RFC for ACLSU - AR POSTING CODING THIRD PARTY BILLING- 11-12-2021-vz.docx

Request for Contract For Acoma-Canoncito-Laguna Indian Health Service Unit (ACLSU) Statement of Work for Medical Accounts/Receivable (A/R) Posting, Coding, and Third Party Billing

BACKGROUND:

The Acoma-Canoncito-Laguna Service Unit (ACLSU) has an immediate requirement for contracted services for Medical Accounts Receivable (AR) Posting, Coding, and Third Party Billing. The purpose of the contract is for provision of medical coding, data entry, third party billing, and to review and complete visits in the Coding Queue and Accounts Receivable services within the ACLSU Business Office.

Services may be required beyond the base year of the contract, option year renewals will be exercised within the timeframes required by FAR Clause No. 52-217-9, Option to Extend the Term of the Contract. It is incumbent upon the Contractor to ensure that all its annual registration requirements for Systems Award Management (SAM) and the Dun and Bradstreet Numbering Systems (DUNS) No. are active in order for the option year processes.

Services under this contract will be performed under a Performance Based Statement of Work (PSW) for each category of service specified.

All services will be guided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), American Health Information (AHIMA), American Hospital Association (AHA), Federal and State regulations and the Indian Health Service (IHS) policies and procedures to ensure third party billing compliance.

The Indian Health Service is required to maintain compliance with the Centers for Medicare and Medicaid Services (CMS), pursuant to Federal, State and Agency regulations, such as Indian Health Service’s Third Party-Revenue Accounts Management and Internal Control Policy.

CMS and other third party payers have precise guidelines and regulations for all reimbursable payments from providers and services; thus the need for the contractor to ensure all the medical coding for each patient visit(s) are accurate and within the proper International Classification of Disease-Clinical Modification (ICD-CM), International Classification of Disease-Procedure Coding System (ICD-PCS) for proper reimbursement for services provided in the in-patient, out-patient departments, as well for surgical, dental and other ancillary reimbursable services. These guidelines include documentation requirements that demonstrate medical necessity, correct coding, and billing that depend on data integrity, The Office of Inspector General (OIG) of the United States Department of Health and Human stress that all participants in the Medicare and Medicaid programs are bound by ethical and legal duty to ensure the integrity of their transaction with CMS, Federal, State rules and all applicable regulations. The services will permit the ACLSU to move forward toward strict adherence to CMS, Federal and State compliance guidelines and maintain consistency with the highest standards of business and professional ethics. Coding and billing compliance are key components of the Medicare’s condition of participation in fostering and monitoring improved health and care outcomes.

The Indian Health Service (IHS) utilizes the official coding guidelines for clinical classification systems, but not limited to, current editions of International Classification of Disease-Clinical Modification, International Classification of Disease-Procedure Coding System (ICD-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedures Coding Systems (HCPCS), American Dental Association (ADA) and complies with the Indian Health System’s Third Party Revenue Accounts Management and Internal Control policy, Revenue Operations Manual, Indian Health Service Manual, Chapter 2, Health Information Management and the Indian Health Service’s statistical and reporting systems for all departments. The Contractor will comply with all the guidelines and regulations from the different agencies listed therein.

The Contractor will have specific and defined access by approved by ACLSU to the following system; Resource and Patient Management System (RPMS) modules and other access as requested by the Contractor and agreed upon by the ACLSU for revenue enhancement purposes:

a. Patient Registration System

b. Admissions/Discharges and Transfer (ADT) System

c. Third Party Billing System

d. Accounts Receivable System

e. Patient Care Component/Electric Health Record (EHR)

f. VISTA Imaging

g. Electronic Dental Record (Dentrix)

h. Pharmacy Point of Sale (POS)

i. Other systems as deemed necessary by the ACLSU or AAO/IHS Business Office Staff

COST/PRICING:

The table below represents the category of the estimated services required for the base year of the contract, and renewal of the option years at the discretion of the Government.

Based on the schedule for labor category; the Offeror/Prospective Contractor shall submit its price/cost independent of the Government’s estimated cost.

Acoma-Canoncito-Laguna (ACLSU) Service Unit (Base Period)

Totals

Total ($)

Inpatient Coding / Data Entry = Record / EHR

920 hrs.

Outpatient Coding / Data Entry = PCC / EHR

920 hrs.

Surgical Coding / Data Entry = PCC / EHR

920 hrs.

TXER Report / Error Report / Coding Queue = Hourly

TBD

Compliance Auditing = Hourly

TBD

Billing – Outpatient = PCC / EHR

920 hrs.

Billing – Inpatient = Record / EHR

920 hrs.

Printing, Mailing & Submission of Bills = Bill

TBD

Accounts Receivable/Posting = Hourly

920 hrs.

Revenue Generation Cycle Training / Education = Hourly

16 hrs.

Inpatient visits coded and data entered:

Outpatient encounters to be coded and data entered:

Surgical visits to be coded and data entered:

TXER Report/Coding Queue Audit:

Compliance Auditing:

Billing outpatient PCC/EHR:

Billing inpatient Record/EHR:

Printing, Mailing and Submission of Bills:

Accounts Receivable:

Revenue Generation Cycle Training/Education:

DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK:

The Contractor must be prepared to provide the following stated task(s) in each category of service upon receipt of the official notice to proceed letter from the Albuquerque Area Indian Health Service, Division of Contracts and Grants Management.

1. Statement of Work for Accounts Receivable/Posting:

To meet the needs of the ACLSU revenue cycle and Health Information Management (HIM), the Contractor must be prepared and able to:

· Provide ICD-9/10 AND ICD-11, ADA, CPT, and HCPCs coding, review and completion of visits in the coding queue, correction of incomplete visits and/or errors and data entry services, third party bill service, account receivable posting and follow-up, and coding queue audits/corrections.

· Perform along with the AAO/IHS Business Office staff, an initial on site/teleconference visit to discuss the contract and contract requirements addressing what functions will be performed. The Contactor will work in partnership with the service unit to assure continuity of support services, either through direct performance of necessary function or in sharing responsibilities with the service unit staff. The Contractor will be expected to serve as an auxiliary resource to the service unit in support services.

· The Contractor will provide technical support on business office and medical records tasks and functions, including but not limited to coding and data entry, third party billing, denial management, accounts receivable posting and follow-up, and other important techniques and procedures per the service unit’s and/or AAO request. shall perform one (1) site visit for the duration of two (2) days per quarter at no additional cost.

· The Contractor will meet the Indian Health Service’s Third Party Revenue Accounts Management and Internal Control Policy timelines. Monthly reports will be submitted to the appropriate AAO/ACLSU staff for any areas that are not meeting the timeframes.

· The Contractor will notify the ACLSU/AAO government within 24-hours in the event a decrease in staffing levels will result in production impacting compliance requirements of this contract. This notice does not eradicate the performance measures required by this contract.

· The Contractor will submit Quality Assurance Performance Improvement (QAPI) data, as identified by ACLSU, to be incorporated into the facility QAPI Program (i.e., number of visits coded, days to be completed coding, number of claims billed, number of days from claim created to approved/submitted, number of A/R accounts posted, etc.)

· The Contractor will not charge for additional reports generated by the Contractor. Reports generated and the frequency will be at the discretion of the ACLSU CEO, HIM/Business Office staff, AAO/HIM/Business Office or AAO Director’s Office and may be modified throughout the performance period.

· The Contractor will schedule weekly, bi-weekly, and monthly conference calls/management meetings, or as needed, to discuss project needs. Minutes of the meetings shall be provided by the Contractor to the Contracting Officer’s Representative (COR) and appropriate ACLSU staff. A toll free telephone number for all scheduled calls shall be provided by the Contractor.

· The Contractor will bear the expense of all costs associated with the performance of this contract; i.e., IT and business office related equipment, office supplies, telephones, fax machines, mailing/postage supplies, etc.

· The Contractor will follow the National Correct Coding Initiative Edits (NCCI), Ethics of Medical Coder, Standards of Ethical Coding, Principles of Medical Record Documentation or IHS service unit level Policy and Procedures.

· At the request of the ACLSU the Contractor will be required to work on-site.

2. Statement of Work for Coding, Data Entry, Compliance Auditing, and Reporting Medical Coding services are to be provided at the Acoma-Canoncito-Laguna Indian Health Service Unit.

The services involve performance of highly technical and specialized functions of outpatient and inpatient medical coding independently. The performance includes but not limited to reviews, analyzes and codes diagnostic and procedural information. The coding function is a primary source for continuity, accuracy, data base information, and the ability to optimize reimbursement.

· The Contractor will review, abstract, code and data enter visits in all service categories (ambulatory, hospitalization, chart review, telecommunications, not found, day surgery, observation, event-historical, nursing home, telemedicine, etc.) and for various clinic types (emergency room, surgery, obstetrics & gynecology, optometry, dental, pharmacy, laboratory, radiology and other clinics as needed) via the Indian Health Service(IHS) Resource Patient Management System (RPMS) Electronic Health Record (EHR), Patient Care Component (PCC), VISTA imaging, Electronic Dental Record (Dentrix) and Admission/Discharge/Transfer (ADT) systems.

· The Contractor will follow the Indian Health Service (IHS), Government Performance Results Act (GPRA), Promoting Interoperability (PI) Programs, Conditions of Participation 482.24 Medical Record Services, Joint Commission (JC), National Correct Coding Initiative Edits (NCCI), AHIMA, CMS and NCHS National Reporting and Official Coding Guidelines.

· The Contractor will utilize the IHS EHR, PCC, PIMS/ADT, Dentrix and VISTA Imaging systems to review notes and supporting documentation of critical care flow sheets, ambulance reports, ancillary tests, special studies and scanned patient care component(s), results to accurately assign codes to the highest level of specificity.

· The Contractor will apply all secondary codes (accidents, injuries, and adverse effects) that provide data for injury research and evaluation of strategies for injury prevention. The external causes codes are used by insurance companies, state legislators, media, state agencies, health and community advocates, FMCRA, individual organizations to improve internal processes and facilities. Knowledgeable about payer and state public health department requirements as well as coding guidelines and conventions, contractor will assist in capturing injury-related information to the highest level of specificity.

· The Contractor will verify the accuracy of the evaluation & management (E&M) level and, when necessary will send a notification to the medical provider to ensure the correct E&M level of service is documented & assigned. The Coder will assign ICD-10 diagnosis code(s), PCS, DRG, CPT, HCPCS, ADA, modifiers and make sure an appropriate diagnosis code is assigned for the service(s) provided.

· The Contractor will insure the assignment of E/M, CPT, and HCPCS, PCS, DRG, and ADA codes will be entered, modified or appended via the RPMS system using the correct mnemonic. The CPE Mnemonic is used to identify a provider when multiple providers provide a service during the same encounter.

· The Contractor will use the IHS coding queue, located in the RPMS PCC Package, and shall access for review, accuracy, and completion of all medical visits before a claim can be generated. When a visit cannot be completed in the coding queue, the vendor will access the PCC data entry and supervisor options to complete enter/create the visit.

· The Contractor will provide a written report of incomplete visits pending completion in the coding queue and will provide it to the providers and ancillary staff who are responsible for the deficiency on a weekly basis. A report will be sent to the Health Information Management Director on a weekly basis.

· The Contractor will follow procedures and/or policies of the ACLSU to insure that editing, appending, merging, moving data elements, and deleting duplicate entries will be part of the process to complete visits accurately via the RPMS.

· The Contractor will review Visit data from PCC or Integrated Problem List (IPL) in the coding queue for accuracy and completeness to the highest allowable level so the facility receives the appropriate level of reimbursement. National Coding Guidelines will be applied via PCC. When there is an application of “billing/claims” guidelines based on the payer – the guideline should be applied via the Third Party Billing (TPB) system with feedback to staff.

· The Contractor, when working with incomplete visits in the coding queue, will send the provider “Notifications” for any record deficiencies (coding, DE, documentation) and review notifications on a daily basis. Incomplete visit reviewed by Contractor will be followed up; the Contractor will not charge the government until visit is completed.

· The Contractors will have a minimum of three (3) years of coding experience and be a certified coder (copy of certification) (AHIMA and/or AAPC – etc.). Will apply National Coding Guidelines, IHS Guidelines and any other applicable guidelines to provide quality coding services.

· The Contractor will have a thorough knowledge of medical terminology, anatomy and physiology, pharmacology, and medical science.

· The Contractor will have a minimum of one year (1) experience in how to use the RPMS PCC Data Entry Operator and Supervisor options, including the Coding Queue, in order to process all contracted medical documents as required.

· The Contractor will also serve as a technical advisor to the Service Unit multi-disciplinary Revenue Enhancement Teams at the Service Units in addressing medical services coding and reporting and any recommended necessary enhancements.

· The Contractor will perform compliance auditing for E&M, ICD-10-CM, PCS, DRG, ADA, HCPCS (supplies), MODIFIERS, and CPT procedures/services will be based on the facility’s number providers, (MD, DO, PA, CNP, and all specialty services). No more than 5% of each provider’s total visits counts of inpatient/outpatient, emergency room, day surgery, etc. visits will be audited. The only visits that will be audited are those completed by the service unit staff and visits by patients that have 3rd party eligibility (Medicare, Medicaid, & Private Insurance). The accuracy formula shall be the number of records audited divided by the number of coding errors found. (Errors will consist of incorrect principle/primary diagnosis (or sequencing), incorrect E/M code selection based on the provider’s documentation in the visit (HPI, ROS, etc.) incorrect ICD-10 coding assignments, acute and chronic conditions coded incorrectly, manifestation codes not coded, injury and poisoning codes not coded. Sign and symptoms codes in ICD will be scrutinized to determine if a more specific diagnosis should have been coded and/or the provider queried. A final summary for each provider will be completed and the auditor will meet with each provider and/or the medical staff to discuss the coding and provider documentation findings and recommendations. The auditor will meet with the Service Unit coding staff to discuss coding errors and recommendations. The contractor will use an E&M audit form (provided by the service unit and/or contractor responsibility) that will have detailed explanation of E&M audit results.

· The Contractor will not use the “In Progress” option in the coding queue, as it’s considered an incomplete visit, without the approval of the ACLSU CEO/HIM Director.

· The Contractor will use the “incomplete” option at the end of chart audit status for incomplete (deficiencies) along, with a provider, reason, and any chart audit notes. Once, the deficiency is corrected and amended the Contractor may “complete” this chart audit status using the Outpatient Chart Deficiency. For inpatient “incomplete” options, the Contractor will use the ADT-IC-NICE menu to track the incomplete inpatient deficiencies. Once, the corrections and amendments have been made; the Contractor can “complete” the chart audit status.

· The Contractor will perform quantitative analysis and to assure the presence of all components parts of the record, PCC, including correct identification and validations of each part by name, medical record number, dates of services, signatures where required and the presence of all reports which are indicated by nature of the case.

· The Contractor will provide assurance that the diagnosis responsible for the Length of Stay (LOS) is appropriately identified and that the secondary diagnoses are sequenced properly in order to assure maximum allocation under the Diagnostic Related Group (DRG) and/or Ambulatory Patient Group (APG) system. If there are questions/problems with documentation the provider is notified immediately.

· The Contractor will ensure that all requirements outlined under the agency Internal Control Policy for coding are met successfully. This is located in Chapter 5-Management Services, Chapter 1-Third Party Revenue Accounts Management and Internal Controls, Section 5-1.3F. Health Information Management Coding/Data Entry: Creates visits for ancillary encounters not occurring on the date of the provider visit; on a weekly basis, reviews and corrects on the Incomplete Coding Report and Error Report (TXER, ZERO, PPPV, MRG, CINC, etc). Independently follows up on all notifications sent to providers weekly; all applicable codes must be entered, verified, and completed in RPMS within four (4) business days of the date of service for all outpatient services, All efforts, should be made to enter, verify, and complete codes within 4 days after chart completion of inpatient stay, max. time is 34 days, Completes billing IRL (billing/claim errors), and Coding/Data Reference Manuals-all reference books must be the most current version. Contractor shall consult with the ACLSU CEO/HIM on specific reporting.

· The Contractor will perform peer review audits on a quarterly basis as part of the Internal Control Policy-Independent Coding/Data Entry Review Requirements using retrospective and focused review random sampling of 10% of patient encounters coded on a quarterly basis. Peer review audits shall be conducted to prevent fraudulent claims, under-coding, over-coding, up-coding, un-bundling habits, code overuse, missing modifiers, procedures, diagnoses, promote prevent recovery audit contractors (RACs) or sine program integrity contractors (ZPICs), etc. The Contractor will not audit their own processes.

· The Contractor will deliver standardized reporting to the Service Unit HIM Supervisor on a weekly basis which includes at the minimum of the following: (method of report delivery to be determined by IHS). Minimum Report to include: HRN, Date of Service, Date Completed, using CNT, Review of Weekly Status Report (total, contractor assigned, service unit assigned), clinics assigned, providers assigned, inpatient days assigned, day surgery assigned, observation days assigned, EHR notifications sent, EHR deficiencies found, number of responses from service unit, etc. Contractor shall consult with ACLSU with regard to the standardized reporting.

Minimum Qualifications:

The Contractor must have at least (3) three years of experience working with health care facilities in developing Revenue Enhancement initiatives including billing and accounts receivable. Must have three (3) years or more of experience in medical records coding (ICD9 and ICD-10-CM combined, PCS, DRG, ADA, HCPCS and CPT). All coding functions and tasks must have oversight by an experience certified coder. Certified coders must take the appropriate training necessary to maintain their certification. Must be familiar with Indian Health Service’s revenue cycle, IPC, Government Performance and Results Act (GPRA), IHS initiatives, Policies and processes. Must possess knowledge of Medicare, Medicaid, Veterans Affairs, Workers Compensation and the Private Insurance program requirements and be able to demonstrate this knowledge. Must have knowledge of a compliance program and HIPAA requirements. Must be familiar with the third party billing RPMS. Must have basic knowledge of New Mexico, Colorado, Utah, Arizona, and Texas Medicaid, Medicare, and Private Insurance programs.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ICD-9-CM, ICD-10-PCS, ICD-11 ADA, DRG, MODIFIERS, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Provide Coding, Data Entry, Compliance Auditing, and Reporting Services as specified in the Statement of Work and Indian Health Manual Part 5, Chapter 1, “Third-party Revenue Accounts Management and Internal Controls”.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ICD-9-CM, ICD-10-PCS, ICD-11 ADA, DRG, MODIFIERS, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Deductions will increase by 1% in subsequent years.

PERFORMANCE-BASED SERVICE DELIVERY SUMMARY

The Contractor’s performance will be measured based on the following Performance Requirements. The Performance Requirements will be measured against Government Performance Standards and monitored in accordance with the following Methods of Government Surveillance or what is known as a Quality Assurance Surveillance Plan (QASP) to determine compliance. A 5% deduction will be assigned to each Performance Requirement. Deductions shall be assessed against individual invoices when services are not performed or do not meet contract requirements. Deductions will be done by the category that was deficient (e.g., coding, billing, etc.) the ACLSU’s delay in getting information to the Contractor will not be held against the vendor.

Performance Requirements Summary (PRS)

STANDARDS OF PERFORMANCE

· Performance Evaluation – If the contractor fails to perform required services at the acceptable quality level, payment may be withheld until the Contractor makes corrections. In the event that the Contractor is failing to perform any required services, the COR will provide written notice of such to the Chief of the Contracting Office and the Contractor. The Contracting Officer will issue to the Contractor, a Contractor Discrepancy Report (CDR). The Contractor shall have 14 calendar days to provide the Contracting Officer with their response to the CDR. Upon evaluation of the Contractor’s response to the CDR for tasks surveilled, the contractor’s payment for the month in which the performance in question occurred will be calculated as outlined below.

· Contractor Payment – If the contractor fails to perform required services at the acceptable quality level, payment may be withheld until contractor makes corrections. If deviations continue after 6 months, then payment may be reduced an additional 1%. If performance is below numerical standards, details will be recorded on “past performance report card.” If performance is below standard for 2 quarters in a row, Government oversight or contractor reporting will be increased. The COR is responsible for documenting and communicating performance deviations, corrective actions, and performance improvements to the Chief of the Contracting Office, and the contractor.

· Performance Based Statement of Work for Third Party Resource Billing Services

· The Contractor will provide third party resource billing services. Direct access and use of the current RPMS (Resource Patient Management Systems) Third Party Billing System via VPN approval and access will be required. The Government will provide access to the RPMS and technical and program support when required.

· The Contractor will review the Visit data from PCC/superbill/EHR to determine the accuracy and completeness for appropriate level of reimbursement based on codes and provider documentation.

· The Contractor will ensure all data is accurate, complete, edited if needed and all alternate resources are properly coordinated prior to approving claims including workman’s comp and third party liability.

Exporting is required daily (Electronic or Hardcopy) for all third party resource bills. Contractor will process and submit secondary and tertiary bills, including cross over claims, within the most current Third-Party Revenue Accounts Management and Internal Controls policy established time frames.

· The contractor will process and submit claims directly to the appropriate carrier or clearinghouse via modem or other communication means in a format acceptable to the appropriate carrier. Electronic submission of claims, in the HIPAA formats, will be the mode of choice when accepted by the carrier/clearinghouse, including NON-electronic submission of claims is required.

· The ACLSU will have the option to have the Contractor pend claims if necessary. If the Contractor pends claims, the Contractor is responsible for following up on all pended claims. The Contractor will be notified by the service unit of all pended claims on a monthly basis. All deleted or cancelled/closed claims report will be followed up with the Contractor; by a supervisor or manager per the IHS approved service unit business office manager, pursuant to the Third-Party Revenue Accounts Management and Internal Controls Policy.

· The Contract will ensure that claims not processed electronically shall be processed and printed on paper and on the most current standard form (ADA, CMS-1500, UB, etc.) available in RPMS. The Contractor will send the processed paper claims to the carrier on a daily basis. Copies of the form shall be provided to the ACLSU Business Office.

· Rejected claims from the carrier will be corrected and resubmitted to the carrier by the ACLSU Business Office. In the event there are no billers available at the service unit, the Contractor will correct and resubmit the claim. In the event, the claim rejected was originally submitted by the Contractor, the Contractor will reprocess and resubmit the bill at the Contractor’s expense. Upon receiving the denial message, the Contractor must interpret the message, reconcile it with the original claim, make the required corrections and resubmit the claim. This process will require the Contractor to compile the data in error and submit the patient information to ACLSU in regards to responses that are required by the payer and communicating this to the payer source. This exchange of claims and denials may be repeated multiple times until a claim is paid in full, or the Contractor accepts an incomplete reimbursement. Denial reasons will be compiled, reported, and approved by ACLSU Business Office Staff on a monthly basis to ensure compliance.

· The Contractor will also determine if the insurance company made correct payment. If the correct payment was not made, the Contractor will appeal the claim(s) and provide documentation to support the appeal. If the appeal is not granted, the claim will only be adjusted off after the Service Unit staff has reviewed the documents.

· The Contractor will generate and provide to the ACLSU on a monthly basis. Reports generated will be at the discretion of the Business Office Manager. (e.g., bills generated, A/R hours used, rejected/denial claims, etc. that the facility would want to track for invoicing.)

· The Contractor will ensure all electronic transactions generated by are HIPAA compliant.

· The Contractor will provide a toll free telephone number, which may be used to transmit claims via modem at the government convenience. The toll free number shall be available seven (7) days per week, 24 hours per day, except for routine maintenance of equipment.

· The Contractor will be responsible for scanning all information directly received/downloaded into the ACLSU Facility folder. The Contractor will print and mail and track all correspondence to the service unit on a weekly basis.

· The Contractor will comply with industry standards, applicable IHS rules, regulations, policies and procedures, state and federal law, including but not limited to the OIG recommendations on compliance programs and HIPAA requirements.

· The Contractor will provide documentation requested by the insurance payor; including but not limited to: audit requests, subpoenas and summons, the Contractor will provide all documentation requested by the insurance payor. A representative from the Contractor and the coders and/or physicians will then review this information. Once all information is gathered, it will be sent to whomever requested it. Any money that may be due in the event of an audit will be repaid by the ACLSU and the Contractor will credit the service unit account for their billing fees. If the audit should arise after the cancellation of this contract, the Contractor will still prepare any documentation that may be necessary to complete the audit.

· The Contractor will provide personnel to perform billing as required. Personnel shall have basic knowledge of all payers, the State Medicaid programs in New Mexico, Arizona, Utah, Colorado, and Texas specific to Indian Health Service (IHS) Rules and regulations. Personnel shall have basic knowledge of all I.H.S. Policies and procedures and the Indian Health Manual pertaining to billing. Personnel shall have prior experience in billing outpatient visits, ambulatory surgeries, inpatient stays, et cetera and have prior experience in medical records coding (ICD-10-CM and CPT-4), preferably one (1) Certified Coder, and the use of applicable computer technology to accomplish duties required.

· The contractor shall have a minimum of three (3) years of experience within the private insurance/Medicare/Medicaid billing industry and proof of experience in electronic claim submission/maintenance with three years minimum.

4. Patient Accounts Receivable Scope of Work:

a. The Contractor will utilize the RPMS Accounts Receivable System.

b. The Contractor will assist the ACLSU with actual posting of payments and adjustments, including non-pays, in the RPMS Accounts Receivable System, utilizing the HIPAA Standard Reason Codes only.

c. The Contractor will employ the use of Electronic 835 remittance advice capabilities when available by third party payers.

d. The Contractor will follow up on all accounts that have an outstanding balance, with the parameters being set by the Service Unit Chief Executive Officer, Business Office Supervisor and IHS Third-Party Revenue Accounts Management and Internal Controls Policy. While maintaining the highest levels of integrity, compliance, and ethics, the Contractor will obtain for the service unit the full explanation of payment or non-payment, including all supporting documentation from the payers. When the Contractor is working the aged accounts, the service unit will have the Contractor correct and resubmit the claim. In the event the claim, originally submitted by the Contract, was rejected or was not received by the payer; the Contractor will reprocess and resubmit the bill at the Contractor’s expense.

e. Per the IHS Third-Party Revenue Accounts Management and Internal Control Policy, the Contractor will add comments/messages to each account in the RPMS A/R Package for all verbal and written contracts made for each account, including any reference numbers.

f. The Contractor will submit outstanding account third party collection letters to insurance companies and non-eligible patients, at the service unit’s discretion on the IHS Debt Management system. Letters are mailed for each account per the IHS Debt Management Policy.

g. At the request of the ACLSU Business Office, the Contractor, will resubmit an IHS bill not received by the payer. Resubmission of the bill will be by electronic or paper method.

h. The Contractor will also be required to serve as a technical advisor to the service unit multi-disciplinary revenue enhancement teams; addressing the accounts receivable processes, changes, and necessary enhancements.\

i. In the event of an overpayment, the Contractor will prepare the refund documentation following the most current AAOIHS procedures and send to ACLSU CEO or Business Office Manager for review and forward to the AAOIHS Financial Management Office for further processing.

The Contractor will provide consultative services on-site as an optional service to the ACLSU on revenue generation cycle functions and processes. The Contractor will provide on the job training for individual staff and program development on the various functions of revenue generation and, will also serve as a technical advisor to the service unit multi-disciplinary revenue enhancement teams in addressing the revenue enhancement work plan.

· The Contractor will provide on the job training for individual staff and program development on the various functions of the Revenue Enhancement process.

· The Contractor will identify key management objectives and accountability in the revenue generation cycle and develop timelines to accomplish key management objectives and develop methods for accountability. Eliminate redundancy of work within the revenue generation cycle, refine and implement new workflow processes. Identify best possible physical location of staff who are in the revenue generation process. The Contractor will provide staff training to accommodate new tasks for each job per workflow process changes.

· In the implementation of new work flow processes, training provided and other consultative services provided, the Contractor must comply with industry standards, applicable I.H.S. rules and regulations, state and federal law, including but not limited to the OIG recommendations on compliance programs and HIPAA requirements. The Contractor will adhere to ACLSU and/or AAOIHS compliance plans.

· As appropriate, the Contractor will engage service unit medical staff and the business office program to manage and improve process using Improve Patient Care model (IPC) and/or Project Management.

· The Contractor will facilitate a process for providers, business office and other staff to improve documentation to ensure proper and accurate coding for revenue generation purposes.

· The Contractor will perform audits on processes of the staff per request of the ACLSU CEO or the Business Office Manager in accordance with the IHS and National Standard Auditing Practices. The Contractor will not audit their own processes.

· The Contractor will assist the ACLSU in developing an audit program and measurements for the revenue cycle. Develop site specific baseline metrics and measurable standards to measure current state of the revenue cycle for effectiveness and to build in accountability. Train the business office staff on the use of various audit techniques and measurements.

· The Contractor will address, define, and implement the use of automated systems as it applies to the revenue generation cycle and provide staff training on techniques of gathering up front information pertaining to third party resources, i.e. patient registration, benefits coordination, etc.

· The Contractor will perform a service unit revenue generation cycle assessment that will include auditing and monitoring of coding, provider documentation, billing and collection processes.

Contractor Minimum Qualifications:

The Contractor must have at least (3) three years of experience working with health care facilities in developing Revenue Enhancement initiatives including billing and accounts receivable. Must have three (3) years or more of experience in medical records coding (ICD9 and ICD-10-CM combined, ADA, HCPCs and CPT). All coding functions and tasks must have oversight by an experience certified coder. Certified coders must take the appropriate training necessary to maintain their certification. Must be familiar with Indian Health Service’s revenue cycle, IPC, Government Performance and Results Act (GPRA), IHS initiatives, Policies and processes. Must possess knowledge of Medicare, Medicaid, Veterans Affairs, Workers Compensation and the Private Insurance program requirements and be able to demonstrate this knowledge. Must have knowledge of a compliance program and HIPAA requirements. Must be familiar with the third party billing RPMS. Must have basic knowledge of Medicaid programs for New Mexico, Arizona, Utah, Colorado, and Texas.

Government Responsibility:

· The Government will provide a proper in-service to the Contractor so to become familiar with the Privacy Act and HIPAA requirements. The Government and Contractor will review all necessary documents pertinent to the Privacy Act, the HIPAA Privacy Rule and HIPAA Security Rule, and HITECH. The Government will notify the Contractor in the event these requirements change

· The ACLSU will provide proper orientation to the Contractor to become familiar with the facility.

· Security clearances of the Contractor’s staff will be on file with the ACLSU. The Contractor will be provided the Third Party Internal Control Policy and instructed on the IHS billing policies and procedures.

· The Government will ensure that adequate work space and support staff are available for the Contractor while providing on-site technical assistance. The Service Unit staff will be responsible for retrieving, copying, and returning appropriate documents, according to facility policy whenever it’s deemed necessary.

· The Government will perform random audits no less than one (1) time per quarter, per year to ensure contract compliance. The ACLSU and the AAOIHS staff will perform the random audits.

· The Government will at their option perform an on-site courtesy visit to the Contractor facility/office within the contract year.

· The Government will work with the Contractor to develop effective communication tools for issues related to the completion of the assigned workload.

· The Government will work with the Contractor to develop defined timelines for the completion of the assigned workloads that are backlogged.

· In compliance with applicable federal law, the Contractor will direct all access requests regarding federal resources and systems to their Contract Officer Representative (COR) or federal designee. The Contractor or its staff are not permitted to directly request access to federal resources and systems. All requests must be made by a federal employee on behalf of the Contractor.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ADA, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Provide Coding, Data Entry, Compliance Auditing, and Reporting Services as specified in the Statement of Work and Indian Health Manual Part 5, Chapter 1, “Third-party Revenue Accounts Management and Internal Controls”.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ADA, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ADA, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Provide Third Party Billing Services as specified in the Statement of Work and Indian Health Manual Part 5, Chapter 1, “Third-Party Revenue Accounts Management and Internal Controls”.

Work is reviewed for accuracy through quality assurance activities performed by Area Business Office and/or Service unit staff, direct observation, and random sampling by Service Unit Business Office Manager or his/her designee. Report to be provided to Project officer at least quarterly

5% deduction from monthly invoice.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately assign ICD-10-CM, ADA, CPT, and HCPCS codes to all patient encounters with 95% accuracy.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately process account receivable functions with 95% accuracy.

5% deduction from monthly invoice.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to accurately process account receivable functions with 95% accuracy.

Deductions will increase by 1% in subsequent years.

Required Service Performance Indicators Acceptable Quality Level (AQL) Method of Surveillance

Payment % for NOT Meeting AQL

Ability to perform this function with 97% accuracy.

5% deduction from monthly invoice.

Deductions will increase by 1% in subsequent years.

Performance-based Service Delivery Summary The Contractor’s performance will be measured based on the following Performance Requirements. The Performance Requirements will be measured against Government Performance Standards and monitored in accordance with the following Methods of Government Surveillance or what is known as a Quality Assurance Surveillance Plan (QASP) to determine compliance. A 5% deduction will be assigned to each Performance Requirement. Deductions shall be assessed against individual invoices when services are not performed or do not meet contract requirements. Deductions will be done by the category that was deficient (e.g., coding, billing, etc.) Service Unit delay in getting information to contractor will not be held against the vendor.

Performance Requirements Summary (PRS)

STANDARDS OF PERFORMANCE

1. Performance Evaluation – If the Contractor fails to perform required services at the acceptable quality level, payment may be withheld until the contractor makes corrections. In the event that the Contractor is failing to perform any required services, the COR will provide written notice of such to the Chief of the Contracting Office and the contractor. The Contracting Office will issue the contractor a Contractor Discrepancy Report (CDR). The contractor shall have 14 calendar days to provide the Contracting Office with their response to the CDR. Upon evaluation of the Contractor’s response to the CDR for tasks surveilled, the contractor’s payment for the month in which the performance in question occurred will be calculated as outlined below.

2. Contractor Payment – If the Contractor fails to perform required services at the acceptable quality level, payment may be withheld until contractor makes corrections. If deviations continue after 6 months, then payment may be reduced an additional 1%. If performance is below numerical standards, details will be recorded on “past performance report card.” If performance is below standard for 2 quarters in a row, Government oversight or contractor reporting will be increased. The COR is responsible for documenting and communicating performance deviations, corrective actions, and performance improvements to the Chief of the Contracting Office, and the Contractor.