PWS San Diego Aged Claims 1.1.pdf

Performance Work Statement (PWS)

FOR NON-PERSONAL SERVICES

Naval Medical Center San Diego

Accounts Receivable Support Services for the Uniform Business Office

1. GENERAL.

This contract is a non-personal services contract to provide Accounts Receivable Support Services

- claims aged at 120 day and older for the Uniform Business Office (UBO) at San Diego. The

Government shall not exercise any supervision or control over the performing the services herein.

The contractor's staff shall be accountable solely to the contractor who in turn is responsible to the Government.

1.1. Background. The Department of Defense (DoD) operates a UBO Program at Defense Health

Program (DHP) MTFs throughout the world that administer Third Party Collections (TPC), Medical Services Account (MSA), and Medical Affirmative Claims (MAC) programs. The UBO offices focus on ensuring that billable services are identified; payer information is available;

accurate and complete claims and invoices are generated; and appropriate collections are received.

Together, the three cost recovery programs provide the business processes for recovery including collections control, accounts receivable, and deposits. DoD policy further requires that all MTFs bill and collect payment for medical services rendered to both authorized beneficiaries who have other health insurance (OHI) and non-beneficiaries where care is performed within the MTF’s purview.

1.2. Scope of Work. The contractor shall provide qualified personnel and services necessary to collect and clean-up aged claims collection and write-off activities for NMCSD using the Armed

Forces Billing and Collection Utilization Solution (ABACUS) system, or any future designated

Government Billing System (GBS). The work to be performed under the provision of this contract is described as: follow-up and denial management actions on unpaid and denied claims where the age of the claim is 120 days from billed date, performing write-off and closing accounts. All payments are posted by the UBO designated NMCSD staff.

1.2.1. The Contractor work performed under this contract is to assist NMCSD UBO with its backlog of claims requiring follow-up and denials management.

1.2.2. All billing and collection information shall remain the property of the U.S. Government.

Access to ABACUS and any other future GBS will be available to the Contractor with the use of a Government-issued CAC. The Contractor shall collaborate with the COR and any other required personnel (i.e., MTF Systems and Security Officers) to obtain access to ABACUS and any other

Government applications (such as DEERS, etc.) as required to execute this contract.

1.2.3. NMCSD shall have the right to audit any data produced, or any function performed by the

Contractor at any time and shall have access to any Contractor owned, managed, or otherwise operated facilities where services are performed under this contract without advance notice.

1.2.4. The contractor shall comply with all applicable laws, rules and regulations for Navy

Medicine and DHA.

1.3. Reserved

1.4. Security Requirements. The Contractor shall comply with all applicable DoD security regulation and procedures during the performance of this requirement. The Contractor shall safeguard procurement sensitive information, data, Privacy Act data, Personally Identifiable

Information, and Government personnel work products obtained or generated in the performance of this contract from disclosure.

1.4.1. Neither the contractor nor any of its contract employees shall disclose or cause to disseminate any information concerning operations of military activities. Such action(s) could result in violation of the contract and possible legal actions.

1.4.2. All inquiries, comments or complaints arising from any matter observed, experienced, or learned of as a result of or in connection with the performance of this contract, the resolution of which may require the dissemination of official information, shall be directed to the contracting officer representative (COR) and the contracting officer (CO).

1.4.3. The contractor shall only conduct business with designated Government personnel listed as points of contact (POCs). Names of authorized personnel will be provided to the contractor by the

Government, in writing within 5 business days of contract award, and within 5 business days of changes throughout the contract period.

1.4.4. U.S. Government records, copies of original results and reports, verified original data, corrected data, and corrected supporting final reports are maintained by the contractor, but remain the property of the U.S. Government.

1.4.5. Trusted Associated Sponsorship System (TASS).

1.4.5.1. The contractor shall comply with agency personal identity verification procedures that implement Homeland Security Presidential Directive-12 (HSPD-12), Office of Management and

Budget (OMB) guidance M-05-24, and Federal Information Processing Standards Publication

(FIPS PUB) Number 201.

1.4.5.2. Reserved

1.4.5.3. The contractor shall ensure compliance with the provisions set forth below. For purposes of the Federal Acquisition Regulation (FAR) Clause 52.204-9, the Government will designate a

Trusted Agent (TA) for this contract. The Government reserves the right to amend or supplement these provisions pursuant to the Changes clause in the contract.

1.4.5.4. Reserved

1.4.5.5. Reserved

1.4.5.7. The Government TA will send a notice through the TASS to the CO e-mail address provided IAW the above requirement. The Contractor Staff's user ID and password will be provided in the e-mail and will be require a change at first log-in. In the event the e-mail message is not received, the contractor may request the username and password from the TA and proceed to the website https://www.dmdc.osd.mil/tass to complete the process.

1.4.5.8. The contractor's staff will log into the TASS and complete the verification process by submitting the application back to the TA for approval.

1.4.5.9. The application will be accepted, returned, or rejected by the TA. Notice as to whether the application has been accepted, returned, or rejected will be provided to the CSP’s e-mail address within 48 hours after submission. If the application is returned or rejected, the Contractor's program manager shall contact the TA and comply with the TA’s guidance to attempt to correct and resolve the issue(s).

1.4.5.10. Upon approval of the application, the Contractor's staff will receive an e-mail stating the

CAC application was approved. The applicant must then schedule an appointment with an authorized RAPIDS Issuing Facility to have the Government credential issued. The RAPIDS appointment Scheduler can be located on the following website: https://rapids-appointments.dmdc.osd.mil/default.aspx. To make an appointment, the Contractor staff will follow the instructions provided by the TA and contact the COR for instructions. The supervisor or Government task manager must send a visitor message prior to the CSPs arrival on-site. The contractor staff must present two acceptable forms of ID which may include: Driver's License, Military ID, Contractor Company ID with picture and expiration date, charge card with picture imprinted, or passport.

1.4.5.11. Contractors requiring CAC. Before CAC issuance, the contractor employee requires, at a minimum, a favorably adjudicated National Agency Check with Inquiries (NACI) or an equivalent or higher investigation in accordance with Navy Directive. The contractor employee will be issued a CAC only if duties involve one of the following: (1) both physical access to a DoD facility and access, via logon, to DoD networks on-site or remotely; (2) remote access, via logon, to a DoD network using DoD-approved remote access procedures; or (3) physical access to multiple DoD facilities or multiple non-DoD federally controlled facilities on behalf of the DoD on a recurring basis for a period of 6 months or more. At the discretion of the sponsoring activity, an initial CAC may be issued based on a favorable review of the FBI fingerprint check and a successfully scheduled NACI at the Office of Personnel Management.

1.4.7.2.3. iWATCH Training. The contractor shall brief all employees on the local iWATCH program (training standards provided by the requiring activity ATO). This locally developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to the COR. This training shall be completed within 10 https://www.dmdc.osd.mil/tass https://rapids-appointments.dmdc.osd.mil/default.aspx https://rapids-appointments.dmdc.osd.mil/default.aspx calendar days of contract award and within 5 calendar days of new employees commencing performance, with the results reported to the COR NLT 10 calendar days after contract award.

1.4.7.2.4. For IA/IT Training. All contractor employees and associated subcontractor employees must complete the DoD Information Awareness (IA) awareness training before issuance of network access and annually thereafter. All contractor employees working IA/IT functions must comply with DoD and Army training requirements in DoDD 8570.01, DoD 8570.01-M, and AR

25-2 within six months of appointment to IA/IT functions. All certificates must be submitted to the COR. All certificates must be submitted to the COR.

1.5. Quality Control (QC). The contractor is responsible for quality control. The contractor shall maintain a complete Quality Control Plan (QCP) that shall ensure the requirements of the contract are provided as specified in this PWS. The Contractor shall maintain a complete Quality Control

Plan that shall ensure the requirements of the contract are provided as specified in Section 5 of the

PWS. Within thirty calendar days after contract award, three copies of a comprehensive written

QCP shall be electronically submitted to the COR and within 5 working days when changes are made thereafter.

1.6. Quality Assurance (QA). The Government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). The QASP is the Government’s internal plan for performing QA, and as such does not become part of the resultant contract.

1.7 Reserved

1.8. Travel. None

1.9. Place of Performance. The place of performance is the Contractor's place of business.

1.10. Hours of Operation. The normal hours of operation are between 7:30 a.m. and 4:30 p.m.

Eastern, Monday through Friday, except federal holidays or when the Government facility is closed due to emergencies, administrative closings, or similar Government-directed closings. The contractor is responsible for providing services between those hours of operation within the time allotted on their normal work schedule.

1.11. Recognized Holidays. The contractor shall not perform services on the holidays listed:

New Year’s Day, January 1st; Martin Luther King’s Birthday, 3rd Monday in January; Presidents’

Day, 3rd Monday in February; Memorial Day, last Monday in May; Independence Day, July 4th;

Labor Day, 1st Monday in September; Columbus Day, 2nd Monday in October; Veteran’s Day, November 11th; Thanksgiving Day, 4th Thursday in November; Christmas, December 25th.

1.11.1. Any of the above holidays falling on a Saturday will be observed on the preceding Friday;

holidays falling on a Sunday will be observed on the following Monday.

1.12. Personnel.

1.12.1. Key Personnel. The contractor shall provide a contractor representative. The name of this person shall act for the contractor in its absence shall be designated, in writing, and submitted to the COR and CO within 5 business days of contract award. The contractor representative shall have full authority to act on behalf of the contractor on all contract matters relating to daily operation of this contract. The contractor representative shall be available between the hours of

8:00 a.m. and 4:00 p.m., Monday through Friday except federal holidays or when the Government facility is closed for administrative reasons.

1.13 Reserved

1.14. Reserved

1.14.1. At any time during the performance of this contract, the CO or COR may direct the contractor to immediately remove from the workplace any contractor staff whose actions or conduct raises reasonable suspicion that clear and present danger of physical harm exists to the contractor staff, a patient or Government personnel.

1.14.2. If the need for a removal occurs, the COR will contact the contractor and direct the contractor to remove that contractor staff from the medical facility and to not use that individual to perform any services required under this contract until the issue has been resolved by the CO.

The contractor shall formally meet with the COR to discuss further action in accordance with the

MTF Quality Assurance and Inspection (QA&I) Plan and AR 40-68. A review of the basis for removal will be made by the CO within 3 working days after the COR directed the removal.

1.14.3. If, after any investigation deemed necessary by the CO and discussions with the contractor's representative, the CO concludes that the contract Contractor’s conduct requires permanent removal from performance under the contract, the CO will notify the contractor that permanent removal is required. In the event of disagreements between the Government and the contractor's representative concerning matters of impaired Contractors staff, the decision of the CO will be final. During the period of time between the removal and the final decision of the CO, the contractor shall not provide a backup/replacement in accordance with the terms and conditions of this contract. Removal of contractor staff does not relieve the contractor of the requirement to perform contract services.

2. DEFINITIONS AND ACRONYMS.

2.1. Definitions

2.1.1. Armed Forces Billing and Collection Utilization Solution (ABACUS). The DOD Web

Based system used to receive data from the CHCS and produce claims and invoices for billing and process collections.

2.1.2. Ambulatory Data System (ADS). Provides clinical encounter information for clinical services.

2.1.3. Ambulatory Data Module (ADM). CHCS module that provides clinical encounter information for clinic services rendered to include coding classifications, provider, and patient information

2.1.4. Ambulatory Procedure Visit (APV). An outpatient surgery procedure.

2.1.5. Coding and Compliance Editor (CCE). Back-end automated coding edit tool.

2.1.6. Composite Health Care System (CHCS). DOD’s medical database that tracks all patient related information.

2.1.7. Code of Federal Regulations (CFR). Federal regulations that set forth federal billing guidelines.

2.1.8. Centers for Medicare and Medicaid Services (CMS). US Federal Agency that administers

Medicare, Medicaid, and the State Children's Health Insurance Program.

2.1.9. Contractor. The term as used in this contract refers to the prime.

2.1.10. Contracting Officer (CO) A person with authority to enter into contracts; administer, or terminate contracts. Make related determinations and findings on behalf of the Government. Note:

The only individual who can legally bind the Government.

2.1.11. Contracting Officer’s Representative (COR). An employee of the U.S. Government appointed by the contracting officer to monitor contractor performance. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.12. Current Procedural Terminology (CPT). Terminology used for coding medical and surgical services.

2.1.13. Department of Defense (DOD) Other Health Insurance (OHI) (DD Form 2569) form used to identify and report third party insurance of beneficiaries eligible to receive medical care at DOD

MTFs.

2.1.14. Diagnosis Related Group (DRG). A Diagnosis-Related Group is a statistical system of classifying any inpatient stay into groups for the purposes of payment.

2.1.15. Explanation of Benefits (EOB). Explains services covered by a patient’s insurance company, under a given claim.

2.1.16. General Fund Enterprise Business System (GFEBS). A Web-based enterprise resource planning (ERP) system for the United States Army.

2.1.17. Healthcare Common Procedural Coding System (HCPCS). HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the

CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.

2.1.18. Health Insurance Portability and Accountability Act of 1996 (HIPAA). Provides guidelines for confidentiality and handling of patient health information.

2.1.19. International Classification of Diseases Codes 10th revision (ICD-10). A medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

2.1.20. Key Performance Indicator (KPI). A measurable value that demonstrates how effectively a company is achieving key business objectives. Organizations use KPIs to evaluate their success at reaching targets.

2.1.21. Judge Advocate General (JAG). Term used to designate the chief of legal services within the military.

2.1.22. Medical Affirmative Claims (MAC). Medical Affirmative Claims (MAC) is the military program is established based on the Federal Medical Care Recovery Act (FMCRA) which authorizes military treatment facilities (MTFs) to recover the cost of furnishing health care to DoD beneficiaries, including active duty members, who are injured or suffer an illness caused by a third party. MAC activities involve billing all areas of liability insurance, including automobile, homeowners and renters, and workers' compensation (for persons other than federal employees).

2.1.23. Medical Services Account (MSA). MSA activities involve the first payer billing of individuals and other Government Agencies for services rendered at a MTF, to include all authorized beneficiaries and civilian emergencies.

2.1.24. Physical Security. Actions that prevent the loss or damage of Government property.

2.1.25. Other Health Insurance (OHI). Third Party Insurance carried by some DOD beneficiaries.

2.1.26. Quality Assurance. The Government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.1.27. Quality Control. All necessary measures taken by the contractor to assure that the quality of an end product or service shall meet contract requirements.

2.1.28. Third Party Collections (TPC). The monies collected by MTFs through the implementation of 32 CFR Part 220 (Reference C), supplemented by Services’ guidelines.

2.1.29. Subcontractor. One who takes a portion of a contract from the principal contractor or from another subcontractor.

2.1.30. Uniform Business Office (UBO). A branch within an MTF responsible for all billing and collection functions in the MTF.

2.1.31. Work Day. The number of hours per day the contractor provides services.

2.1.32. Work Week. Is defined as Monday through Sunday (dependent on workload and mobilization requirements).

3. GOVERNMENT FURNISHED ITEMS AND SERVICES.

3.1. Government Services and Materials.

3.1.2. The Government will provide access to the GBS 24 hours per day/365 days per year;

however, the Contractor is expected to perform work during a normal work week, observing

Federal holidays. Scheduled downtime, related to system updates and maintenance, restricting access to the GBS will be communicated to the Contractor, allowing for preparation for off-line work activities.

3.2. Facilities. The Government will not provide any facility support. Contract employees will perform their work remotely from the contractor's business office and will need access to the GBS.

4. CONTRACTOR FURNISHED ITEMS AND RESPONSIBILITIES.

The contractor shall furnish all items deemed by the Contractor as necessary for performance of this requirement that are not listed under Section 3 of this PWS.

4.1. Materials. The Contractor shall furnish any materials deemed by the Contractor as necessary for performance of this requirement that is not listed in Section 3 of this PWS.

4.2. Supplies. The Contractor shall furnish any supplies deemed by the Contractor as necessary for performance of this requirement that is not listed in Section 3 of this PWS.

4.3. Equipment. The Contractor shall furnish any equipment deemed by the Contractor as necessary for performance of this requirement that is not listed in Section 3 of this PWS.

4.4. Personnel. The Contractor shall furnish all qualified personnel for performance of this requirement.

4.4.1. Personnel Qualifications. The Contractor shall employ and ensure qualified staff with at least three (3) years of experience in the operation of personal computers and familiarity with common office software such as Microsoft Excel, Microsoft Word, and Microsoft PowerPoint, Microsoft Access, and electronic mail systems.

4.4.1.1. Follow-Up and Denials Management :

4.4.1.1.1. Contractor shall have the ability to read and interpret medical documentation and understand medical terminology.

4.4.1.1.2. Contractor shall have a working knowledge of Ambulatory Procedure Groupings

(APGs), Diagnosis Related Group (DRG) codes, International Classification of Diseases-Versions

9 & 10 (ICD-9 & ICD-10), Current Procedural Terminology-Version 4 (CPT-4) coding, other code sets such as Claim Adjustment Reason (CAR) codes, and electronic billing and collection procedures to correctly prepare a record for both outpatient and inpatient billing services.

4.4.1.1.3. Contractor shall stay relevant as new procedures and code versions are established and become available in the commercial market.

4.4.1.1.4. Contractor shall have the ability to analyze denied reimbursement claims and coordinate with insurance companies to correct errors to ensure reimbursement. These personnel shall perform Charge Recovery Specialist type work.

4.4.1.1.5. Recovery Specialists shall have a minimum of two years’ experience. In addition, at a minimum, there shall be at least one (1) Recovery Specialist who possesses either three (3) years of experience in medical billing and collections or have completed a medical biller certification program. The Government considers experience acceptable if it was performed within the DoD or in a commercial healthcare organization; however, it must be specific to medical billing and collection services

5. DESCRIPTION OF WORK.

5.1. The contract shall augment billing and collecting activities and support the UBO program by performing the duties described below:

5.1.1. Facilitation of Collection Activities:

5.1.1.1. The COR will provide a listing of Naval approved reasons for write offs. Contractor shall make available all hardcopy/written documentation received on claims by scanning all hard copy documents into PDF format and uploading those documents to the GBS. Examples of documentation include, copies of checks, verification of electronic payments, explanations of benefits (EOBs), demand letters, non-payment documentation, legal determination, proof of preauthorization, pre-certifications, notes of phone conversations with insurance company or other payer personnel (including the name of the insurance representative, date/time of the phone call, and a brief summary of the discussion), and any other relevant information. CSPs shall be responsible for shredding all hard copy documents, only AFTER the documents are scanned and verified to be successfully uploaded into the GBS. Most billing data will automatically flow from other DoD automated information systems to the GBS. CSPs shall collect all required data necessary to produce claims and invoices that did not automatically flow, per MEDCOM provided business rules. Examples of encounter data that may not automatically flow to the GBS include ambulance runs, dental care, immunizations, and pathology services.

5.1.1.2. The Contractor and its CSPs shall abide by Navy Medicine/DHA UBO billing and collection policies and procedures..

5.1.3. Follow-Up and Denials Management

5.1.3.1. Follow-Up . The Contractor shall perform active and aggressive follow-up actions for all claims without action within 30 days from Receipt Date. The Contractor shall annotate within the

GBS all follow-up efforts, including the name of the insurance representative contacted, date/time of the phone call, and a brief summary of the discussion. If follow-up actions were performed via insurance company website, the Contractor shall notate or upload status onto the claim. The annotations shall be clear and convey the cause for delay in payment. The Contractor shall ensure documentation of correspondence with insurance companies (or any other party) to include copies of all demand letters are maintained in the GBS. All collection efforts made by the Contractor shall be communicated to the Government by documenting notes in or attaching supporting documentation to the relevant claim in the GBS. Throughout the life of the contract, all claims over 120 days old from date of claim filing should be resolved.

5.1.3.2. Denials Management. The Contractor shall perform denials management for all claims, regardless of amount, to ensure compliance with the timelines referenced in this PWS and as directed by the COR. To effectively manage this process, the Contractor shall utilize industry best practices in denials management by trending and reporting performance metrics to the COR on a monthly basis. The Contractor shall identify industry ratios/indicators they intend to utilize for this contract beyond those outlined within this PWS and shall include this information in their proposal.

Collections and denials management activities are constrained by regulation and policy to a narrow window of opportunity.

5.1.3.3. If Follow-Up or Denials Management activities result in information suggesting no payment shall be received from the payer, in the absence of an EOB documenting the valid denial, the Contractor shall document in the GBS and forward to the MTF UBO Manager to write-off or approval to write-off.

5.2. Deliverables.

5.2.1. Progress Reports. The Contractor shall provide monthly reports of the number of accounts successfully collected, written off. This report is due no later than the 5th business day of the following month.

5.2.2. The Contractor shall provide the COR with a list of the Top Ten Payers (i.e., third party insurance companies) with claim adjudication issues. This report is due no later than the 5th business day of the following month.

5.2.3. CONTRACTOR MANPOWER REPORTING. The Contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract via a secure data collection site. The Contractor is required to completely fill in all required data fields using the following web address: http://www.ecmra.mil/.

Reporting inputs will be for the labor executed during the period of performance during each

Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2017. Contractors may direct questions to the help desk at http://www.ecmra.mil/.

6. APPLICABLE REGULATIONS, DIRECTIVES, AND MANUALS.

6.1. Mandatory.

6.1.1. DoD 6010.15-M, Military Treatment Facility, Uniform Business Office (UBO) Manual, November 2006

6.1.2. AR 40–400, Patient Administration, 8 July 2014

6.1.3. DoD Financial Management Regulation (FMR) 7000.14

6.1.4. GBS Training Manuals and CBTs

7. EXHIBITS AND ATTACHMENTS.

Listed below are all Exhibits and Attachments related to the PWS. Exhibits are terms and conditions of the contract and may be directly linked to the pricing of a contract line item number.

Attachments are informational only, and will not become part of the resultant contract.

QUALITY ASSURANCE SURVEILLANCE PLAN

Key Performance

Objectives

PWS

paragraph

Performance Standard Method of

Surveillance

#1 Error Clean-up

The contractor shall resolve in the GBS Interface module and Patient Billing module any record with an error older than 30 days

5.1.3. 4000 records resolved per month

Monthly - COR will validate compliance via audit samples obtained from the

Government billing system (GBS).

#2 Follow-up The Contractor shall conduct follow-up actions for unanswered claims within 90 days of claim filing throughout the life of the contract, all claims

5.1.3.1. 80% of records over 120 days old resolved within

60 days from the 120-day mark; and 95% of records over 120 days old resolved within 90

COR will validate via periodic (monthly) and Random

Inspections from

Government billing http://www.ecmra.mil/ http://www.ecmra.mil/ over 120 days old from date of claim filing should be resolved.

days from the 120-day mark.

system (GBS);

customer feedback.

Performance above or below the standard will be documented in

CPARS.

#3 Denials Management

The Contractor shall submit appeals and resolve denied/under-paid claims that are within the appeal window.

The contractor shall resolve any denied/under-paid claims within 120 days of notification from payer.

5.1.3.2. The contractor shall

submit appeals within the timelines specified in the

PWS. 90% of appeals shall be submitted in accordance with the timelines specified in the

PWS.

Monthly - COR will validate compliance via audit samples obtained from the

Government Billing

System(GBS).

Periodic (monthly) and Random

Inspections from billing systems;

customer feedback.

Performance above or below the standard will be documented in

CPARS