RFP 2024-13 Clarifying Questions #2 - 9-4-2024 FINAL.pdf

315 SW Fifth Ave, Portland, OR 97204 | 800-224-4840 | TTY 711 | careoregon.org

George Marlton Procurement Director

Procurement Department 503-488-7646 vendorservices@careoregon.org

REQUEST FOR PROPOSALS #2024-13

IBR & DRG BILLING SERVICES

RESPONSE TO CLARIFYING QUESTIONS #2

September 4, 2024

Note that these are questions submitted by interested firms to the above referenced solicitation.

The below answers are for clarification purposes only and in no way alter or amend the RFP as published.

1. Please detail your current IBR (Itemized Bill Review) and DRG (Diagnosis-Related Group) review processes.

Answer: IBR is performed on a pre-payment basis. Claims that meet a specific dollar threshold are sent for review. The itemized statement is requested from the provider. Once received, the itemized statement is reviewed by the current vendor who then returns the recommendation for processing.

DRG is performed on a post-payment basis. Based on a dollar threshold and DRG applied to the claims the current vendor requests medical records from the providers to determine if the DRG was correct. If incorrect, the vendor returns to us their suggested DRG for the claim. The providers are allowed to appeal the decision and request clinical peer-to-peer review with the current vendor teams.

2. Are you utilizing any external vendors for these services?

Answer: Yes.

3. Do you conduct IBR and DRG reviews on a pre-payment, post-payment basis, or both?

Answer: IBR is for pre-payment, DRG is for post-payment, although we are open to both.

4. Do you perform any IBR or DRG reviews in-house?

Answer: No.

5. What fee model do you use for these services? Do you compensate vendors based on a percentage of savings, a flat fee, a per member per month (PMPM) rate, or another fee structure?

Answer: Section 5.5 Fees states, “CareOregon prefers fee proposals based on a set fee per claim reviewed. Propose a set fee per claim reviewed for the services.

OR

CareOregon will accept fees based on a percentage of the dollar amount of all recovered claim overpayments. Propose a percentage fee of recovered claim overpayments for the services.”

6. How do you define high-dollar claims? Is there a specific threshold, such as $100k, $50k, or $25k?

Answer: We currently define high dollar as over $25,000 but are open to adjusting the thresholds for claim reviews based on additional claim criteria.

http://careoregon.org/ mailto:vendorservices@careoregon.org

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7. What was CareOregon's annual DRG spend in 2023, and what is the projected spend for 2024?

Answer: Annual DRG spend for 2023: $2.24M - projected spend for 2024: $2.25M.

8. What was CareOregon’s number of itemized bills and dollar volume in 2023, and anticipated in 2024 and 2025?

Answer: IBR: volume – 787 for 2023. A slight percentage more anticipated for 2024 and 2025.

Dollar volume set at $1.4M.

9. Are there any hospital providers whose contract requires that audits be completed onsite?

10. Are applicable claims paid at a percentage of billed charge/ a percentage of billed charge with stoploss threshold/ or DRG outlier or mix?

Answer: We currently have provider contracts under all three payment models.

11. Does the payer have a published payer policy/provider manual or contract language in place detailing reimbursement on Unbundled/Rebundled charges?

Answer: yes.

12. If no published payer policy/ provider manual or contract language in place detailing reimbursement on unbundled/rebundled charges, does payer have internal proprietary list to be used?

Answer: CareOregon follows CMS and OHA standards.

13. On DRG audits, will CareOregon reprice the claims or will the vendor?

Answer: Vendor should suggest price adjustments along with the suggested DRG.

14. When a provider submits an incomplete medical record, should the vendor request additional documentation or proceed with what was submitted?

Answer: Contractor to request the documentation needed to complete an audit.

15. Are coding certifications as described in Scope of Work (CPC, CCS, other AAPC/AHIMA certifications) applicable for IBR or is RN acceptable?

Answer: Yes, RN is acceptable.

16. The RFP specifies daily invoicing for IBR findings. Does CareOregon anticipate paying commission fees separately for each daily invoice or an accumulated weekly or monthly amount?

Answer: Monthly amount.

17. Do CareOregon provider contracts allow providers to invoice for medical records or charge onsite audit fees? If yes, are those fees a reimbursable expense?

Answer: CareOregon cannot answer this question at this time.

18. "Expected DRG claim volume is about 500 for the first year of the Contract". Can CareOregon reconfirm if this is the claim volume applicable for entire year? Also, as part of your response to a vendor question, it is mentioned that DRG claims would be 150-200 claims

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Answer: CareOregon expects a lower claim volume for the first year due to timeline of implementation. No current limits are in place but could potentially be implemented based on a statement of work. There are about 128 claims per month for claim volume.

19. From the initial set of responses to clarifying questions, we can understand that the membership in scope for this program is 500k. Can CareOregon provide the split of membership by LOB? Is there any growth projections to these numbers which CareOregon can share?

Answer: Medicare: 17,677, Medicaid: 558,570. No growth projections to be listed.

20. What are some of the challenges that CareOregon is looking to solve as part of the services requested in this RFP? Is there a specific pain point that has led to the issuance of the RFP?

Answer: See RFP 3.2.2 .

21. Does CareOregon have programs specified in RFP (high dollar inpatient claim DRG, IBR) currently in place? And if yes, is this outsourced or currently handled in-house? Also, if, yes, how much is currently identified as savings across both the requested programs?

Answer: Yes, we currently have a vendor. Current savings IBR: $6.4M; DRG: $8M.

22. In Project Summary, CareOregon has mentioned that DRG and IBR audit reviews are required on a pre-payment basis, but in section 3.2 (Scope of work), the proposer is obliged to return the overpayment amounts. Can CareOregon explain their modality (prepay/post pay) and recovery processes?

Answer: Current state is IBR as pre-pay and DRG as post-pay. We are exploring both pre-pay and post-pay for both initiatives.

23. Will the award of contract for the services be split among different vendors? Or is CareOregon going to select a single vendor for the services requested?

Answer: CareOregon has issued Addenda #1 to let proposers know that we my issue contracts to more than one vendor.

24. If the vendor already has a professional service contract with CareOregon, is the vendor allowed to leverage the existing contract?

Answer: Other existing contracts, for the same services, will be terminated by CareOregon.

25. Section 5.5 says “provide fees.” Does Section 5.5 mean that you want us to list fees in the actual response to the RFP, or is that just saying what will be required later, during contract negotiation?

Answer: Yes, this Section is asking Proposers to either propose a set fee per claim reviewed or alternatively, propose a percentage fee of recovered claim overpayments. Add this information to your RFP response.

26. Is this program entirely pre-payment IBR?

Answer: Currently yes, but we are open to post-pay review.

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27. If CareOregon, is also seeking post payment reviews will the selected vendor be expected to perform overpayment recoveries?

Answer: If appropriate, please include in your proposal. The Scope of Work will be finalized with the awarded Contractor.

28. Do you currently have vendors performing IBR for you today?

29. What is the low dollar claim threshold the vendor should anticipate amount for reviews?

Answer The Scope of Work will be finalized with the awarded Contractor.

30. If CareOregon anticipates a post pay review, will it include a lookback period?

Answer: yes.

31. Is CareOregon willing to accept proposals that support IBR only? If not, can your selected vendor perform DRG with one of their channel partners?

Answer: CareOregon may end up selecting multiple vendors. Also, please see Section 2.14 Prohibition on Commissions and Subcontractors.

32. Our Itemized bill reviews are performed solely by Registered Nurses which is a superior licensure to a certified coder (reference 3.2.1) Is that acceptable?

Answer: Yes

33. Please detail your current IBR (Itemized Bill Review) and DRG (Diagnosis-Related Group) review processes. Are you utilizing any external vendors for these services? Do you conduct these reviews on a pre-payment, post-payment basis, or both? Additionally, do you perform any IBR or DRG reviews in-house?

Answer: See question 1. Yes, we are using a vendor. We are doing both pre-payment and post-payment reviews.

34. What fee model do you use for these services? Do you compensate vendors based on a percentage of savings, a flat fee, a per member per month (PMPM) rate, or another fee structure?

Answer: See Section 5.5 Fees, which describes the acceptable fee models.

35. What are the biggest challenges CareOregon faces with its current IBR and DRG review processes?

Answer: see RFP 3.2.2 Services

36. What are the timeframe expectations to complete audits from medical record receipt through audit in both Pre and Post-payment?

Answer: see RFP 3.2.2 Services

37. What is the total amount of annual savings realized over a recent 12-month period, broken down by DRG and itemized bill separately?

Answer: IBR: $6.4M; DRG: $8M.

38. Does CareOregon desire ACH transfer of funds for all recoveries, or are some providers set up for claim offset?

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Answer: ACH transfer is preferred.

39. Do any providers have medical record request limitations? i.e. volume and frequency, EMR access only, etc.?

Answer: no.

40. What pricer(s) does CareOregon use? Is vendor expected to reprice the claims? If so, do you have a preferred repricing tool?

Answer: We use Microdyn for external pricing and is our preferred repricing tool.

41. Can CareOregon share percentage breakdown of reimbursement types, i.e., DRG, percent of billed charge, per diem, etc.?

Answer: This information is not readily available.

42. Is provider sign off required for all overpayments identified?

43. Do CareOregon provider contracts have a provision for access or copies of medical records or itemized bills at no cost for the purpose of an audit?

Answer: yes, check provider handbook

44. How many medical records did vendors review over a recent 12-month period?

Answer: 787 medical records.

45. Can CareOregon please confirm the intended milestones? We noticed a desired go-live by

April 2025, but that the contract would extend only to October 2025.

Answer: The contract is estimated to be effective around November 1, 2024, with implementation beginning in November 2024. There is an option to extend the contract for two additional 2-year periods after October 31, 2025.

46. Would CareOregon be open to increasing the RFP response page limit to 25 pages?

Answer: Yes, CareOregon has increased the RFP response page limit to 35 pages in Addenda #1.

47. Are medical records expected to be reviewed for hospital acquired conditions and level of care discrepancies for IBR?

Answer: yes.

48. Could you please clarify if this if for one single claim not to exceed findings? “A forensic review report detailing Proposer’s findings, or a “not warranted” report advising that a forensic review of the claim has not identified savings equal to or greater than CareOregon threshold of $5,900,000.00.”

Answer: This is for the body of claims.

49. Do your contracts prohibit or have limitations on prepayment review?

50. Would we have access to contracts?

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Answer: Yes, if required.

51. Do you have reimbursement policies in place pertaining to inpatient or outpatient high dollar claim review?

52. Do we get first pass on reviewing claims?

Answer: Claims editing software and clearinghouse review runs a first pass review on all claims.

53. Do you have an internal itemized bill review team currently performing reviews for both inpatient and outpatient claims?

54. Is there a claim dollar amount threshold for itemized bill review?

55. What claims processing systems are utilized?

Answer: We utilize QNXT.

56. Would read-only system access be provided to the vendor?

Answer: Not currently granted to existing vendor but may be granted if required.

57. Do you allow for denying a claim for DRG Validation service when medical records are not received and requested pre-pay?

58. What is your current process for DRG Validation?

Answer: CareOregon declines to answer.

59. Are claim reviews completed for DRG Validation after the claims have been paid?

Answer: Currently yes, DRG is done post-pay.

60. How do you recoup payment for overpaid DRG Claims?

Answer: Currently the incumbent vendor recoups payments.

61. Are claim reviews completed for IBR after the claim has been paid?

Answer: No, currently IBR is pre-pay.

62. How do you recoup payments for IBR claims?

Answer: This is done pre-pay, no recoupment needed.

63. Listed below are conflicting statements about the start date of the contract work. Please clarify the start date of the work:

a. First paragraph, page 1, “Work is to begin approximately November 1, 2024 and continue through October 31, 2025 with the option for two (2) additional two (2) year renewals thereafter.”

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b. Page 8, Section 3.2.5, “The list below outlines target timelines for this project. It is important for Proposers to highlight their ability to meet these timelines or to propose alternatives based on their recommendations.

Milestones/Timeline

a. Target date for contract award November 1, 2024.

b. Notification of changes sent to providers by January 31, 2025.

c. Data exchange testing completed by February 28, 2025

d. Implement solutions and go-live by April 2, 2025.

i. Train internal/external customers one month before go-live.

ii. Training and support provided by Proposer firm at no charge for three months after go-live.”

Answer: Contract signing is anticipated to be around November 1, 2024, with implementation to begin immediately thereafter.

64. For IBR, will this service be performed on DRG claims that have moved into DRG outlier status or percent of charge paid claims?

Answer: Currently we do not perform DRG review on the same claims subject to IBR.

65. Are outpatient facilities (e.g., observation, outpatient/ambulatory surgery) claims in-scope? If so, what reimbursement methodology is used (i.e., % of charges, APC, EAPC)?

Answer: Typically, IBR and DRG reviews are only performed on inpatient services. If you have a proposed process for an efficient review of outpatient claims, please submit that with your proposal and include any associated fees

66. Regarding the requirement that CareOregon shall supply any missing information to Proposer within fifteen (15) business days. CareOregon Contract Administrator shall determine whether Proposer is authorized to request such information directly from providers. For services that require clinical documentation, such as DRG audits, is CareOregon asking for vendors to request approval prior to sending a request to the provider for every instance?

Answer: Vendor will not need to request approval to send requests for records on every claim. Thresholds will be identified in the finalized Scope of Work.

67. Regarding the requirement that CareOregon shall supply any missing information to Proposer within fifteen (15) business days. CareOregon Contract Administrator shall determine whether Proposer is authorized to request such information directly from providers. For services that require clinical documentation, such as DRG audits, is CareOregon asking for vendors to request approval prior to sending a request to the provider for every instance?

Answer: Vendor will not need to request approval to send requests for records on every claim.

68. How are post-pay overpay recoveries processed today by the plan (e.g., claims adjustments, offsets, refund requests, etc.)?

Answer: in most instances, claims adjustments and offsets.

69. What portion of the DRG and IBR services (audit programs) are outsourced to vendors versus performed internally by CareOregon? Can CareOregon elaborate a bit more on the

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Answer: Currently IBR and DRG reviews are performed by the current vendors. We are exploring options for replacing or subsidizing existing solutions.

70. For services requested in this RFP, are in-scope pre-pay claims those that are processed in CareOregon's Cognizant Trizetto - QNXT platform? If not, can CareOregon please clarify?

Answer: CareOregon uses QNXT for processing all medical claims.

71. Will you clarify whether fraud review is an expected component of the IBR?

Answer: Fraud review is not a requirement, although it would be encouraged and proposer can outline in their submitted proposal.

72. DRG Audits: Will the proposer get access to pricing tool to see potential savings?

Answer: Proposer will have access to our current DRG methodology.

73. What is the review period on prepay?

Answer: See Section 3.2.2 Services, Itemized Bill Review (IBR) Forensic Review Cost Containment Services, subsection b.

74. What is CareOregon’s 2024 projected claim spend?

Answer Unknown at this time.

75. What is the current average overpayment amount for DRG? For IBR?

Answer: DRG recovered an average of $5960 per claim in 2023, IBR saved an average of $8780 per claim in 2023

76. What is the current monthly hit rate/findings rate?

Answer: Unknown at this time.

77. Will you please clarify the peer review panel process and medical director requirement vis-a-vis vendor clinical nurse expertise on staff?

Answer: DRG reconsiderations submitted by providers should be completed by clinical staff and peer review should be available if requested.

78. Will you clarify whether fraud review is an expected component of the IBR?

Answer: Fraud review is not a requirement, though would be encouraged.

79. Diagnosis-Related Group (DRG) Audit Review & Overpayment Recovery: Projected volume is 500 reviews for year 1.

a. Are there any DRG audits happening currently?

b. Can you provide details on audits, appeals, overturns etc.?

Answer: a. Yes, b. CareOregon declines to answer.

80. DRG Audits: Will the proposer get access to pricing tool to see potential savings?

Answer: Proposer will have access to our current DRG methodology.

81. Itemized Bill Review (IBR) Forensic Review Cost Containment:

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a. Can you elaborate on "CareOregon threshold of $5,900,000.00." Is this number based on current internal IBR reviews?

b. Can you provide more details on the reviews done, appeals, overturns, etc?

Answer: a. current IBR target. b. CareOregon declines to answer.

82. Turnaround time: What is the expected Turnaround Around time on the Audits?

Answer: See Section 3.2.2 Services, Itemized Bill Review (IBR) Forensic Review Cost Containment Services, subsection b.

83. It was stated Clarifying Questions #1 Question 5. that a post pay RFP will be put out for post pay Data Mining and Recovery. Are there other Post Pay services that will be included in this RFP? Is there a set date or estimated time frame for that RFP?

Answer: Yes, there will be credit balance services, as well as Home Health, and

Prescription Drug services. Separate RFP’s are being facilitated for these services.

84. Can CareOregon confirm the status of claims that will be selected for review?

Answer: IBR pre-pay, DRG post-pay.

85. Is CareOregon open to including Post-pay DRG/IBR audit services in scope of work?

86. What is the DRG Type and Grouper Version that is currently being utilized?

Answer: CareOregon declines to answer

87. Are you able to coordinate MR requests from internal teams and vendors to avoid duplicate requests?

88. What is the current process of storing records from providers?

Answer: currently records are stored within our secure efile storage systems.

89. Do you use technical denials for providers not compliant with sending in medical records? If not, what is your policy if a provider is non-compliant?

90. What was the total volume & savings values on DRG & IBR reviews in 2023…Prepay vs Post Pay?

Answer: IBR: volume – 787; savings - $6.4M // DRG: volume – 1,347; savings - $8M.

91. Regarding Section 3.2.2 Diagnosis Related Grouping (DRG) Audit Review & Overpayment

Recovery Services, would CareOregon be open to utilizing the Vendor’s claim selection process to ensure maximum efficiency and potential savings according to prepay best practices and prepay process expertise?

92. Per Section 3.2.2 Diagnosis Related Grouping (DRG) Audit Review & Overpayment

Recovery Services: Proposer shall be responsible for the process of recovering overpayment amounts identified in Proposer’s findings.

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a. Can CareOregon describe the current prepay process that would necessitate an overpayment recovery?

b. Can CareOregon explain the current process for coordinating appropriate prepay savings with Vendor?

c. Are post-pay overpayments included in this scope of work?

Answer: CareOregon declines to provide complete outline of current processes. The total amount of recoveries processed was $8M.

93. Section 3.2.2 Itemized Bill Review (IBR) Forensic Review Cost Containment Services

Section B. “Proposer shall deliver the forensic review findings to CareOregon within five

(5) business days after Proposer’s receipt of all the necessary and required documents.”

Would CareOregon be open to working with Vendor, in partnership, to determine the most appropriate timelines for reviews to ensure support of maximum efficiency and potential savings according to prepay best practices and prepay process expertise?

Answer: We are confined by state requirements for timely reimbursement to providers.

94. Section 3.2.3 Deliverables, Itemized Bill Review (IBR) Forensic Review Cost Containment

Services-The stated expectation for the IBR savings threshold is $5.9 MM stated as "A forensic review report detailing Proposer’s findings, or a “not warranted” report advising that a forensic review of the claim has not identified savings equal to or greater than CareOregon threshold of $5,900,000.00.”

a. Can CareOregon describe how this threshold was determined?

b. Would CareOregon be open to working with Vendor, in partnership, to enhance the threshold determination for IBR reviews to ensure support of maximum efficiency and potential savings according to prepay best practices and prepay process expertise?

Answer: Threshold based on previous years recoveries. Open to adjustment based on proposal.

95. Section 2.11, Oral Presentations (page 3) states, “At CareOregon’s sole option, Proposers may be required to give an oral presentation of their Proposals to CareOregon, a process which would provide an opportunity for the Proper to clarify or elaborate on the Proposal…”. What is the anticipated date(s) CareOregon would hold such oral presentations should CareOregon elect to hold these presentations?

Answer: Presentations from top scoring firms may be scheduled in late September or early October 2024.

96. Section 3.2.1, Scope, paragraph 5 (page 4) indicates, “Proposer shall use only Certified Coding Specialists (‘CCS’) or Certified Professional Coders (‘CPC’).”

Please provide the following clarifications:

a. Concerning DRG reviews, is clinical validation of the primary diagnosis avoidable?

Answer: RNs are also acceptable for IBR review, as well as LPNs. DRG requires clinical validation. Readmissions and short-stay audits could be within scope.

97. Section 3.2.2, Services, Implementation, item h (page 6) indicates, “Proposer shall attend onsite meetings with CareOregon Contract Administrator as requested by

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CareOregon.” Please confirm the schedule of these onsite meetings are the same as those stated in Section 3.2.4, Performance Requirements, item b on page 8. If not, what is the frequency of the onsite meetings required by this section?

Answer: Section 3.2.4 states, “Proposer to conduct a minimum of one (1) annual onsite meeting and three quarterly meetings (either in person or via telephone/web) with CareOregon Contract Administrator to review Proposer’s services under this schedule. The location of each meeting will be determined by CareOregon. Proposer shall be responsible for all travel and expenses incurred by Proposer in connection with such meetings.”

98. Section 3.2.2, Services, Diagnosis Related Grouping (DRG) Audit Review & Overpayment Recovery Services, item a (page 6) states, “Proposer shall…send its qualified personnel to perform the audit reviews…”. Will CareOregon permit the vendor to conduct remote desk audits instead of onsite at the provider/facility?

Answer: Section 3.2.2 Services Itemized Bill Review (IBR) Forensic Review Cost Containment Services Letter J states, “Services shall be performed at Proposer’s location(s), which may include work performed remotely, except for the rare occasion of a Proposer’s onsite visit to a provider.”

99. Section 3.2.2, Services, Diagnosis Related Grouping (DRG) Audit Review & Overpayment Recovery Services, item e (page 6) indicates, “Proposer shall show evidence of an overturn rate of less than 2%.” Does the percentage calculation net out reviews for which additional documentation is made available upon appeal that was not presented for the initial audit?

Answer: Determinations should be made with complete records. Denials due to insufficient records would not be counted in the overturn rate.

100. Section 3.2.2, Services, Diagnosis Related Grouping (DRG) Audit Review & Overpayment Recovery Services, item g (page 7) indicates, “Proposer shall return all CareOregon overpayment amounts to CareOregon via ACH direct deposit within fifteen (15) days of receipt of the overpayment from the provider.” Will post payment audit findings be offset by CareOregon, or is the vendor required to collect/recover payment directly from the provider?

Answer: CareOregon is open to different payment methods, see fees section 5.5.

101. Section 5.3, Scope of Work, DRG Questions, item 3 (page 11) asks, “How are claims submitted to Proposer for review if claim system access is not provided?”. Please provide the following clarifications:

a. Does CareOregon not anticipate providing a post-adjudication, pre-payment claims data file?

b. Does CareOregon not intend to provide read-only claim system access to the selected vendor?

Answer: A claims data file can be provided, but direct read-only access will only be granted if required.

102. Are you looking for chart review results to address ALL coding related opportunities (i.e., DRG Accuracy, HCC, RAF, Procedure Code Accuracy, all secondary code assignments)?

Please specify.

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Answer: the Proposer can submit on a single solution and is not required to provide solutions across all opportunities.

103. At what rate do your physicians respond to queries?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

104. Can you confirm that PB is not within scope for this RFP?

Answer: PB would not be within scope for IBR or DRG.

105. Can you provide payer and payment methodology by month for FY 2023 discharge volumes?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

106. Can you provide payer mix including estimated annual discharges by payer as well as payment methodology (MS-DRG, APR-DRG, per diem, contracted rates, etc.)?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

107. Do coders initiate queries?

Answer: For DRG, Yes. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

108. Do Coding and CDI work any claim edits?

Answer: Yes. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

109. Do you have a Physician Advisory Program that supports Coding and CDI?

Answer: Yes. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

110. Do you have a second level review process? If yes, what is included in this scope?

Answer: No. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

111. Do you have an internal quality/query compliance review process? If yes, would you share the past two outcome reports and associated education provided?

Answer: Yes, CareOregon declines to share outcome reports at this time.

112. Do you issue Quality cohort and/or risk adjustment accuracy related queries?

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Answer: No. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

113. Do you prefer Chart Review/Education to be at a pre-bill or post-bill level?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

114. Do you provide ongoing education to your Physicians/Providers?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

115. Does CDI currently utilize software/technology that supports daily workflows, data capture, reporting, and/or prioritization? If yes, please share the name of the tool(s) used.

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

116. Does Coding manage a pre-bill coding process?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

117. Does revenue integrity report coding and clinically related denials to department leadership?

Answer: Yes. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

118. Does Revenue Integrity track clinically related denials for HB and PB claims?

Answer: N/A. CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

119. Does the Coding Department outsource to any vendor(s)?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

120. Has your organization utilized an outside vendor for Pre-Bill purposes in the past?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

121. How long have you had an IP CDI program?

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122. How many FTEs do you have dedicated to your IP CDI Program?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

123. How many FTEs do you have dedicated to your IP Coding Program?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

124. How many physician practices do you support?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

125. Is medical necessity validation expected to be included in the prebill workflow/chart assessment with DRG validation?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

126. Is there formal training for your Physician Advisors?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

127. Please describe the titles/roles of your clinical staff.

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

128. Please provide the number of facilities involved (hospitals and clinics) in this Pre-Bill Chart Review.

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

129. What are the current KPIs being monitored today for the CDI program?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

130. What credential requirements do you require for your cdi team (RN, BSN, CCDS etc.)?

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131. What Encoder and/or CAC tool are you utilizing?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

132. What is the average wait time before access is granted for chart review?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

133. What is your current ALOS?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

134. What is your current CMI and is it improving over the last 12 months?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

135. What is your current DNFB goal?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

136. What LMS technology is currently used for internal education?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review

137. What payment methodologies are within scope of the RFP?

Answer: See RFP Section 5.5 Fees.

138. What reporting software is currently being utilized for KPI and process?

on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

139. What title/role in the organization does your IP CDI Program report to?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

140. What title/role in the organization does your IP Coding Program report to?

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141. What type (and frequency) of interaction does the CDI staff have with the coding staff?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

142. Which EMR is being currently utilized?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

143. Which Payers are included in this prebill scope? Please identify which Payers reimburse on MSDRG vs. APRDRG methodology?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

144. Will you be willing to establish dedicated WQs for the chart review component?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

145. Will you provide an overview of the reporting structure with HIM, Coding, CDI, and Quality departments?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review

146. Will you provide annual volumes for coding and denials?

147. Will you provide the last 6 months outcomes (PEPPER, HAC, CMI, Quality, KPI) reports to assist us in education content development?

Answer: CareOregon is a health insurance payor and is seeking RFP for IBR and DRG review on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP.

148. How would you like RFP submitted? Is it through OregonBuys or is a formal proposal via word or PDF acceptable?

Answer: Page 1 Submission states, “All proposals must be emailed to vendorservices@careoregon.org. Do not attempt to submit proposals through or to the OregonBuys website. All proposals must be submitted to the email listed here.”

149. Is there anything within OregonBuys that needs to be completed once vendor is registered in the system?

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150. Are Short Stay/Place of Service reviews paid by a DRG in scope for reviews for this RFP?

Answer: yes.

151. What is the SLA (Service Level Agreement) for a pre-pay DRG claim review? Team, what are your service level requirements for current vendor? List them here.

Answer: CareOregon declines to answer

152. What is the Annual Inpatient Spend and Average Claim Paid Amount?

Answer: Average claim paid amount is $10k.

153. What Audit Types are in-scope for review (i.e., Place of Service, DRG Review)?

Answer: Inpatient high dollar claims that are subject to DRG pricing.

154. Does Current Bid Include Integration with Client Recovery System?

on facility claims that are submitted to us (the payor) from multiple hospitals and provider groups. This question is outside of the scope of the current RFP

155. Does Current Bid Include New Concepts Outside of Place of Service & DRG Review?

Answer: no.

156. Does Current Bid Include Additional Plans?

Answer: no.

157. Are high dollar claims paid via a DRG outlier contract or as a percent of charge?

Answer: DRG outlier contract.

158. Will the DRG Audit Review include both Clinical Validation and Coding Validation or only Coding Validation?

Answer: both.

159. For DRG, is an overturn rate of less than 2% negotiable?

Answer: would need a breakdown of why the overturn rate is >2%.

160. Is this IBR based on claims data alone? Or is this review including review of the medical record? What is the average number of lines for IBR subject to the Forensic Review?

Answer: IBR is based on the itemized bill provided to us by the provider/facility. Average number of lines is unknown.

161. Can you confirm that first year volume for DRG reviews would only be 500 claims?

Answer: CareOregon expects a lower claim volume for the first year due to timeline of implementation. There are about 128 claims per month for claim volume.

162. For IBR, will the appeal process include participation in Administrative Law Judge (ALJ) virtually or onsite?

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163. What specific types of PHI/PII will be involved?

Answer: IBR will include the itemized bill. DRG will include the complete health record. All reviews will include transfer of claims data which is PHI.

164. What data retention policies are required?

Answer: CareOregon’s data retention requirements can be viewed in the Business Associate Agreement and the CareOregon Data Security Agreement Tier 1 – Sample available at this link.

165. Are there specific encryption requirements for data at rest and in transit?

Answer: Yes, HIPAA compliance.

166. Compliance and regulatory requirements:

What regulatory frameworks must be followed (e.g., HIPAA, CCPA)?

a. Are there any industry-specific certifications required (e.g., HITRUST, NIST 5, ISO 27001)?

b. Is there a need for third-party audits or assessments (e.g., SOC 2, PCI DSS)?

c. What are the reporting and breach notification requirements?

Answer: HIPAA, 42 CFR Part 2, CMS, Oregon Revised Statues and Oregon Administrative Rules. A. IS evaluates the vendor and then assigns one of three risk tiers which calculated through a combination of reputational risk and business operational risk. b. Yes, depending on tier level. SOC2 for Tier 1 organizations and ISO 27001 or HITRUST may be considered in place of a SOC 2 Type II audit. Other tiers require the contractor to each tier identifies that CareOregon reserves the right to audit the Contractor’s compliance program and systems used to store, transmit or process CareOregon data. C. Yes, we have asked for 1 day notification of discovery of an incident or presumed breach.

167. Access control and authentication:

a. Who will have access to the PHI/PII, and how is access controlled?

b. What authentication methods are required (e.g., multi-factor authentication)?

c. Are there specific roles and permissions that must be adhered to?

Answer: Our IT Department will direct Access control.

168. Data sharing and data breach:

a. Will any third parties be involved in processing or storing the data?

b. What are the data-sharing policies and agreements with third parties?

c. Are there specific requirements for third-party vendors (e.g., business associate agreements for HIPAA)?

d. What is the required incident response plan for data breaches?

e. What are the timelines and procedures for notifying affected parties in the event of a breach?

f. What are the penalties or liabilities for non-compliance or breaches?

g. What are the requirements for data destruction or anonymization after the project is completed?

h. Are there specific methods or certifications required for data destruction?

Answer: a. only if outlined in proposal and agreed upon

b. HIPAA minimum necessary http://careoregon.org/ https://careoregon.org/about-us/vendor-resources

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c. yes, BAA and Data Security Exhibits

d. ONE (1) business day.

e. ONE (1) business day.

f. see sample contract document and Tier 1 Data Security Exhibit.

g. data must be saved for a legally required minimum of years, then destroyed appropriately per federal regulations.

h. Yes, HIPAA defined

169. Technical requirements:

a. Are there any specific technical standards or security protocols that must be implemented?

b. What are the requirements for network security (e.g., firewalls, intrusion detection systems)?

c. Is there a need for continuous monitoring or vulnerability scanning?

Answer: View the documentation here: https://careoregon.org/contact-us/vendor-resources.

170. Legal and contractual obligations:

a. Are there any specific legal terms or conditions related to data security that must be included in the contract?

b. What indemnification clauses are required in case of data breaches?

c. What are the penalties for non-compliance with data security requirements?

Answer: CareOregon’s data security requirements can be viewed in the Business Associate Agreement and the CareOregon Data Security Agreement Tier 1 – Sample available at this link.

171. Training:

a. What training is required for personnel handling PHI/PII?

b. Are there ongoing education or certification requirements for staff?

Answer: CareOregon does not provide such training to vendors.

172. Reporting:

a. What are the reporting requirements for security incidents or compliance audits?

b. How frequently must security assessments or audits be conducted?

Answer: CareOregon’s data security reporting and auditing requirements can be viewed in the Business Associate Agreement and the CareOregon Data Security Agreement Tier 1 – Sample available at this link.

173. What would warrant an onsite audit? Will this be left to the proposers discretion, or is CareOregon setting parameters in which the proposer must conduct an onsite audit?

Answer: Site audits of the providers will be left at the proposers discretion.

174. Will requests for documentation go through CareOregon or directly to the provider?

Answer: direct to provider.

175. Please provide a sample forensic review report that the proposer will be required to submit to CareOregon.

Answer: CareOregon is requesting proposer to submit a sample forensic review report that they currently use.

http://careoregon.org/ https://careoregon.org/contact-us/vendor-resources.

https://careoregon.org/about-us/vendor-resources

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176. Please provide a sample monthly and quarterly performance report.

Answer: Per Section 3.2.4 Performance Requirements, “Proposer to submit monthly and quarterly performance reports by facility to the CareOregon Contract Administrator, documenting cases reviewed, original cost, final cost, savings per case, all appeal activity, and total cost savings.”

177. The RFP mentions training for CareOregon staff. What specific training is needed?

Answer: The only training required is to implement claims adjustments as requested by proposer.

178. Is automobile liability required if all work is conducted remotely?

179. What are the…