RFI Recovery Audit.docx

REQUEST FOR INFORMATION (RFI)

Recovery Audit (RA) Services for the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Finance (OF)

1.0 INTRODUCTION

This notice is issued solely for information and planning purposes. There is no obligation for the Government to acquire any products or services described in this RFI. In accordance with the Federal Acquisition Regulations (FAR) Subpart 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. No funds have been authorized, appropriated, or received for this effort. The information provided may be used by VA in developing its acquisition strategy and informing, refining, and finalizing a Performance Work Statement (PWS). Interested parties are responsible for adequately marking proprietary, confidential, restricted, or competition sensitive information contained in their response. Only electronic responses to this RFI will be accepted. The Government will not pay for any time expended or information submitted in response to this RFI. Eligibility in participating in a future acquisition does not depend upon a response to this RFI.

2.0 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, in support of the Payment Integrity Information Act of 2019 (PIIA) (Public Law No. 116-117). Each program has specific payment methodologies and eligibilities as defined by VA regulations. The auditing of these various programs will be organized into mandatory and options tasks with any exclusions noted.

The Office of Finance intends to award a no cost (contractor is paid of out recovered funds only) task order to provide recovery 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.

The contractor shall review 100% of supplied paid claim data in accordance with their approved audit plan and report results to the Office of Finance. First level disputes will be reviewed by the contractor before submitting final results to OF. The OF will coordinate recoupment activities with appropriate stakeholders and the contractor shall be paid a percentage of recovered funds. 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.

See attached for draft Performance Work Statement (PWS) for more details.

3.0 QUESTIONS AND CRITICAL CONSIDERATIONS FOR INTERESTED CONTRACTORS

This request for capabilities information does not constitute a request for proposals; submission of any information in response to this market survey is purely voluntary; the government assumes no financial responsibility for any costs incurred. Your responses may be shared with all stakeholders, thus the information received will not be considered proprietary. If your organization has the potential capacity to perform these contract services, please provide the following information:

3.1 Capabilities Statement

Cover Sheet – 1 page

Please provide the following information:

1. Organization name, address, and web site.

2. Point of contact to include e-mail address and telephone number.

3. Business size (large or small). If small, please provide type of small business.

4. North American Industry Classification System (NAICS) that best fits these task areas.

5. If applicable, GSA contract number, schedule, and SIN category.

Index – 1 page

Please provide an index to assist the Government in identifying where you have addressed each question below in your Capabilities Statement and Market Information. Please provide question number and corresponding page and section heading and/or paragraph number.

Capabilities Statement and Market Information – 5 pages

Please respond to the following questions by providing a capabilities statement and market information.

1. Breadth of Functionality

· What specific areas of payment integrity recovery auditing does your solution address (e.g., claims editing, fraud, waste and abuse detection, coordination of benefits)?

· Please describe how your solution supports pre-payment and/or post-payment integrity checks.

· Does your solution include artificial intelligence (AI) or machine learning (ML) capabilities? If so, please describe their application and effectiveness.

· To what extent can your solution be customized to address specific policy or program requirements?

· How does your solution handle data ingestion from multiple sources (e.g., EHRs, claims systems, third-party databases)?

· Describe experience working with third party administrators who have the contractual relationship with the Providers and who are contracted to provide claims processing. Include processes, communications, etc and any variation in process and procedures from working directly with Providers.

Propose specific ideas and processes on how to work with a Third Party Administrator (TPA) under a VA contract. Please propose specific ideas on how to optimize the process to reduce process time, staff time and potential conflicts.

Describe experience with recoupment under a TPA model. (VA pays the TPA to process claims to Providers on our behalf). Provide recommendations or experience on how to ensure coordination between VA and VA contractors when recoupment activities need to occur. (e.g., audit findings shared with VA, then shared with CCN TPAs, if there are questions/clarifications on audits, VA may want to have joint discussions with auditor and TPAs and would expect joint cooperation.) VA currently utilizes an offset process to collect overpayment by TPA to Providers. Describe experience with this model and any ideas or recommendations to implement ensuring data integrity, accuracy and quality to the current invoicing lineage.

2. Proven Track Record and Experience

· Please provide examples of measurable outcomes from your solution (e.g., reduction in overpayments, cost savings, improved compliance).

· How do you measure and report the ROI of your solution to clients?

· Please provide your experience in Recovery Audits, especially work with other federal governmental agencies and government-sponsored health plans.

3. Scalability and Capacity

· What range of claims volume can your organization support?

· How do you ensure scalability during peak processing periods or organizational growth?

4. Vendor Considerations

· What information about our organization or technical requirements would you need to craft a proposal tailored to our needs?

· What specific challenges or risks would you anticipate in implementing your solution for a federal agency?

· Are there best practices or lessons learned from previous implementations you would recommend we consider?

· What contract type or pricing structure does your firm expect to see for this acquisition based on the PWS (Firm-Fixed-Price, Cost, T&M/LH)? Please explain your rationale.

· What additional information if any do you have to share with the technical and procurement teams?

· If significant subcontracting or teaming is anticipated to deliver technical capability, address the administrative and management structure of such arrangements.

4.0 STRUCTURE AND SUBMISSION OF RESPONSES

Interested parties who consider themselves qualified to perform the above-listed services are invited to submit a response to this RFI by January 14, 2025 by 3 PM ET via e-mail. All responses under this RFI must be emailed to Melissa.Maloy@va.gov. Limit all responses to 15 pages.