RFP 2024-13 IRB DRG Billing Services - final.pdf

RFP 2024-13 IBR & DRG Billing Services

REQUEST FOR PROPOSALS #2024-13

IBR & DRG BILLING SERVICES

Publish Date: August 8, 2024

CareOregon, Inc. (“CareOregon”) on behalf of Health Share of Oregon and CareOregon Advantage, is inviting submission of proposals for the IBR & DRG Billing Services project.

Closing Date/Time: September 9, 2024 - 2:00 PM, Pacific Time

Project Summary: The Centers for Medicare and Medicaid Services (“CMS”) and the Oregon Health Authority (“OHA”) require managed Medicare and Medicaid plans to implement payment integrity programs. Outsourcing Itemized Bill Reviews (“IBR”) and Diagnosis Related Grouping (“DRG”) for high dollar inpatient hospital claims on a prepayment basis allows CareOregon to meet these regulatory requirements and minimize claim overpayments. 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.

Contact Information: The sole point of contact for procurement process or technical questions is: Lee

Reinholtz, Procurement and Contract Analyst II; reinholtzl@careoregon.org;

503-416-1797.

RFP Location: RFP Documents can be downloaded from OregonBuys at the following address:

https://oregonbuys.gov/bso/. Prospective Proposers will need to sign in to download the information and that information will be accumulated for a Plan Holder's List. Prospective Proposers are responsible for obtaining any Addenda or clarifying questions from OregonBuys.

Submission: 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.

CareOregon encourages proposals from minority, women, service-disabled veteran, and emerging small businesses.

**NO PROPOSALS WILL BE RECEIVED OR CONSIDERED AFTER THE ABOVE

RFP CLOSING DATE/TIME**

SCHEDULE

Request for Proposals Issued……...............................................August 8, 2024

Deadline to Submit Clarifying Questions....................................August 22, 2024, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........September 12, 2024, 2:00 PM, Pacific Time

Anticipated Contract Start Date……...........................................January 1, 2025 mailto:reinholtzl@careoregon.org https://oregonbuys.gov/bso/ mailto:vendorservices@careoregon.org

SECTION 2

INSTRUCTIONS TO PROPOSERS

2.1 Modification or Withdrawal of Proposal: Any Proposal may be modified or withdrawn at any time prior to the Closing deadline, provided that a written request is received by Procurement, prior to the Closing. The withdrawal of a Proposal will not prejudice the right of a Proposer to submit a new Proposal.

2.2 Requests for Clarification and Requests for Change: Proposers may submit questions regarding the specifications of the RFP until the deadline in the Schedule. Requests for changes must include the reason for the change and any proposed changes to the requirements. The purpose of this requirement is to permit CareOregon to correct, prior to the opening of Proposals, RFP terms or technical requirements that may be unlawful, improvident or which unjustifiably restrict competition. CareOregon will consider all requested changes and, if appropriate, amend the RFP. No oral or written instructions or information concerning this RFP from CareOregon employees or agents to prospective Proposers shall bind CareOregon unless included in an Addendum to the RFP.

2.3 Addenda: If any part of this RFP is changed, an addendum will be published on OregonBuys. It shall be Proposers responsibility to regularly check OregonBuys for any notices, published addenda, or response to clarifying questions.

2.4 Submission of Proposals: Proposals must be submitted in accordance with Section 5. All Proposals must include a signature that affirms the Proposer’s intent to be bound by the Proposal (this may be on cover letter, or on the Proposal). The Certification page must be signed as well. If a Proposal is submitted by a firm or partnership, the name and address of the firm or partnership shall be shown, together with the names and addresses of the members.

If the Proposal is submitted by a corporation, it shall be signed in the name of such corporation by an official who is authorized to bind the contractor. No late Proposals will be accepted.

2.5 Acceptance of Contractual Requirements: Failure of the selected Proposer to execute a contract and deliver required insurance certificates within thirty (30) calendar days after notification of an award may result in cancellation of the award. This time period may be extended at the option of CareOregon.

2.6 Investigation of References: CareOregon reserves the right to investigate all references in addition to those supplied references and investigate past performance of any Proposer with respect to its successful performance of similar services, its compliance with specifications and contractual obligations, its completion or delivery of a project on schedule, its lawful payment of subcontractors and workers, and any other factor relevant to this RFP. CareOregon may postpone the award or the execution of the contract after the announcement of the apparent successful Proposer in order to complete its investigation.

2.7 RFP Proposal Preparation Costs and Other Costs: Proposer costs of developing the Proposal, cost of attendance at an interview (if requested by CareOregon), or any other costs are entirely the responsibility of the Proposer, and will not be reimbursed in any manner by CareOregon.

2.8 Clarification and Clarity: CareOregon reserves the right to seek clarification of each Proposal, or to make an award without further discussion of Proposals received. Therefore, it is important that each Proposal be submitted initially in the most complete, clear, and favorable manner possible.

2.9 Right to Reject Proposals: CareOregon reserves the right to reject any or all Proposals or to withdraw any item from the award, if such rejection or withdrawal would be in CareOregon’s interest, as determined by CareOregon.

Proposals may be rejected in whole or in part if they attempt to limit or modify any of the terms, conditions, or specifications of the RFP or the Sample Contract.

2.10 Proposal Terms: All Proposals, including any price quotations, will be valid and firm through a period of one hundred and eighty (180) calendar days following the Closing date. CareOregon may require an extension of this firm offer period. Proposers will be required to agree to the longer time frame in order to be further considered in the procurement process.

2.11 Oral Presentations: 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 Proposer to clarify or elaborate on the Proposal but will in no material way change Proposer’s original Proposal. Any costs of participating in such presentations will be borne solely by Proposer and will not be reimbursed by CareOregon. Note: Oral presentations are at the discretion of the evaluating committee and may not be conducted; therefore, written Proposals should be complete.

2.12 Review for Responsiveness: Upon receipt of all Proposals, the Procurement Department will determine the responsiveness of all Proposals before submitting them to the evaluation committee. If a Proposal is incomplete or non-responsive in significant part or in whole, it will be rejected and will not be submitted to the evaluation committee.

CareOregon reserves the right to determine if an inadvertent error is solely clerical or is a minor informality which may be waived, and then to determine if an error is grounds for disqualifying a Proposal. The Proposer’s contact person identified on the Proposal will be notified, identifying the reason(s) the Proposal is non-responsive.

2.13 Communication Blackout Period: Except as called for in this RFP, Proposers may not communicate with members of the Evaluation Committee or other CareOregon employees or representatives about the RFP during the procurement process until the apparent successful Proposer is selected. Communication in violation of this restriction may result in rejection of a Proposer.

2.14 Prohibition on Commissions and Subcontractors: CareOregon will contract directly with persons/entities capable of performing the requirements of this RFP. Contractors must be represented directly. Participation by brokers or commissioned agents will not be allowed during the Proposal process. Contractor shall not use subcontractors to perform the Work unless specifically proposed or authorized to do so by CareOregon. Contractor represents that any employees assigned to perform the Work, and any authorized subcontractors performing the Work, are fully qualified to perform the tasks assigned to them, and shall perform the Work in a competent and professional manner. Contractor shall not be permitted to add on any fee or charge for subcontractor Work. Contractor shall provide, if requested, any documents relating to subcontractor’s qualifications to perform required Work.

2.15 Collusion: By responding, the Proposer states that the Proposal is not made in connection with any competing Proposer submitting a separate response to the RFP, and is in all aspects fair and without collusion or fraud. Proposer also certifies that no officer, agent, or employee of CareOregon has a pecuniary interest in this Proposal.

2.16 Evaluation Committee: Proposals will be evaluated by a committee consisting of representatives from CareOregon and potentially external representatives. CareOregon reserves the right to modify the make-up in its sole discretion.

2.17 Nondiscrimination: The successful Proposer agrees that, in performing the Work called for by this RFP and in securing and supplying materials, contractor will not discriminate against or treat differently, any person on the basis of race, color, religious creed, political ideas, sex, age, marital status, sexual orientation, gender identity, veteran status, physical or mental disability, national origin or ancestry, or any other class protected by applicable law.

2.18 Best and Final Offer: CareOregon may request best and final offers from those Proposers determined by CareOregon to be reasonably viable for contract award. However, CareOregon reserves the right to award a contract on the basis of initial Proposal received. Therefore, each Proposal should contain the Proposer’s best terms from a price and technical standpoint. Following evaluation of the best and final offers, CareOregon may select for final contract negotiations/execution the offers that are most advantageous to CareOregon, considering cost and the evaluation criteria in this RFP.

2.19 PROPOSAL CONFIDENTIALITY: Submitted proposals will be treated as confidential and will only be shared internally with applicable staff for this project. Proposers that responded to the RFP will be notified of the award at the completion of the process. Proposer scores and evaluation notes shall remain private and confidential information for CareOregon purposes only.

SECTION 3

SCOPE OF WORK

3.1 BACKGROUND

Founded in 1993, CareOregon is a 501(c)(3) public benefit nonprofit company that draws nearly all its revenue from public programs such as Medicaid (the Oregon Health Plan – “OHP”), Medicare and the State Children’s Health Insurance Program (“SCHIP”). Coordinated care organizations (“CCOs”) are an Oregon innovation that integrates physical, behavioral and oral health care, and treats the whole person.

Through partnerships with our CCOs, we provide integrated managed care services. We partner with Health Share of Oregon to serve the tri-county Portland metro area. We own Jackson Care Connect and Columbia Pacific CCO. In addition to Medicare plans and CareOregon Dental lines of business, Housecall Providers delivers primary, palliative and hospice care to home-bound patients.

Our mission is to inspire and partner to create quality and equity in individual and community health. Our vision is healthy communities for all individuals, regardless of income or social circumstances.

We focus on the total health of our members, not just traditional health care. In teaming up with members, their families and their communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.

We care about people We serve Oregonians eligible for the OHP and Medicare Advantage members who have us as their health care option. But that’s not all. We are a managed health care company with an overarching goal: to make world-class, high-quality health care available to all Oregon residents, regardless of income.

We support our neighbors We know that some Oregonians are in need but don’t qualify for OHP benefits. We work to strengthen the health care safety net that these Oregonians rely upon, from local health departments and community clinics to rural and migrant health centers. We partner with policy makers and legislators to improve services and provide access to quality care throughout the state, from urban centers to rural neighborhoods.

We work with first-class providers CareOregon has built a health care delivery system that assures access to physicians and health care professionals who understand special needs and provide quality care regardless of a patient’s financial resources.

We work with policy makers to ensure access We provide OHP enrollees access to health care services in exchange for a per member, per month capitation rate. The Oregon Legislature sets this payment rate. The payments are subject to available state funding.

CareOregon takes full financial risk for the health care services our members use. CareOregon, formed by safety net health care providers in the state, is a Safety Net Health Plan. Safety Net Health Plans are nonprofits that derive their revenue from public programs.

To put it simply, CareOregon ensures that members have timely access to high quality health care from a broad network of providers, and CareOregon works hard every day to keep people healthy and active in their homes and communities.

Equity, Diversity, and Inclusion:

CareOregon recognizes that to achieve the vision of “Healthy communities for all individuals, regardless of income or social circumstances,” it must intentionally cultivate authentic member engagement, community partnerships, and recruit, retain and develop a staff as diverse as the communities it serves. CareOregon has embarked on a continuous effort to understand the effects of historical, institutional and structural oppression on the various communities represented within its membership and personnel. CareOregon strives to internally, and in partnership with other like-minded organizations across sectors, to redress policies, systems and health related environmental issues that affect health care disparities and inequities.

Equity, diversity, and inclusion is a cornerstone of CareOregon’s mission, vision and strategic objectives.

CareOregon’s priority is strengthening our communities by making health care work for everyone by ensuring access to a broader and more diverse network of physical, behavioral, and oral health services that address the individual needs and cultural values of our members and reduces barriers to getting needed care.

It is the intent of CareOregon, through issuance of this RFP, to collaborate with like-minded firms that share the same values and that will take actual steps to embody those values in the services provided to CareOregon and its providers, members and clients.

Project Background:

The Centers for Medicare and Medicaid Services (“CMS”) and the Oregon Health Authority (“OHA”) require managed Medicare and Medicaid plans to implement payment integrity programs. Outsourcing Itemized Bill Reviews (“IBR”) and Diagnosis Related Grouping (“DRG”) for high dollar inpatient hospital claims prior to claim completion allowing CareOregon to meet these regulatory requirements and minimize claim overpayments.

3.2 SCOPE OF WORK

3.2.1 Scope:

CareOregon, along with its subsidiaries Health Share of Oregon, and CareOregon Advantage, is seeking a payment integrity program that offers forensic review cost containment services to include review of referred inpatient claims for potential billing errors and inconsistencies. Once potential billing issues are identified through Itemized Bill Review (“IBR”) and Diagnosis Related Grouping (“DRG”) audit review, and if claim savings warrant it, Proposer shall prepare a forensic review report (reports can be submitted as frequently as daily) listing each identified issue and specifying the adjusted billed charge amount for all uncontested charges.

Under the direction of the CareOregon Contract Administrator, Proposer to assist CareOregon with resolution and/or appeal support for the billing issues identified for up to one year following delivery of said report to CareOregon.

Proposer shall provide all personnel, materials, equipment, peer review, and peer review panel costs necessary for Proposer’s performance of the services.

Proposer must keep current on Oregon Health Authority guidelines.

Proposer must keep current on CMS guidelines.

Proposer shall use only Certified Coding Specialists (“CCS”) or Certified Professional Coders (“CPC”) and Proposer personnel must be currently certified by the American Health Information Management Association (“AHIMA”) or the American Academy of Professional Coders (“AAPC”). Proposers are required to have a medical director on staff.

3.2.2 Services:

Implementation Proposer shall provide implementation services.

a. Identify respective team members and responsibilities.

b. Implement data interface and claims transmission.

c. Provide guidelines for targeting claims.

d. Account for any missing information.

e. Implement rules for provider interface and negotiations.

f. Establish periodic claim status meeting processes.

g. CareOregon Contract Administrator to meet virtually each week with Proposer’s implementation manager during the implementation process.

h. Proposer shall attend onsite meetings with CareOregon Contract Administrator as requested by

CareOregon.

i. Proposer shall provide three (3) months’ post-implementation support services at no additional charge to CareOregon.

j. Data exchange testing.

k. Notification of changes to be sent to Providers.

Diagnosis Related Grouping (DRG) Audit Review & Overpayment Recovery Services

a. Claim files shall be shared only via secure file transfer protocol (“SFTP”). Proposer shall review the extract claim file and select claims for audit review, notify providers of the intent to perform audit reviews, request supporting documentation, send its qualified personnel to perform the audit reviews, and provide a written summary of the audit review to CareOregon and the provider.

b. Proposer shall be responsible for the following time sensitive tasks as part of provider appeals process: review provider appeal, send a determination letter to the provider, process appeals through its physician medical director if required.

c. If, at any time during the appeals process (first, second or third level), a provider requests a medical director review or sends Proposer an appeal that has been written and signed by a physician, that appeal is automatically sent to the Proposer’s medical director for final review.

d. Proposer shall notify the provider that the provider must, following Proposer’s audit review and review by provider of Proposer’s findings:

i. Sign the acknowledgement form; or

ii. Refuse to sign the acknowledgement form and appeal Proposer’s findings to CareOregon within thirty (30) days.

e. Proposer shall show evidence of an overturn rate of less than 2%.

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

g. 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.

h. Proposer shall conduct a minimum of one (1) annual onsite meeting and three (3) quarterly meetings, either in person or remotely, with CareOregon Contract Administrator to review Proposer’s DRG services.

Itemized Bill Review (IBR) Forensic Review Cost Containment Services

a. Proposer shall review the extract claim file and select claims to determine whether a full forensic review report of the claim is warranted, will prepare a forensic review report for all warranted claims, and a daily not warranted report for all claims that do not warrant a forensic review report. See section 3.2.3 for further details.

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.

c. Provider packets, pursuant to the forensic review report, shall be completed and distributed by Proposer within fifteen (15) business days following the date the forensic review report is sent to CareOregon.

d. Proposer to manage the administrative appeals process regarding the forensic review findings.

CareOregon to review and approve all appeal responses prior to submission to provider.

e. Proposer to focus its forensic reviews on these sources of questionable claims billing, including but not limited to:

i. Billing errors.

ii. Duplicate charges.

iii. Unbundling.

iv. Hospital acquired conditions.

v. Level of care discrepancies.

vi. Item descriptions that lack details needed for IBR review.

vii. Level of drug price mark-ups and implant pricing disparities.

viii. Off-label utilization of pharmaceuticals that are excluded from coverage by experimental/investigational limitations.

f. In the rare event of onsite provider visit, Proposer shall notify each provider to be audited that Proposer will require an internet connection and onsite access to records, which may require access to the provider’s electronic record system, for Proposer’s performance of audit reviews.

g. Proposer shall perform process changes as requested by CareOregon, such as a requested change to a threshold claim amount for audit.

h. For each claim for which a provider desires to appeal Proposer’s findings, Proposer will be responsible for the appeals process.

i. Proposer shall return all CareOregon overpayment amounts to CareOregon via ACH direct deposit within fifteen (15) business days of receipt of the overpayment from the provider.

j. 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.

k. 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.

3.2.3 Deliverables:

Diagnosis-Related Group (DRG) Audit Review & Overpayment Recovery

a. Proposer shall provide to CareOregon quarterly reporting which shall include a summary of Proposer’s performance to include the number of bills audited, savings due to the audit, and issues found.

b. CareOregon shall provide Proposer an extract claim file containing paid claims on a monthly basis, unless parties agree to an alternate schedule.

Expected DRG claim volume is about 500 for the first year of the Contract. Beginning in year two, Proposer to adjust the claim volume based on data from the prior year(s) to find an accurate annual claim volume.

Itemized Bill Review (IBR) Forensic Review Cost Containment

a. 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.

b. CareOregon to provide documentation:

i. Uniform Billing Form 04 (“UB-04” or “CMS-1450”).

ii. Itemized bills.

iii. CareOregon’s payment methodology, including discount calculation and member responsibility.

c. Proposer must have the ability to customize reports for CareOregon requirements.

3.2.4 Performance Requirements:

a. 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.

b. 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 such meeting will be determined by CareOregon. Proposer shall be responsible for any and all travel and expenses incurred by Proposer in connection with such meetings.

3.2.5 Work Schedule:

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.

Term of Contract: The term of the contract shall be from the effective date through October 31, 2025 with the option for two (2) additional two (2) year renewals thereafter subject to the mutual agreement of the parties.

3.2.6 Sample Contract: Submission of a Proposal in response to this RFP indicates Proposer’s willingness to enter into a contract containing substantially the same terms (including insurance requirements) of the sample contract identified below. No action or response to the sample contract is required under this RFP. Any objections to the sample contract terms should be raised in accordance with Paragraphs 2.2 of this RFP pertaining to requests for clarification of the RFP/specifications. This RFP and all supplemental information in response to this RFP will be a binding part of the final contract.

The applicable Sample Professional Services Contract for this RFP can be found at https://careoregon.org/contact-us/vendor-resources.

Professional Services Contract (unless checked, item does not apply) The following paragraphs of the Professional Services Contract will be applicable:

Travel and Other Expense is Authorized Protection of Patient Privacy and Security (PHI) Criminal Background Check Requirements Key Persons On-Call Contract Basis CareOregon Data Security Requirements Hosted Software

The following insurance requirements will be applicable:

Commercial General Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for Bodily Injury and Property Damage.

Professional Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for damages caused by error, omission, or negligent acts.

Automobile Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence for Bodily Injury and Property Damage.

Cyber Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence for network security (including data breach), privacy, interruption of business, media liability, and errors and omissions.

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

SECTION 4

EVALUATION PROCEDURE

4.1 An evaluation committee will review all Proposals that are initially deemed responsive and they shall rank the Proposals in accordance with the below criteria. The evaluation committee may recommend an award based solely on the written responses or may request Proposal interviews/presentations.

Interviews/presentations, if deemed beneficial by the evaluation committee, will consist of the highest scoring Proposers. The invited Proposers will be notified of the time, place, and format of the interview/presentation. Based on the interview/presentation, the evaluation committee may revise their scoring.

Written Proposals must be complete and no additions, deletions, or substitutions will be permitted during the interview/presentation (if any). The evaluation committee will recommend award of a contract to the final CareOregon decision maker based on the highest scoring Proposal. The CareOregon decision maker reserves the right to accept the recommendation, award to a different Proposer, or reject all Proposals and cancel the RFP.

Proposers are not permitted to directly communicate with any member of the evaluation committee during the evaluation process. All communication must be facilitated through the assigned Procurement Analyst.

4.2 Evaluation Criteria

Category Points available:

Proposer’s General Background and Qualifications 0-30 Scope of Work 0-35 Equity, Diversity, and Inclusion Efforts 0-10 Fees 0-25

Available points 0-100

4.3 Once a selection has been made, CareOregon will enter into contract negotiations. During negotiation, CareOregon may require any additional information it deems necessary to clarify the approach and understanding of the requested services. Any changes agreed upon during contract negotiations will become part of the final contract. The negotiations will identify a level of Work and associated fee that best represents the efforts required. If CareOregon is unable to come to terms with the highest scoring Proposer, discussions shall be terminated and negotiations will begin with the next highest scoring Proposer. If the resulting contract contemplates multiple phases and CareOregon deems it is in its interest to not authorize any particular phase, it reserves the right to return to this solicitation and commence negotiations with the next highest ranked Proposer to complete the remaining phases.

SECTION 5

PROPOSAL CONTENTS

5.1 Vendors must adhere to submission instructions and be advised as follows:

1. Complete Proposals must be emailed to vendorservices@careoregon.org. The subject line of the email must identify the RFP title. Proposers are encouraged to contact Procurement to confirm receipt of the Proposal.

2. CareOregon reserves the right to solicit additional information or Proposal clarification from the vendors, or any one vendor, should CareOregon deem such information necessary.

3. Proposal may not exceed a total of 20 pages (single-sided), inclusive of all exhibits, attachments or other information.

4. Proposers are required to structure Proposals following the below question outline. It is important for answers to be clear and concise.

5.2 Proposer’s General Background and Qualifications (Max 30 points):

1. Description of the firm.

2. Credentials/experience of key individuals that would be assigned to this project.

3. Description of providing similar services to non-profit entities of similar size within the past five (5) years.

4. Describe your typical customer profile, such as size and service provided. What are your customer retention rates?

5. Description of the firm’s ability to meet the requirements in Section 3.

6. Description of what distinguishes the firm from other firms performing a similar service.

7. Describe if any of the proposed services will be performed by offshore (not US state or US territory) employees or subcontractors?

8. Describe if your firm is currently or potentially engaged in litigation.

9. Provide non-confidential information demonstrating that your firm is financially stable, such as balance sheets or income (profit/loss) statements.

10. Identify any issues or concerns in social media about your firm.

5.3 Scope of Work (Max 35 points)

1. Provide an implementation plan and estimated timeline from a hypothetical contract execution date.

2. Describe the skills and experience of the individuals residing in the continental USA location (only) who would be assigned to the project.

3. Describe the training provided by vendor to CareOregon staff members.

4. Please give the typical timeframe from start to finish when providing a bill review and your response time back to the department.

DRG Questions

1. Specify the thresholds your algorithm uses to identify claims requiring audit. Provide a flow chart of the process from claim identification to initial audit findings.

2. Will Proposer request access to CareOregon claim systems?

3. How are claims submitted to Proposer for review if claim system access is not provided?

4. Does Proposer have access to medical records from facilities in CareOregon’s network of providers?

5. How are the audit findings submitted to the provider?

6. How are the audit findings submitted to CareOregon?

7. How does the provider submit a claim reconsideration/appeal? Provide a flow chart of the process with timeline.

8. What percentage of your current Medicaid product DRG claim denials are appealed by providers?

9. Of those that are appealed, what percentage are overturned to the original DRG or a different DRG all together?

10. Describe the invoice reconciliation process.

mailto:vendorservices@careoregon.org

IBR Questions

1. Is CareOregon required to provide claim system access to Proposer?

2. How are claims submitted to Proposer for review if claim system access is not provided?

3. Are there automated processes where CareOregon doesn’t need to manually refer a claim?

4. What is your criteria for identifying claims to be reviewed?

5. How are the review findings submitted to the provider?

6. How are the review findings submitted to CareOregon?

7. Provide a flow chart of the process from claim identification to initial review findings.

8. How does the provider submit a claim reconsideration/appeal? Provide a flow chart of the process with timeline.

9. Describe the invoice reconciliation process.

10. Does the Proposer have a HIPPA compliant secure portal for sending and receiving data?

11. CareOregon requires IBR reviews to be returned within five days in order to meet its payment deadlines. How does CareOregon request escalation when a review has not been returned within the mandatory timeframe of five (5) days?

12. Does CareOregon have the ability to request an escalation in the rare times CareOregon submits an initial review request that needs to be escalated? What does this process look like?

13. If there is a portal, how are inquiries to be addressed when there is a problem with the portal, for example if something is not working as intended?

14. Is the system set up for customization or is it one size fits all?

15. Demonstrate that your firm has sufficient knowledge of Oregon legislation as well as Oregon Health

Authority and other regulators’ requirements, to manage the administrative appeals process.

5.4 Equity, Diversity and Inclusion Efforts (Max 10 points)

1. Describe your firm’s equity, diversity and inclusion values, policies, efforts, and successes. Include specific details of efforts and how they have shaped the composition and spirit of your firm.

2. Supplier diversity is the intentional inclusion of historically underutilized businesses in a firm’s supply base to achieve innovation, cost reduction, and building economic growth in our communities. If you plan to use subcontractors or other third-party services for the services proposed to CareOregon, describe your supplier diversity program.

3. Outline the specific elements of your proposed services that will support and advance CareOregon’s equity, diversity, and inclusion mission.

5.5 Fees (Max 25 points)

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

Proposer shall return recovered claim overpayments to CareOregon via ACH direct deposit within fifteen (15) days of receipt of such claim overpayments from providers.

Proposer’s firm to submit monthly invoices to CareOregon except IBR invoices, which shall be submitted daily.

Fees should be sufficiently descriptive to facilitate acceptance of a Proposal. For each term of the Contract, the fees shall be fixed. After the first term, Contractor may request an increase in the fees in an amount not to exceed the increase in the Consumer Price Index (CPI Index) for the West Region up to a maximum of three percent (3%). Any such increase shall only be approved through an Amendment to the Contract. There are no other expenses to CareOregon anticipated under this Contract.

5.6 References

Provide at least three (3) references from clients your firm has served similar to CareOregon in the past three (3) years, including one client that has newly engaged the firm in the past thirty-six (36) months and one (1) long-term client. Provide the name, address, email, and phone number of the references. Please note the required three references may not be from CareOregon staff, but additional references may be supplied. Points awarded for this criteria are based on both the providing of references as well as information gleaned from the provided contacts. Evaluation Committee members may contact references at their sole discretion.

5.7 Sample Contract Template

Submission of a Proposal in response to this RFP indicates Proposer’s willingness to enter into a contract containing substantially the same terms (including insurance requirements) of the sample contract identified in Section 3.2.6 above. No action or response to the sample contract is required under this RFP. However, any objections to the sample contract terms should be raised in accordance with Paragraphs 2.2 of this RFP pertaining to requests for clarification of the RFP/specifications. This RFP and all supplemental information in response to this RFP will be a binding part of the final contract.

5.8 Completed Proposal Certification (see the below form)

PROPOSAL CERTIFICATION

RFP #2024-13 IBR & DRG Billing Services

Submitted by:

(Must be Entity’s full legal name, and the State of Formation)

Each Proposer must read, complete and submit a copy of this Proposal Certification with their Proposal. Failure to do so may result in rejection of the Proposal. By signature on this Proposal Certification, the undersigned certifies that they are authorized to act on behalf of the Proposer and that under penalty of perjury, the undersigned will comply with the following:

SECTION I. NONDISCRIMINATION: That the Proposer has not and will not discriminate in its employment practices with regard to race, color, creed, age, religious affiliation, sex, marital status, disability, sexual orientation, gender identity, national origin, veteran status, or any other protected class. Nor has Proposer or will Proposer discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business that is certified under ORS 200.055.

SECTION II. CONFLICT OF INTEREST: The undersigned hereby certifies that no officer, agent or employee of CareOregon is personally interested, directly or indirectly, in any resulting contract from this RFP, or the compensation to be paid under such contract, and that no representation, statements (oral or in writing), of the CareOregon, its officers, agents, or employees had induced Proposer to submit this Proposal. In addition, the undersigned hereby certifies that this proposal is made without connection with any person, firm, or corporation submitting a proposal for the same material, and is in all respects fair and without collusion or fraud.

SECTION III. COMPLIANCE WITH SOLICITATION: The undersigned further agrees and certifies that they:

1. Have read, understand and agree to be bound by and comply with all requirements, instructions, specifications, terms and conditions of the RFP (including any attachments);

2. Are an authorized representative of the Proposer, that the information provided is true and accurate, and that providing incorrect or incomplete information may be cause for rejection of the Proposal or contract termination; and

3. Will furnish the designated item(s) and/or service(s) in accordance with the RFP and Proposal.

Name:_______________________________________ Date:______________________________________

Signature:____________________________________ Title:______________________________________

Email:_______________________________________ Phone:_____________________________________

Oregon Business Registry Number:________________ OR CCB # (if applicable):________________________

Proposer Primary Point of Contact (Coordination during process and for award information):

Name:_______________________________________

Email:_______________________________________ Phone:_____________________________________

Business Designation (check one):

Corporation Partnership Sole Proprietorship Non-Profit Limited Liability Company

Minority (MBE), Women (WBE), Service-Disabled Veteran (SDV), and Emerging Small Business (ESB):

Certified by the State of Oregon (provide certification number as applicable):

MBE WBE SDV ESB

Self-identified (check as applicable):

MBE WBE SDV ESB