registration (if not already fully established) and any necessary IT system integration to support flat file import/export or API calls.

Initial set-up fees shall be $20,000.

Ongoing Quarterly Service Fee (Base Fee)

• This recurring quarterly fee covers the continuous management of the Section 111 reporting process, ensuring compliance and proactive oversight. This includes:

• RRE Profile Recertification: Managing the annual recertification of the RRE Profile Report to maintain active status and avoid deactivation of the RRE ID.

• Compliance Oversight: General management and monitoring of reporting files, and access to a self-service web-based portal for management reports and compliance oversight.

• Error Management Framework: Providing easy-to-understand error reports and offering expert assistance in reviewing and resolving identified errors.

• Adherence to Reporting Schedule: Ensuring quarterly submission of claims within the assigned seven-day submission timeframe, including "empty files" if no payments are made.

Ongoing quarterly fees shall be $12,000.

Per-Claim Reporting Fee

This fee is assessed for each individual claim record that requires reporting to CMS, including Ongoing

Responsibility for Medicals (ORM) establishment, Total Payment Obligation to Claimant (TPOC) events, ORM terminations, and any subsequent updates or corrections to reported claims.

There is no additional charge for this service.

Medicare Eligibility Query Fee

This fee covers the monthly queries performed to determine Medicare beneficiary status for all claimants, including the collection of "Big Five" data points (SSN/MBI/HICN, first name, last name, date of birth, and gender) and processing PAID Act data for Medicare Part C and Part D enrollment information.

There is no additional charge for this service.

Additional Services (Variable/As Needed)

Additional services can be provided on a per-request or project basis, depending on the ICA's evolving needs. These may include:

• Comprehensive Training Programs: Tailored training for ICA claims handlers, paralegals, and compliance officers on MSP reporting best practices and evolving CMS guidance.

• Data Cleanup and Remediation: Assistance with identifying and correcting historical data errors or discrepancies.

• Advanced Analytics and Reporting: Beyond standard management reports, offering deeper insights into compliance metrics, risk assessment, and operational efficiency.

• SSN/Date of Birth Research Service: Assistance in obtaining missing claimant data points to ensure compliance.

Billing Details

The first invoice for the initial setup and implementation fees shall be raised at the beginning of the contract. Remaining invoices will be submitted on a quarterly basis and will include itemized details such as the date, invoice due date, service dates, and specific services or products rendered.

This flexible pricing model aims to provide the ICA with a cost-effective and compliant solution for its

Mandatory Section 111 MSP Reporting requirements, ensuring accuracy, timeliness, and adherence to

CMS regulations.