PWS clean for RFI.docx

RAC DRAFT PWS

I. INTRODUCTION & BACKGROUND

The Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Finance (OF) requires a highly skilled contractor to conduct Recovery Audit (RA) activities for a variety of programs, as described below. Each program has specific payment methodologies as defined by VA regulations. In general, the audit will review various types of paid claim data with specific dates and criteria included in the description of each auditing scenario.

OF intends to award a RA, no cost (contractor is paid out of recovered funds only) task order, to provide auditing services. The Government’s obligation to make payments to the contractor under this task order is contingent upon both the contractor’s correct identification of valid overpayments and the Government’s subsequent recovery of overpayments, or portion of overpayments. The contractor shall bear the burden of costs of performing the task associated with the RA and will be compensated only on a percentage of the actual funds recovered.

Throughout this document, the term “improper payment” is used to refer to overpayments only. Situations where the provider submits a claim containing an error (e.g., an incorrect diagnosis code, incorrect/missing modifier), but the payment amount is not altered by the error, are not considered improper payments.

Key objectives of the RA contract are to receive access to paid claim data, audit that data for potential overpayments to providers, verify overpayments and report results to VA. The contractor shall also identify root causes or trends for potential reduction of improper payments. Another key objective of the contract is to establish a Customer Service Center (CSC) for addressing questions from providers.

This Performance Work Statement (PWS) includes all tasks and responsibilities associated with auditing paid claim data as well as other contractual requirements as defined in Section III, Specific Tasks.

Requests for access to the VA Network, PIV cards and access to secondary VA systems for auditing claims, shall be submitted to the VA Contracting Officer Representative (COR) for authorization.

The contractor shall ensure compliance with all PWS and VA system requirements, including Information Technology (IT) systems security policies, procedures and practices. This includes participating in the necessary security testing to obtain an Authority to Operate (ATO). Section V, Privacy and Information Security, describes these requirements in further detail.

The auditing of various OF programs has been organized into mandatory and optional tasks with any exclusions noted in the task descriptions. Each of the auditing tasks has criteria for the specific data set for that scenario. In the case of VA Community Care (VACC), there are five (5) different sets of criteria that define the data.

The contractor shall review 100% of the supplied paid claim data in accordance with their approved audit plan and report results to OF. OF will initiate recoupment activities, and the contractor shall be paid a percentage of the recovered funds. OF may elect to name another VA organization, another government entity, or a separate contractor to perform the collections on its behalf.

VA will use filters and algorithms to restrict the data provided the contractor to claims data the contractor is required to audit. However, some claim data not required to be audited under this contract may still find its way past those filters and algorithms and become comingled with the required data. The contractor shall not take any action on that data and the contractor shall treat all data in their possession in accordance with Appendix C.

Tasks Associated with Contract Requirements:

In addition to auditing the broad spectrum of program-specific data, the contractor also has non-auditing contract requirements to meet. These tasks are further defined in Section III, Specific Tasks.

Tasks Associated with Auditing VA Paid Claim Data:

The 11 auditing scenarios listed in the table below (Tasks 7 – 16) show the programs that could potentially be audited (mandatory and optional tasks) and the authorities under which the claims were paid. The fiscal year ranges identified below refer to Dates of Service (DOS); actual claims payment dates may vary.

Task 8

VACC

Claims preauthorized with individual authorizations (FY22 – FY29) 38 U.S.C. § 1703 (FY15 – June 6, 2019) then

PL115 – 182

“MISSION Act of 2018” (June 6, 2019 and forward)

(FY22 – FY29)

38 U.S.C. § 1781, 38 C.F.R. § 17.270 – 17.278

(FY22 – FY29)

PL 104-204,

PL 110-387,

PL 108-183,

38 C.F.R. § 17.900 – 17.905

(FY22 – FY29)

38 U.S.C. § 1725

(FY22 – FY29)

38 U.S.C. § 1728

Task 13

National Dialysis Contract (NDC)

(FY22 – FY29)

38 U.S.C. § 8153

II. GENERAL REQUIREMENTS

The PWS is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. § 794d) as amended by the Workforce Investment Act of 1998 (P.L. 105-220). All documentation created by the contractor and submitted to VA is subject to Section 508 Compliance for Communications as applicable. Independently and not as an agent of the Government, the contractor shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform all requirements of this PWS. VA will provide minimum administrative support, which may include standard system changes when appropriate, policy interpretations as necessary and other support deemed necessary by VA to allow the contractor to perform the tasks accurately and efficiently. The VA will support changes it determines are necessary but cannot guarantee timeframes or constraints. In changing systems to support greater efficiencies for VA, the end product could result in additional administrative tasks being placed on the contractor that were not previously presented. These administrative tasks will be within the scope of this contract and will be applicable to the identification and recovery of improper payments.

Unless otherwise stated, any mention of days in this PWS shall be understood to mean business days. If any due dates occur on a Saturday, Sunday, or federal holiday, the due date will be recognized as the next business day.

The contractor shall use standard terminology found in VA regulations and policies to the greatest extent possible in all reports and communications.

A: Kick-Off Meeting with VA The contractor’s Program Director and the VA COR shall mutually determine a date for the Kick-Off Meeting. Contractor representatives should include key personnel. VA representatives will include the VA Contracting Officer (CO), VA COR and appropriate VA staff.

The purpose of the Kick-Off Meeting will include, but not be limited to:

· Discussion of the overarching AMP and provision of VA specific feedback

· The process for submitting security documentation and contractor responsibilities

· Discussion of training requirements/needs

· Discussion of the General Requirements Section of the contract

· Discussion of the Tasks in detail

· Discuss the Financial Management Section of the contract

· Any other contractual questions

Within two (2) weeks of the Kick-Off Meeting, the contractor shall submit an updated AMP outlining the resources and timeframe for completing the work outlined. The initial AMP will be for the base year of the contract. The AMP is described in more detail in Section III, Specific Tasks.

B: Position Sensitivity, Background Investigations (BIs) & Security Categorization:

The contractor will be responsible for all costs associated with obtaining their BI and having security documentation processed. The VA COR will provide the contractor with the appropriate forms needed for obtaining a BI.

The Risk Designation for non-IT personnel has been designated as a Tier 1 (Low).

There could be two types of personnel requiring the Tier 1 BI:

· Tier 1 personnel requiring VA Network access and will require a Personal Identity Verification (PIV) badge.

· Tier 1 personnel that will view and handle Protected Health Information (PHI), but do not require a PIV badge.

The Risk Designation for IT personnel that will be obtaining and maintaining the ATO has been designated as Tier 2 (Moderate) and they will require a Tier 2 BI.

This contract has a Security Categorization of Moderate.

C: Access to the VA Network and Systems and PIV requests:

All personnel working on this contract will be required to have an adjudicated Special Agreement Check and an appropriate level of adjudicated BI for their contract duties before they are allowed to work on this contract.

Some contractor personnel will require access to the VA Network which as noted above requires a PIV. Some of these contractor personnel shall require access to the VA systems noted in the table in Task 5 – Audit Documentation.

Requests for access to the VA Network and all VA systems as well as requests for PIV cards must be submitted to the VA COR. The VA COR will provide instruction on how to proceed with each type of request.

D: Conference Calls:

On a weekly basis, unless otherwise instructed by VA, the contractor’s key project staff will participate in a conference call with the VA COR to discuss the progress of work, assess any problems and discuss plans for immediate next steps of the project. The contractor will be responsible for setting up the conference calls, preparing an agenda, documenting the minutes of the meeting, and preparing any other supporting materials as needed.

The contractor must use VA credentials and the VA telecommunications system for all calls with VA.

At VA’s discretion, the frequency of the conference calls may be changed. There may also be additional conference calls to discuss additional items and/or issues.

E: Electronic Case File The contractor shall maintain an electronic case file for each claim that is audited. At a minimum, the case file shall include:

· Digital copies of documents reviewed

· Provider information (name, address and tax identification number)

· Amount of overpayment

· Payment methodology used for calculation

· Digital reports of contact with VA or providers to include dates of any calls made and notes indicating what transpired during the call

· Any additional documentation received

· Record of provider requests (disputes, appeals, payment plans and compromises) When requested, the entire case file shall be sent to VA within three (3) business days of the request. The case file should be provided electronically unless an alternate transmission method is approved by the VA COR. Any costs (e.g., materials, shipping) associated with the file transfer to VA shall be incurred by the contractor.

Case File Disposition In accordance with Appendix C at VA’s request no later than fifteen (15) business days after contract termination, the contractor shall return all case files. The contractor shall not destroy any supporting documentation relating to the overpayment identification or recovery process unless otherwise directed.

F: Validation The contractor’s performance shall be subject to validation by VA or a third party. Under this requirement, the contractor shall comply with all requests for audit samples and supporting documentation.

The contractor shall forward any requested information to the appropriate VA validation point of contact. The contractor shall provide the case files through electronic submission, hard copy, or any other method VA prescribes, within three (3) business days of notification by VA.

The contractor’s accuracy shall be validated quarterly based on the federal fiscal year (October 1 through September 30). The contractor shall maintain an accuracy rate of at least 95%.

For each percentage point above 98%, the contractor shall earn a .2% contingency fee increase for the following quarter. For example, a contractor with a base contingency fee rate of X% and a 98% accuracy score in Quarter 1 would receive a .2% contingency fee increase, or X% + .2% in Quarter 2.

Conversely, for each percentage point below 95%, the contractor’s contingency fee will be reduced by .2% for the following quarter. For example, if the contractor’s accuracy rating is 94% in Quarter 1, the contractor would then have a reduction of .2% to their fee, or X% – .2% for Quarter 2.

For the purposes of applying incentives and penalties, accuracy ratings will be rounded to the nearest whole percentage. Percentages up to .49 will be rounded down (for example, 94.49 would equate to 94%); percentages of .5 and higher will be rounded up (for example, 94.51 would equate to 95%).

Once audits have been completed, the results will be sent to the contractor. The contractor will have the opportunity to review results and present rebuttal information if they wish to dispute the results. The contractor must provide any documentation or explanation in writing to the VA COR within five (5) business days of receiving the audit results for a dispute to be considered. VA will make the final determination of accuracy ratings within five (5) business days of receiving the contractor’s rebuttal information.

Accuracy rates and contingency fees will be recalculated annually.

G: Other Auditors:

Should other VA authorized auditors choose to conduct an audit of the contractor, the contractor shall provide workspace and produce all needed reports and case files within three (3) business days of the request.

H: Recovery Audit Contractor Staff The primary point of contact for the contractor for all operational tasks in this PWS or any aspect thereof shall be the VA COR or his/her delegate. Contractors shall not contact anyone in VA regarding work being performed under this contract without approval of the VA COR. The VA CO shall be the primary point of contact for all contract issues/questions.

The contractor’s Project Manager shall be available to the VA COR during normal business hours. If the Project Manager is not going to be in the office, the VA COR will be notified at least one (1) business day in advance. In such cases, the Project Manager will designate a back-up person to serve as the central point of contact with VA. Anyone serving as a back-up for the Project Manager will be required to have the ability to answer questions and/or provide data to the same degree that the Project Manager would be able to provide.

1. Key Personnel

a. General Information:

Certain experienced professional and/or technical personnel are essential for accomplishing the work to be performed. These individuals are defined as "key personnel" and are those persons whose resumes will be submitted and marked by the vendor as "key personnel." Key personnel may be dedicated less than full time. Substitutions shall only be accepted if in compliance with “Substitution of Key Personnel" provision identified below.

b. Substitution of Key Personnel and Other Personnel Considerations:

During the first ninety (90) calendar days of performance, the contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment. All contractor requests for approval of substitutions hereunder shall be submitted in writing to the VA COR and the VA CO at least thirty (30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the VA CO necessary to approve or disapprove the proposed substitution. The VA CO will evaluate such requests and promptly notify the contractor of approval or disapproval in writing.

Personnel assigned by the contractor to the performance of work on this order shall be acceptable to VA in terms of personal and professional conduct and technical knowledge. Should the assignment to this order of any person by the contractor be deemed to conflict with the interests of VA, or in the event performance is deemed to be unsatisfactory at any time during the life of the task order, the VA CO will notify the contractor and request the person be immediately removed from the assignment. The reason for removal shall be documented and a request to receive personnel replacement within three (3) business days of the notification shall be made. Replacement personnel qualifications shall be equal to or greater than those of the personnel being replaced. Employment and staffing difficulties shall not be justification for failure to meet established schedules.

Staff Qualifications:

The contractor shall thoroughly train its staff. The contractor shall maintain a sufficient number of staff dedicated to operations, administration, customer service, and support of services under this task order to include, at a minimum, key personnel listed below. The contractor may propose additional staff beyond the minimum listed below, with specific expertise to fully meet the requirements outlined in this PWS.

· Program Director: A Program Director will be assigned who has documented skills and experience in directing the accomplishment of work equal or comparable to the requirements under this task order. The Risk Designation for this position (non-IT personnel) has been designated as a Tier 1 (Low).

· Information Technology Security Analyst (ITSA): The ITSA will be knowledgeable of the regulations and requirements related to obtaining and retaining an ATO and able to provide continuous Assessment and Authorization (A&A) support. The ITSA will be required to obtain VA network access in order to input information into the Governance Risk and Compliance (GRC) tool initially, then as maintenance. The Risk Designation for this position (IT personnel that will be obtaining and maintaining the ATO) has been designated as Tier 2 (Moderate) and they will require a Tier 2 BI.

I: Public Communications The contractor must receive prior approval from VA for all contractor press releases or information sharing with any outside entities related to contract efforts. The contractor shall not respond to requests from industry publications, newspapers, and journals for information involving the VA RA Program. These requests shall be forwarded to the VA COR.

VA internal working documents shall not be released to the public without approval from the VA COR.

VA will handle all congressional inquiries with support from the contractor if needed.

J: Provider Outreach The contractor will be required to obtain access to VA systems and locate needed documentation to audit claims. In the event the medical documentation in the VA systems is not sufficient to make a determination, the contractor is allowed to contact providers to request additional medical documentation when such documentation is necessary to complete auditing.

The contractor will only request documentation needed to substantiate a payment was made in a correct amount for authorized services. The contractor shall make every effort to minimize contacts with providers. When requesting medical documentation, the contractor shall also ask for any evidence of an agreed-upon rate outside of the applicable CMS rate or VA fee schedule.

The contractor shall draft a standardized letter requesting documentation; this letter must receive approval by the VA COR prior to being issued. If the contractor does not receive any response from the provider after a letter has been sent, the contractor may call the provider.

Should the contractor obtain information from a provider that impacts collections (e.g., change of address, provider death, dissolution of practice), such information will be reported to the VA in the Weekly Report.

K: Period of Performance The Period of Performance (POP) for the base period shall be from the date of award for a period of one (1) year with four (4), one (1) year option periods to be awarded at the discretion of the Government.

L: Place of Performance The Government will not provide office spaces, telecommunication services or other technologies needed to accomplish the tasks associated with this PWS. The VA anticipates that tasks under this PWS shall be performed at the contractor’s facilities as specified in their proposal.

M: Financial Capability This contract will require an ATO which could take up to a year to obtain. The contractor must be able to support their contract personnel and resources during this period.

The contractor shall have the financial capacity (e.g., working capital, and other resources) to achieve contract requirements.

N: Recalled Cases The VA may determine that it is in the best interest of the OF RA Program to cease work in certain areas. Should VA initiate a recall, the contractor shall immediately stop all activities included in the recall.

Recalls may occur for several reasons including areas of political sensitivity or for performance related issues. Recalls may be indefinite and may require a corrective action plan to resume activity. The scope of recalls includes but is not limited to specific codes, specific claim types, specific providers, specific jurisdictions or regions. The recall instructions issued by VA will determine whether contingency fee payments will be made for collections occurring as a result of audits performed prior to the recall.

O: Travel: There will be no reimbursement for travel under this contract.

III. SPECIFIC TASKS

Tasks for Other Contract Requirements:

A: TASK 1 – AMP:

The AMP is a dynamic document that the contractor will create to document how they will manage the audits of this contract.

Within thirty (30) calendar days of the Kick-Off Meeting, the awardee will be required to create an overarching AMP and integrate understandings and direction received from the Kick-Off Meeting. This overarching plan will describe the sequence of audits and the contractor’s approach to ensuring all required audits are completed during the contract’s period of performance. The AMP will be updated and maintained throughout the task order POP. The contractor will validate or correct assumptions they had prior to the Kick-Off Meeting and incorporate the current processes, internal controls, staffing and resources used to conduct the audit activities. The AMP will also need to be updated to reflect obstacles presented, solutions proposed and selected and the progress of how well the implemented solution works.

Additionally, under this task, the contractor shall create a specific audit plan for each of the audit universes identified as an audit task (Tasks 7-16). These audit plans shall address the following subject areas:

1. Auditing Plan:

The contractor shall develop an audit plan that details how audits will be conducted. The audit plan will include, at minimum:

a. A defined objective and scope

b. The type(s) of claim(s) to be audited

c. The payment methodology used to audit the claims

d. How the contractor will review and submit sample test claims

e. Types of documents reviewed

Due to the unique nature of the universe of claims associated with each task, an audit plan for each task will be required.

The contractor’s audit plans will ensure that all overpayments for a provider for a fiscal year are reported to VA in a single instance. For example, if a single tax identification number (TIN) has one hundred (100) claims associated with it in a single fiscal year, the contractor will audit all one hundred (100) claims prior to reporting any overpayments to VA for collection. This will allow VA to streamline communications with providers.

2. Audit Plan Approval Process:

The following approval process will ensure a contractor’s claim review does not conflict with VA policies or reimbursement methodologies used to assess payment accuracy. As the audit plan for each task is submitted, the VA will review and approve or suggest revisions. Once approved, the contractor will post the audit plan to a public facing website for comments for no less than thirty (30) calendar days.

The contractor will be provided a test sampling for the universe to be audited during the thirty (30) calendar day comment period to complete and return to the VA. The VA will assess the accuracy of the contractor’s findings. After review of the test samples a conference call will be established to discuss findings and any remediation needed to the contractor’s process. During this conference call, the contractor will present comments received from the public. VA will provide guidance on how to address those comments.

Within five (5) business days of the conference call or the date VA provides the final guidance needed, the contractor will submit a final audit plan to VA. The audit plan will include VA-directed revisions. A separate document will contain the public comments and how they have been addressed.

VA will have five (5) business days to approve the contractor’s final audit plan. Upon VA approval, the contractor will post the final audit plan and the response to public comments to the public website and the contractor will begin the audit.

If the audit plan is rejected by VA, the contractor will have three (3) business days to make corrections. VA will approve or reject this revised plan within three (3) business days. This process shall be repeated until the audit plan is approved by VA. Multiple resubmissions will be viewed negatively in performance evaluations.

B: TASK 2 – Reporting:

The contractor will develop a reporting system that will support production of the following reports of audit findings to OF or designee. The contractor shall provide report templates for OF approval within twenty-one (21) calendar days after the Kick-Off Meeting.

The VA shall have ten (10) business days to review each document and provide feedback if necessary. The contractor shall have five (5) business days to incorporate any comments. Multiple resubmissions will be viewed negatively in performance evaluations.

Weekly: Two weekly reports will be required: 1) the Weekly Status Report (WSR) and 2) the Weekly Batch Transmission (WBT) report.

WSR: The WSR will include data from the week prior and will include data for the fiscal year to date. The following information will be required in the WSR:

· Audits completed

· Estimated % completion of the entire task

· Number of overpayments identified

· Overpayments by provider

· Dollar value of overpayments identified

· Number of improper payments pending for fiscal year (no payment received by VA)

· Dollar value of pending payments

· Information obtained from providers that impacts collections

· For auditing tasks nearing completion, the contractor shall begin highlighting when the contractor achieves 75% estimated completion and 90% estimated completion and when the contractor is 2 weeks from 100% completion.

The WSR will be due by close of business (COB) every Monday.

WBT report: The WBT will include data required for collections. The WBT will be transmitted directly to the VA or designee in the format they require for collections.

The WBT will be due on the same day of the week on a recurring basis. The specific due date will be determined after contract kick-off.

Monthly: The Monthly Reports will be in Excel format and include the following data from the prior month.

· Provider name

· Provider Tax ID Number (TIN)

· Case number

· Case creation date

· VISN and station numbers for each case

· Audits completed

· Number of overpayments identified

· Dollar value of overpayments payments identified

· Number of improper payments pending for fiscal year (no payment received)

· Dollar value of pending payments

· Aging of recoverables: if overpayment has been identified, but is still outstanding: zero (0) – six (6) months, six (6) months to one (1) year and older than (one) year

· Number of disputes received by provider and results (overturned, upheld or pending) and dollar amount

· Number of payment plan requests received by provider

· Number of compromises requests received by provider

· Number and dollar amount of underpayments identified, if any, and identified root causes Unless the VA COR approves alternative arrangements, each Monthly Report shall be due by COB on the fifth (5th) business day following the end of the month. The Monthly Report shall be sent via e-mail to the VA COR.

Annual Reports: The Annual Report will include a summary of data and any important events or highlights from the Monthly Reports from the current fiscal year and is due to VA by October 2nd each POP the contract is active. If October 2nd is a Saturday, Sunday or federal holiday, the report will be due by Noon MST the next business day.

At a minimum, the Annual Report will include:

· Lessons learned

· Recommendations to mitigate root causes

· Suggested corrective actions

· Trends

Ad Hoc Reports: Ad Hoc Reports are requests due to a unique or urgent need for specific information in a specified format. The VA will request any Ad Hoc Reports by email to the contract point of contact. The contractor shall provide Ad Hoc Reports one (1) business day after the request or by the date indicated by the VA COR.

Final Report: When the contract is scheduled to end, regardless of reason, the contractor shall submit a Final Report. The Final Report shall include a synopsis of the entire contract project by Base and Option Years. This includes reporting the final amounts of all debt identified, collected and outstanding amounts at the end of the contract by provider, by year. The Final Report will also include:

· Lessons learned

· Recommendation to mitigate root causes

· Suggested corrective actions

· Trends identified.

The Final Report shall be due by COB sixty (60) calendar days prior to the end of the contract.

C: TASK 3 – Public Website:

The contractor will establish and maintain a public website that allows posting of VA-approved audit plans in accordance with the Audit Plan Approval Process. The website will also allow for public commenting on the audit plans as well as posting of responses. The contractor must receive VA COR approval prior to launching the website or website updates and prior to posting any information available to the public.

The website shall be clearly represented as a website of and for the contractor and shall include no VA logo(s) or branding. In all external facing sites/pages, the contractor shall not portray itself as representing VA in any manner. If necessary for context, clarifying comments about the contractual relationship between VA and contractor are acceptable.

Regardless of format, all Web content or communications materials produced, including text, audio or video - must conform to applicable Section 508 standards to allow federal employees and members of the public with disabilities to access information that is comparable to information provided to persons without disabilities. All contractors (including subcontractors) or consultants responsible for preparing or posting content must comply with applicable Section 508 accessibility standards, and where applicable, those set forth in the referenced policy or standards documents below. Remediation of any materials that do not comply with the applicable provisions of 36 CFR Part 1194 shall be the responsibility of the Recovery Auditor (or subcontractor or consultant).

D: TASK 4 – Secure portal The contractor shall establish a secure portal through which sensitive data can be transmitted in accordance with all privacy laws and regulations. The sensitive data may be transmitted to or from VA and the contractor. When the secure portal is ready to be launched, the contractor will provide a virtual demonstration to VA at a time mutually established by the VA COR and the contractor.

The contractor must submit notification when the portal is ready and receive VA COR approval prior to launching the secure portal or any portal updates. The contractor will be given a list of VA staff as well as other personnel who need to be given access to the secure portal in order to facilitate RA activities.

E: TASK 5 – Audit Documentation:

As noted in the General Requirements, some contractor personnel will require access not only to the VA Network but also to other VA systems (shown in the table below) in order to pull the supporting documentation required for the audit. Obtaining access to these other VA systems can be challenging. VA handles vast amounts of sensitive information and has very stringent requirements for contractors having a need for and obtaining restricted accesses to many VA systems. There can be lengthy delays within VA as VA personnel assist with working through processes to obtain accesses for contractors.

The successful contractor will identify which personnel require what system accesses and begin the access processes as quickly as possible, but before an ATO is issued to the contractor. The contractor must have VA COR approval before obtaining access to any VA systems for obtaining documentation.

As noted above, access can be difficult to obtain. Therefore, it is extremely important the contractor does not allow any system accesses they have been granted to lapse or become disabled. These accesses require logging in at least once every twenty-five (25) calendar days to each system. The contractor will develop and manage an Access Tracking Plan that demonstrates how the contractor will monitor the status of their own accesses and ensure contractor personnel’s access to the VA Network and VA systems does not lapse. The Access Tracking Plan will be due COB sixty (60) calendar days following the Kick-Off Meeting. Requests for re-establishing lapsed accesses must include the reason the account lapsed. If accesses lapse, VA may require the contractor to submit and implement a corrective action plan. At a minimum, for VACC claims, prior to finalizing an audit finding, the contractor will review the associated authorization, the claim, and additionally for inpatient claims the Non-VA Hospital (NVH) Pricer and clinical tracking.

The list of systems below is current as of the posting of this PWS. Data may be moved to other systems prior to the audits beginning. VA shall provide an updated list of required accesses prior to each audit beginning. VA recommends prospective offerors have expertise in data pyramids and complex databases, such as Structured Query Language (SQL).

F: TASK 6 –CSC:

The contractor shall establish and maintain a CSC to provide accurate and timely responses to VA and provider inquiries. The contractor shall submit a plan of how they will set up and operate the CSC and how the requirements of this task as described below will be met. The VA COR will approve this plan. Documentation concerning potential disputes and appeals should be notated in the contractor system.

The contractor will send a notification to the VA COR when the CSC is ready to be launched. The contractor must receive VA COR approval prior to launch of the CSC.

Contractor personnel staffing the CSC will respond telephone inquiries within one (1) business day and resolve issues in five (5) business days, unless otherwise directed by the VA COR. The contractor will create a team to receive incoming calls from providers concerning audit findings. If calls are recorded, call records must be destroyed upon termination of the contract.

1. Customer Service

a. The contractor shall provide a toll-free customer service telephone number on all correspondence sent to providers. The customer service number shall be staffed by qualified personnel during normal business hours. Hours of operation will be determined post award. Correspondence sent by VA or designee related to collections of debts will refer questions about the audit to this customer service number. The contractor shall act as the initial point of contact for all customer service inquiries related to the recovery audit program. The caller must identify themselves and who they represent before the contractor may provide information regarding an audit.

b. Customer service staff shall be available to providers on all business days except for federal holidays. After normal business hours, a message shall indicate the normal business hours for customer service. All messages playing after normal business hours or while on hold must be approved by the VA COR.

c. The contractor shall utilize a Quality Assurance (QA) program to ensure that all customer service representatives are knowledgeable, being respectful to providers and providing timely follow-up calls. The QA program must be detailed in the AMP.

d. The contractor shall respond to written correspondence, including mailed and faxed documents, within fifteen (15) business days. If the contractor is waiting for an outside or VA response, the contractor will contact the sender and give them status updates weekly until it is resolved.

e. The contractor shall respond to all email inquiries within two (2) business days of receipt. This includes requests from VA as well as inquiries from providers and other external entities.

f. The contractor shall provide the VA COR with copies of all correspondence (including email) indicating displeasure with the contractor, in the overpayment identification, or in the recovery methods utilized, within two (2) business days of receipt of such correspondence via VA encrypted email or mail. If the contractor is not sure how the correspondence will be interpreted, it should forward the correspondence to the VA COR.

Tasks for Auditing Paid Claims:

The auditing tasks for this task order include a backlog of claims (generally dating back to FY22 until the contractor’s audit begins), as well as claims paid more recently. The contractor’s audit plan shall include provisions to review claims from the most recently completed fiscal year, as well as to concurrently work down the backlog starting with the oldest claims. In the first option year, if exercised, the contractor will audit claims paid during the base year of the contract and FY22, and so forth.

As noted above, the fiscal year ranges identified below refer to Dates of Service (DOS); actual claims payment dates may vary.

G. TASK 7 - Auditing VA Paid Claim Data The auditing related to this task order includes claims paid between FY22-FY28. The contractor’s audit plan shall include provisions for each program authority and their individual eligibilities and payment methodologies. The contractor will be responsible for obtaining and reviewing medical records and creating a first level dispute process.

G: TASK 8 – Audit of VACC The contractor shall audit pre-authorized VACC paid claims under 38 U.S.C. § 1703 between October 1, 2023 – September 30, 2028 as described in Task 8below. VA will include claims paid directly to providers under the Veteran Care Agreement universe.

The following exclusions will apply to all claims included in Task 8:

· Claims paid to Department of Defense (DoD)

· Claims paid to Indian Health and Tribal Health providers

· Claims paid by VA for care furnished outside of the United States and its territories

· Claims paid for State Home Per Diem Program

· Claims paid related to domiciliary

· Claims paid for contract nursing homes care

· Claims paid for bowel and bladder care

· Claims currently under investigation by the VA for potential Fraud Waste and Abuse (FWA)

· Claims included in equitable relief

· Claims in pre-payment review

· Claims paid directly to Veterans

Prior to finalizing audit results for Task 8 claims, the contractor will ask the provider if they can make available evidence of an agreement to be paid rates other than Medicare rates for the services provided. The VA COR shall approve the contractor’s letter to be sent to providers prior to use.

Task 8 –Audit of VACC – Claims preauthorized with Veteran Care Agreements:

The contractor shall audit all other claims paid under 38 U.S.C. § 1703 from October 1, 2023 – J through September 30, 2028, that are not included on the Task 8 exclusion list.

Whenever Medicare payment methodologies change, VA uploads Centers for Medicare and Medicaid Services (CMS) Fee Schedules into eCAMS that help determine what VA should pay providers for their services. However, some Fee Schedules were not uploaded in a timely manner resulting in claims being paid erroneously. In some cases, VAMCs entered into agreements with providers to pay other than Medicare rates. In these cases, if there is evidence to substantiate the agreed-upon rate, the agreed upon rate will be used to determine the proper payment amount. Claims with CPT/HCPS codes or for services not paid be Medicare are paid at lesser of the local VAMC fee schedule or billed charges.

H: TASK 9 – Audit of CHAMPVA claims (FY15 – FY23):

CHAMPVA is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The contractor will audit claims paid under 38 U.S.C. § 1781 and 38 C.F.R. § 17.270 – 17.278 between October 1, 2015 – September 30, 2023 for CHAMPVA services to eligible beneficiaries. The contractor shall only review claims received from providers.

Exclusions include:

· Claims paid directly to a beneficiary

· Claims currently under investigation by the VA for potential FWA

· Claims included in equitable relief

· Claims in pre-payment review

· Claims where CHAMPVA was secondary payer

· Claims for dental

· Claims for travel other than ambulance associated with medical care

· Pharmacy claims including “Meds by Mail”

I: TASK 10 – Audit of Spina Bifida Program Claims (FY15 – FY23):

Among other benefits, the VA SB program provides VA financed health care benefits to certain Korea and Vietnam Veterans' birth children who have been diagnosed with SB. The contractor will audit claims paid under Title 38 C.F.R. § 17.900 – 17.905 from October 1, 2015 – September 30, 2023 for VA financed health care benefits to eligible beneficiaries diagnosed with SB. The contractor shall only review claims received from providers.

Exclusions include:

· Claims paid directly to a Veteran or beneficiary

· Claims currently under investigation by the VA for potential FWA

· Claims included in equitable relief

· Claims in pre-payment review

· Claims paid for bowel and bladder care

· Claims for travel other than ambulance associated with medical care

· Pharmacy claims including “Meds by Mail”

J: TASK 11 – Audit of VACC Emergency Care for Non-Service Connected Veterans claims (FY15 – FY23):

Commonly called Mill Bill, this program was developed to provide emergency care for non-service connected Veterans. To be eligible, the Veterans must meet specific criteria.

The contractor will audit claims paid under 38 U.S.C. § 1725 and 38 C.F.R. § 17.1000 from October 1, 2015 – September 30, 2023 for services provided under this program. The contractor shall audit the payment and administrative eligibility of claims and shall assume that clinical eligibility determinations were correct.

Exclusions include:

· Claims paid directly to a Veteran

· Claims currently under investigation by the VA for potential FWA

· Claims in pre-payment review

· Claims where VA was secondary payer

K: TASK 12 – Audit of VACC Emergency Care for Service Connected Veterans claims (FY15 – FY23):

VA can generally pay for emergency medical care for a Veteran’s service-connected condition or if the care is related to a Veteran’s service-connected condition. However, there are specific criteria that must be met in order to be eligible to use this program. The contractor will audit claims paid under 38 U.S.C. §1728, 38 C.F.R. §17.120 and 38 C.F.R. §17.132 from October 1, 2015 – September 30, 2023 for services provided under this program. The contractor shall audit the payment and administrative eligibility of claims and shall assume that clinical eligibility determinations were correct.

Exclusions include:

· Claims paid directly to a Veteran

· Claims currently under investigation by the VA for potential FWA

· Claims included in equitable relief

· Claims in pre-payment review L: TASK 15 – Audit of National Dialysis Services Contract claims (FY22 – FY29):

The NDSC Program was established to provide dialysis for eligible Veterans when VA cannot provide those services due to geographic inaccessibility or if the care is not available at a VA HCF. The contractor will audit claims paid under 38 U.S.C. § 8153 from October 1, 2022 – September 30, 2029, for contract dialysis services paid through PCM and eCAMS.

Exclusions include:

· Claims currently under investigation by the VA for potential FWA

· Claims included in equitable relief

· Claims in pre-payment review

· Claims paid for nephrologist services

IV. FINANCIAL MANAGEMENT

A: Collections Activity Following the contractor’s determination of an overpayment per fiscal year, per provider, the details of the overpayment(s) will be provided to VA. In turn, VA will record the overpayment(s) and issue a Bill of Collection (BOC) to the provider. The BOC will include both a Notice of Rights and Responsibilities (NRR) and a Notice of Indebtedness (NOI) that details specifics of the overpayment(s). Providers have thirty (30) calendar days to make payment on the identified debt. When payments are received past thirty (30) calendar days, VA assesses interest, penalties and administration fees (IPA). VA will not pursue collection on debts less than $25, aggregated for a single provider per fiscal year.

When payment is received past thirty (30) calendar days, VA will settle the IPAs first before applying payment to the identified debt. The contractor will receive their contingency fee based on amounts applied to identified debt only.

If payment is not received within ninety (90) calendar days, VA may internally offset debt to future VA payments (internal process) or refer the debt to the Department of Treasury’s Cross-Servicing program (external process). The contractor will receive their contingency fee based on amounts applied to identified debt only. VA may refer debt for administrative offset. The contractor will be paid contingency fees based on the recoveries through offset. The IPA and related collection fees are settled first and contingency is applied to the remaining balance. Cases under $25 will not be referred for offset. In order to satisfy a debt, providers may request a payment plan or compromise as outlined in the NRR. The contractor shall not use the threat of litigation or other aggressive tactics under this task order to elicit payment from providers.

B: Disputes and Appeals If a provider receives the NOI and has questions or disputes the findings, the NOI will direct them to contact the contractor CSC.

Dispute: A dispute occurs when a provider disagrees with the audit findings. The contractor shall review the audit methodology utilized to determine the overpayment and answer any questions the provider may have. Within three (3) business days the contractor will establish communication with disputing providers for presenting and discussing their findings. The provider may submit exculpatory documentation for consideration.

If after discussion with the contractor the provider still disagrees with the finding, the provider may request a second level dispute.

Appeal: The contractor will notify VA of the appeal request within two (2) days and forward the electronic case files. VA may use a third party to review appeal requests, but VA retains the final decision-making authority on all appeal decisions. Following the appeal review, one of the following determinations may be made:

· Upheld: The identified overpayment is deemed correct and the overpayment stands.

· Overturned: The identified overpayment is deemed incorrect, in part or in whole, requiring the contractor to adjust the findings accordingly and notify the provider of the changes. The contractor will be required to reflect the adjustments in the weekly WBT report.

If VA determines a substantial number of findings are adjusted based on appeal, VA may direct the contractor to create and implement a corrective action plan. Multiple cases adjusted based on appeal will be viewed negatively in performance evaluations.

C: Payment Plans and Compromises VA has authority to enter into payment plans and compromises with individual or groups of providers without requiring the contractor’s approval or input. If VA approves a payment plan or compromise, the payment to the contractor will be adjusted so that the contingency fee payment is based only on the portion of the overpayment that remains collected or recouped.