RFP 36C10X25R0021_0003.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. UEI: EFT:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION (REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C10X25R0021

07-29-2025

LaShawn Knight | lashawn.knight@va.gov

09-11-2025

12:00 EDT

36C10X Strategic Acquisition Center - Frederick Department of Veterans Affairs

5202 Presidents Court, Suite 103 Frederick MD 21703

X

541219

$25 Million

N/A

36C10X

Strategic Acquisition Center - Frederick Department of Veterans Affairs

TBD

VAFSC

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

(see Section B.3 invoicing/payment) Austin TX 78714-8917

1-(877)-489-6135

See CONTINUATION Page

VHA OFFICE OF FINANCE (OF) – RECOVERY AUDIT SERVICES

SEE B.2 PRICE/COST SCHEDULE AND B.3 PERFORMANCE WORK STATEMENT

ALL PROPOSAL INTENTIONS, QUESTIONS AND PROPOSALS SHALL BE

SUBMITTED IN ACCORDANCE WITH SECTION E.

Jacky.Jean-Jacques@va.gov PROPOSAL INTENTIONS: SEND VIA EMAIL: lashawn.knight@va.gov and

QUESTIONS: DUE 8/8/2025 @15:00 ET VIA EMAIL (SAME AS ABOVE)

PROPOSALS: SEE BLOCK 8 ABOVE

See CONTINUATION Page

Jacky Jean-Jacques mailto:lashawn.knight@va.gov mailto:Jacky.Jean-Jacques@va.gov mailto:lashawn.knight@va.gov

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 PRICE/COST SCHEDULE

B.3 PERFORMANCE WORK STATEMENT(PWS)

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (NOV 2023)

C.2 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.3 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

C.4 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.5 VAAR 852.203-70 COMMERCIAL ADVERTISING (MAY 2018)

C.6 VAAR 852.211-76 LIQUIDATED DAMAGES – REIMBURSEMENT FOR DATA BREACH

COSTS (FEB 2023) ALTERNATE I (FEB 2023)

C.7 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-OWNED

SMALL BUSINESS EVALUATION FACTORS (JAN 2023) (DEVIATION)

C.8 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (OCT 2019)

C.9 VAAR 852.222-71 COMPLIANCE WITH EXECUTIVE ORDER 13899 (DEVIATION)(APR

2025)

C.10 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2018)

C.11 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES (JAN 2025) (DEVIATION FEB 2025)

SAC 18-01 – SAC Service Level Agreement Fee and Submission of Quarterly Sales Reports; (January, 2019)

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 SUBCONTRACTING PLAN

D.2 BUSINESS ASSOCIATE AGREEMENT BETWEEN THE DEPARTMENT OF VETERAN

AFFAIRS VETERANS HEALTH ADMINISTRATION……………………………………………….. 58

D.3 APPENDIX B - CONTRACTOR RULES OF BEHAVIOR

D.4 APPENDIX C – VA INFORMATION AND INFORMATION SYSTEM SECURITY AND

PRIVACYLANGUAGE

D.5 PAST PERFORMANCE QUESTIONAIRE (PPQ)

D.6 OFFEROR ATTESTATION OF RESPONSIBILITY

D.7 QUALITY ASSURANCE SURVEILANCE PLAN

D.8 RFP QUESTION SHEET

SECTION E - SOLICITATION PROVISIONS

E.1 ADDENDUM TO FAR 52.212-1 INSTRUCTIONS TO OFFERORS-COMMERICIAL

PRODUCTS AND COMMERCIAL SERVICES

E.2 EVALUATION APPROACH

E.3 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND

VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.4 52.204-29 FEDERAL ACQUISITION SUPPLY CHAIN SECURITY ACT ORDERS—

REPRESENTATION AND DISCLOSURES (DEC 2023)

E.5 52.207-6 SOLICITATION OF OFFERORS FROM SMALL BUSINESS CONCERNS AND

SMALL BUSINESS TEAMING ARRANGEMENTS OR JOINT VENTURES (MULTIPLE-AWARD

CONTRACTS) (AUG 2024)

E.6 52.216-1 TYPE OF CONTRACT (APR 1984)

E.7 52.233-2 SERVICE OF PROTEST (SEP 2006)

E.8 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)76

E.9 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JAN 2025) (DEVIATION

FEB 2025)

E.10 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

PRODUCTS AND COMMERCIAL SERVICES (MAY 2024) (DEVIATION FEB 2025)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR: TBD

b. GOVERNMENT: Jacky Jean-Jacques, Jacky.Jean-Jacques@va.gov Contracting Officer 36C10X Strategic Acquisition Center - Frederick Department of Veterans Affairs

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer—System For Award Management, or

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly []

b. Semi-Annually []

c. Other []

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

5. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO DATE

6 . INVOICING INSTRUCTIONS: Additional instructions will be provided at the time of the award.

mailto:Jacky.Jean-Jacques@va.gov

B.2 PRICE/COST SCHEDULE1

ITEM INFORMATION

BASE PERIOD: Anticipated Period of Performance (Month, Day, Year – Month, Day, Year)

ITEM

NUMBER DESCRIPTION OF SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE%

0001 Recovery Audits Services NSP 0001AA <10,000,000 claims annually 1 LT 0001AB 10,000,001 to 25,000,000 claims annually 1 LT 0001AC >25,000,000 claims annually 1 LT

OPTION PERIOD ONE: Anticipated Period of Performance (Month, Day, Year – Month, Day, Year)

ITEM

NUMBER DESCRIPTION OF SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE%

1001 Recovery Audits Services NSP 1001AA <10,000,000 claims annually 1 LT 1001AB 10,000,001 to 25,000,000 claims annually 1 LT 1001AC >25,000,000 claims annually 1 LT

OPTION PERIOD TWO: Anticipated Period of Performance (Month, Day, Year –

ITEM

NUMBER DESCRIPTION OF SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE%

2001 Recovery Audits Services NSP 2001AA <10,000,000 claims annually 1 LT 2001AB 10,000,001 to 25,000,000 claims annually 1 LT 2001AC >25,000,000 claims annually 1 LT

OPTION PERIOD THREE: Anticipated Period of Performance (Month, Day, Year –

ITEM

NUMBER DESCRIPTION OF SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE%

3001 Recovery Audits Services NSP 3001AA <10,000,000 claims annually 1 LT 3001AB 10,000,001 to 25,000,000 claims annually 1 LT 3001AC >25,000,000 claims annually 1 LT

1 1 UNIT PRICE% represents quoted percentage of recovered overpayment dollars due the contractor as payment for audit and identification of overpayments. Actual payment amount depends upon actual amounts recovered by the VA Debt Management Center. The Government’s obligation to make payments to the contractor under this contract 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 tasks associated with the RA and will be compensated only on a percentage of the actual funds recovered. Due to numerous variables, the Government does not guarantee any specific amount of overpayment recovery and does not guarantee a specific sum of dollars to the contractor

OPTION PERIOD FOUR: Anticipated Period of Performance (Month, Day, Year –

ITEM

NUMBER DESCRIPTION OF SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE%

4001 Recovery Audits Services NSP 4001AA <10,000,000 claims annually 1 LT 4001AB 10,000,001 to 25,000,000 claims annually 1 LT 4001AC >25,000,000 claims annually 1 LT

B.3 PERFORMANCE WORK STATEMENT

1.0 INTRODUCTION & BACKGROUND

The Department of Veterans Affairs (VA), VHA Office of Finance (OF) has a requirement for up to 3 highly skilled contractor(s) to conduct Recovery Audit (RA) activities of healthcare claim payments made for a variety of VHA Community Care programs, as described below. Automated reviews occur at the system level while complex reviews require a qualified individual to review the medical record. Each program has specific payment methodologies as defined by VA regulations. In general, the audit will review various types of paid healthcare claim data with specific dates and criteria included in the description of each auditing scenario.

Requests for access to the VA Network, PIV cards and access to secondary VA systems for auditing claims, shall be submitted to the VA Contracting Officer Representative (COR) for authorization. The contractor shall ensure compliance with all PWS and VA system requirements, including Information Technology (IT) systems security policies, procedures and practices. This includes participating in the necessary security testing to obtain an Authority to Operate (ATO). Section V, Privacy and Information Security, describes these requirements in further detail.

Throughout this document, 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.

1.1 OBJECTIVES

Key objectives of the RA Contract (RAC) are to receive access to paid Community Care healthcare claims data; audit that data for potential overpayments to providers based on laws, regulations, policies and industry standard practices (e.g., medical coding) using RAC’s technology solutions and validated by qualified individuals employed by the contractor; verify overpayments through a defined dispute process by qualified individuals employed by contractor; and report results to VA. The contractor shall also identify root causes or trends for potential reduction of improper payments. Another key objective of the RAC is to manage and perform all provider communications and interactions through the entire lifecycle of each claim’s audit and recovery process, which includes announcements of RAs for new audit topics (e.g., claim types, programs) on a provider portal established and operated by the RAC contractor;

receiving documentation from providers (e.g., via RAC’s provider portal); notifying providers of audit findings; communicating findings according to the defined dispute process; and establishing and operating a Customer Service Center (CSC) for addressing questions from providers.

The auditing of various VA Community Care Programs has been organized into mandatory and optional tasks with any exclusions noted in the task descriptions. Each of the auditing tasks has criteria for the specific data set for that scenario. The contractor shall review 100% of the supplied paid claims data in accordance with their approved audit plan, unless otherwise directed by VA, and report results to OF, who will validate findings and perform collection processes once the RAC’s contractor-managed dispute process is exhausted. The contractor shall be paid a percentage of the recovered funds. VA may elect to name another VA organization, another government entity, or a separate contractor to perform the collections on its behalf.

VA will use filters and algorithms to restrict the data provided the contractor to claims data the contractor is required to audit. However, some claim data not required to be audited under this contract may still find its way past those filters and algorithms and become comingled with the required data. The contractor shall not take any action on that data and the contractor shall treat all data in their possession in accordance with Appendix C.

1.2 TYPE OF CONTRACT CONTEMPLATED

The VA intends to award one (1) but not more than three (3) FFP (fixed percentage of recovery) contract(s) to provide healthcare claims recovery auditing services. Contractor compensation under this contract will be contingent upon the accurate identification of valid overpayments and the successful recovery of those overpayments by the Government. The contractor shall assume all costs associated with the execution of RAC tasks and will only be reimbursed based on a fixed percentage of actual funds recovered.

If more than one contract is awarded, the highest-rated contractor will be given an exclusive 90-day period to review and select claims from the dataset provided by VA. Then the remaining data set will drop to the next highest-rated contractor(s) for a similar period to repeat and close the cycle..

The Government’s obligation to make payments to the contractor under this contract is contingent upon both the contractor’s correct identification of valid overpayments and the Government’s subsequent recovery of those overpayments, or portions thereof.

1.3 PERIOD OF PERFORMANCE

The Period of Performance (POP) for the base period shall be from the date of award for a period of one

(1) year base period, followed by four (4) year option periods to be awarded at the discretion of the Government.

1.4 PLACE OF PERFOMANCE

The Government will not provide office spaces, telecommunication services or other technologies needed to accomplish the tasks associated with this PWS. The VA anticipates that tasks under this PWS shall be performed at the contractor’s facilities as specified in their proposal.

1.5 GOVERNMENT-FURNISHED INFORMATION, EQUIPMENT, AND FACILITIES

Government-Furnished Information (GFI), Government-Furnished Equipment (GFE), and Government- Furnished Facilities (GFF), if applicable, will be specified as necessary by each individual task order. VA implemented and enforces two-factor authentication (2FA) for all remote access to its networks. Network access through the Citrix Access Gateway (CAG) will require the use of a personal identity verification (PIV) card to complete the login process. The only method for users to access the VA network is with a PIV card.

The Contractor shall request other Government documentation deemed pertinent to the work accomplishment directly from the Government officials with whom the Contractor has contact. The Contractor shall consider the COR as the final source for needed Government documentation when the Contractor fails to secure the documents by other means. The Contractor is expected to use common knowledge and resourcefulness and when in doubt, shall ask the COR

1.6 FINANCIAL CAPABILITY

At the time of award, the contractor must be able to support their contract personnel and resources. The contractor shall have the financial capacity (e.g., working capital, and other resources) to achieve contract requirements.

1.7 RECALL CASES

The VA may determine that it is in the best interest of the OF RA Program to cease work in certain areas.

Should VA initiate a recall, the contractor shall immediately stop all activities included in the recall.

Recalls may occur for several reasons including areas of political sensitivity or for performance related issues. Recalls may be indefinite and may require a corrective action plan to resume activity. The scope of recalls includes but is not limited to specific codes, specific claim types, specific providers, specific jurisdictions, or regions. The recall instructions issued by VA will determine whether contingency fee payments will be made for collections occurring as a result of audits performed prior to the recall.

1.8 TRAVEL

There will be no reimbursement for travel under this contract.

1.9 TASK AREAS

1.9.1 Tasks Associated with Contract Requirements:

In addition to auditing the broad spectrum of program-specific data, the contractor also has non- auditing contract requirements to meet. These tasks are further defined in Section III, Specific Tasks.

Task Task Name Description Task 1 Audit Management Plan (AMP) Overall plan for managing all aspects of this contract Task 2 Reporting Provide findings to OF or designee

Task 3

Public Website

Establish and maintain a public website for posting of audit plans and receipt of public comments

Task 4 Secure Portal Establish and maintain a secure portal for transfer of sensitive data

Task 5

Audit Documentation

Obtain access to VA systems and secure documentation required for the audit

Task 6 Customer Service Center (CSC) Establish and maintain a CSC for responding to questions from providers and the public

Task 7

Auditing VA Paid Claim Data

Audit paid claims with qualified individuals supplemented by ready- made technology platforms under authorities in which claims were paid, including request of medical records to verify findings and first level disputes of said findings.

1.9.2 Task 7 Associated with Auditing VA Paid Claim Data:

The Task 7 auditing scenarios listed in the table below (Tasks 7a – 7g) show the VA Programs that could potentially be audited through mutual agreement between the parties, and the authorities under which the claims were paid. The values represent an estimated percentage of paid claim volumes per program category and are not indicative of contract value or anticipated audit recovery amounts.

The fiscal year ranges identified below refer to actual claims payment dates. Volume and total value may vary.

Task VA Program Authority Total estimated value of all claims in each category (FY24 sample)

Task 7a

VACC Preauthorized Claims

38 U.S.C. 1703 Inpatient: 9K-6M ($139M-11B);

Outpatient: 77K-5.5M ($110M- 6B); Professional: 760K-31M ($1.3M-10B)Skilled Nursing

Facility: 800K ($1.4M)

Task 7b

VACC Emergency Care for Non-Service-Connected Veterans

38 U.S.C. 1725

Inpatient: 3000 ($41M);

Outpatient: 37,000 ($32M);

Professional: 114,000 ($21M) Task 7c VACC Emergency Care for

Service-Connected Veterans

38 U.S.C. § 1728 Inpatient: 5700 ($110M);

Outpatient: 46,000 ($59M);

Professional: 112,000 ($57M) Task 7d VACC Emergency Care for

Acute Suicidal Crisis 38 U.S.C. 1720J Inpatient: 560 ($7M);

Outpatient: 800 ($700K);

Professional: 10,000 ($4M

Task 7e

Civilian Health and Medical Program of the Department of Veterans Affairs

(CHAMPVA)

(FY24 – FY29)

38 U.S.C. 1781 $250k-$400k Inpatient: 180K ($379M); Outpatient: 3M ($492M); Professional: 5.5M ($570M); Skilled Nursing: 10K ($26M)

Task 7f

Spina Bifida 38 CFR 17.900-17.905

Task 7g National Dialysis Contract

(NDC)

38 U.S.C. § 8153 215,000 claims ($800M)

1.10 Third Parties

Some tasks involve auditing healthcare claims processed by third party organizations that VA has contracted to perform administrative functions. The contractor will be required to work with these third parties as instructed by VA. For the purposes of this contract, “VA” is inclusive of third parties performing processes on VA’s behalf.

2.0 GENERAL REQUIREMENTS

This PWS includes all tasks and responsibilities associated with auditing paid claim data as well as other contractual requirements as defined in Section III, Specific Tasks.

Requests for access to the VA Network, PIV cards and access to secondary VA systems for auditing claims, shall be submitted to the VA Contracting Officer Representative (COR) for authorization.

The contractor shall ensure compliance with all PWS and VA system requirements, including Information Technology (IT) systems security policies, procedures and practices. This includes participating in the necessary security testing to obtain an Authority to Operate (ATO). Section V, Privacy and Information Security, describes these requirements in further detail.

The PWS is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. § 794d) as amended by the Workforce Investment Act of 1998 (P.L. 105-220). All documentation created by the contractor and submitted to VA is subject to Section 508 Compliance for Communications as applicable. Independently and not as an agent of the Government, the contractor shall furnish all the necessary services, qualified personnel, material, equipment, and facilities not otherwise provided by the Government, as needed to perform all requirements of this PWS. VA will provide minimum administrative support, which may include standard system changes when appropriate, policy interpretations as necessary and other support deemed necessary by VA to allow the contractor to perform the tasks accurately and efficiently.

The VA will support changes it determines are necessary but cannot guarantee timeframes or constraints.

In changing systems to support greater efficiencies for VA, the end product could result in additional administrative tasks being placed on the contractor that were not previously presented. These administrative tasks will be within the scope of this contract and will be applicable to the identification and recovery of improper payments.

Unless otherwise stated, any mention of days in this PWS shall be understood to mean business days. If any due dates occur on a Saturday, Sunday, or federal holiday, the due date will be recognized as the next business day.

The contractor shall use standard terminology found in VA regulations and policies to the greatest extent possible in all reports and communications.

2.1 Post-Award Kick-Off Meeting

The contractor’s Program Director and the VA CO shall collaboratively establish a date for the Kick-Off Meeting within a few weeks. Contractor representatives should include essential personnel. VA representatives will consist of the VA CO, the VA COR, and other relevant VA staff.

The purpose of the Kick-Off Meeting will include, but not be limited to:

• Discussion of the overarching AMP and provision of VA specific feedback

• The process for submitting security documentation and contractor responsibilities

• Discussion of training requirements/needs

• Discussion of the General Requirements Section of the contract

• Discussion of the Tasks in detail

• Discuss the Financial Management Section of the contract

• Any other contractual questions

Within two (2) weeks of the Kick-Off Meeting, the contractor shall submit an updated AMP outlining the resources and timeframe for completing the work outlined. The initial AMP will be for the base year of the contract. The AMP is described in more detail in Section III, Specific Tasks.

2.2 Position Sensitivity, Background Investigations (BIs) & Security Categorization:

The contractor will be responsible for all costs associated with obtaining their BI and having security documentation processed. The VA COR will provide the contractor with the appropriate forms needed for obtaining a BI.

The Risk Designation for non-IT personnel has been designated as a Tier 1 (Low).

There could be two types of personnel requiring the Tier 1 BI:

• Tier 1 personnel requiring VA Network access and will require a Personal Identity Verification (PIV) badge.

• Tier 1 personnel that will view and handle Protected Health Information (PHI), but do not require a PIV badge.

• The Risk Designation for IT personnel that will be obtaining and maintaining the ATO has been designated as Tier 2 (Moderate) and they will require a Tier 2 BI.

This contract has a Security Categorization of Moderate.

2.3 Access to the VA Network and Systems and PIV requests:

All personnel working on this contract will be required to have an adjudicated Special Agreement Check and an appropriate level of adjudicated BI for their contract duties before they are allowed to work on this contract.

Some contractor personnel will require access to the VA Network which as noted above requires a PIV.

Some of these contractor personnel shall require access to the VA systems noted in the table in Task 5 – Audit Documentation.

Requests for access to the VA Network and all VA systems as well as requests for PIV cards must be submitted to the VA COR. The VA COR will provide instructions on how to proceed with each type of request.

2.4 Conference Calls:

On a weekly basis, unless otherwise instructed by VA, the contractor’s key project staff will participate in a conference call with the VA COR to discuss the progress of work, assess any problems and discuss plans for immediate next steps of the project. The contractor will be responsible for setting up the conference calls, preparing an agenda, documenting the minutes of the meeting, and preparing any other supporting materials as needed.

At VA’s discretion, the frequency of the conference calls may be changed. There may also be additional conference calls to discuss additional items and/or issues.

2.5 Electronic Case File

The contractor shall maintain an electronic case file for each claim that is audited. At a minimum, the case file shall include:

• Digital copies of documents reviewed

• Provider information (name, address and tax identification number)

• Amount of overpayment

• Program type by Task

• Payment methodology used for calculation

• Digital reports of contact with VA or providers to include dates of any calls made and notes indicating what transpired during the call

• Any additional documentation received

• Record of provider requests (medical record requests, level 1 and 2 disputes)

When requested, the entire case file shall be sent to VA within three (3) business days of the request.

The case file should be provided electronically unless an alternate transmission method is approved by the VA COR. Any costs (e.g., materials, shipping) associated with the file transfer to VA shall be incurred by the contractor.

2.5.1 Case File Disposition

In accordance with Appendix C, at VA’s request no later than fifteen (60) business days after contract termination, the contractor shall return all case files. The contractor shall not destroy any supporting documentation relating to the overpayment identification or recovery process unless otherwise directed.

2.6 Validation

The contractor’s performance shall be subject to validation by VA, or a VA designated third party. Under this requirement, the contractor shall comply with all requests for audit samples and supporting documentation.

The contractor shall forward any requested information to the appropriate VA validation point of contact.

The contractor shall provide the case files through electronic submission, hard copy, or any other method VA prescribes, within three (3) business days of notification by VA.

The contractor’s accuracy shall be validated quarterly based on the federal fiscal year (October 1 through September 30). The contractor shall maintain an accuracy rate of at least 95%.

Accuracy is based on VA validation of correctness of contractor’s overpayment findings, under the assumption that the contractor could have reasonably come to the same decision as VA with the information provided by VA. Examples of inaccuracy include false positives and overturned disputes.

For the purposes of applying incentives and penalties, accuracy ratings will be rounded to the nearest whole percentage. Percentages up to .49 will be rounded down (for example, 94.49 would equate to 94%); percentages of .5 and higher will be rounded up (for example, 94.51 would equate to 95%).

Once audits have been completed, the results will be sent to the contractor. The contractor will have the opportunity to review results and present rebuttal information if they wish to dispute the results. The contractor must provide any documentation or explanation in writing to the VA COR within five (5) business days of receiving the audit results for a dispute to be considered. VA will make the final determination of accuracy ratings within five (5) business days of receiving the contractor’s rebuttal information.

Accuracy rates will be recalculated quarterly.

2.7 Other Auditors:

Should other VA authorized auditors choose to conduct an audit of the contractor, the contractor shall provide workspace and produce all needed reports and case files within three (3) business days of the request.

2.8 Recovery Audit Contractor Staff

NON-PERSONAL SERVICE STATEMENT: Contractor employees performing services under this contract shall be controlled, directed, and supervised at all times by management personnel of the Contractor. Contractor management shall ensure that employees properly comply with the performance work standards outlined in the PWS.

Contractor employees shall perform their duties independent of, and without the supervision of, any Government official. The tasks, duties, and responsibilities set forth in the contract may not be interpreted or implemented in any manner that results in any contractor employee creating or modifying Federal policy, obligating the appropriated funds of the United States Government, overseeing the work of Federal employees, providing direct personal services to any Federal employee, or otherwise violating the prohibitions set forth in Parts 7 and 37 of the FAR. The Government will control access to the facility and will perform the inspection and acceptance of the completed work.

The Contractor shall be responsible for managing and overseeing the activities of all Contractor personnel efforts used in performance of this engagement. These are defined as individuals crucial to the successful performance of the contract and the variety of programs being supported by the contract.

The personnel listed in section 2.8.1 are not considered a complete list of key personnel but are required or recommended and have proven successful in similar requests. It is highly recommended that the Contractor has a diverse staff that would have the specific knowledge, skills, and abilities to successfully complete the required deliverables.

The CO may notify the Contractor and request immediate removal of any personnel assigned to the contract by the Contractor that are deemed to have a conflict of interest with the Government. The reason for removal will be documented and replacement personnel shall be identified within three (3) business days of the notification. Any personnel the Contractor offers as a substitute shall have the ability and qualifications equal to or better than the personnel that are being replaced.

Employment and staffing difficulties shall not be justification for failure to meet established schedules.

The Contractor shall provide resources that are fully trained and have the level of experience to accomplish the requirements of this PWS. In addition, the Contractor personnel shall be acceptable to the Government in terms of personal and professional conduct and in technical knowledge. Should any Contractor personnel be determined to be unacceptable in terms of technical competency or unacceptable personal conduct during duty hours, the Contractor shall immediately remove and replace the unacceptable personnel at no additional costs to the Government.

The Contractor is aware that the level of work required to complete the tasks required may vary considerably and shall staff the contract appropriately. Contractor staff shall be fully qualified and possess the level of experience necessary to accomplish the requirements outlined in the PWS.

The primary point of contact for the contractor for day-to-day operational tasks in this PWS or any aspect thereof shall be the VA COR or his/her delegate. Contractors shall not contact anyone in VA regarding work being performed under this contract before coordination with the VA COR. The VA CO shall be the primary point of contact for all contract issues/questions.

The contractor’s Project Manager shall be available to the VA COR during normal business hours. If the Project Manager is not going to be in the office, the VA COR will be notified at least one (1) business day in advance. In such cases, the Project Manager will designate a back-up person to serve as the central point of contact with VA. Anyone serving as a back-up for the Project Manager will be required to have the ability to answer questions and/or provide data to the same degree that the Project Manager would be able to provide.

2.8.1 Key Personnel

General Information:

Certain experienced professional and/or technical personnel are essential for accomplishing the work to be performed. These individuals are defined as "key personnel" and are those persons whose resumes will be submitted and marked by the vendor as "key personnel." Key personnel may be dedicated less than full time. Substitutions shall only be accepted if in compliance with “Substitution of Key Personnel" provision identified below.

Substitution of Key Personnel and Other Personnel Considerations:

During the first ninety (90) calendar days of performance, the contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death, termination of employment, or VA’s request. All contractor requests for approval of substitutions hereunder shall be submitted in writing to the VA COR and the VA CO at least thirty (30) calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the VA CO necessary to approve or disapprove the proposed substitution. The VA CO will evaluate such requests and promptly notify the contractor of approval or disapproval in writing.

Personnel assigned by the contractor to the performance of work on this order shall be acceptable to VA in terms of personal and professional conduct and technical knowledge. Should the assignment to this order of any person by the contractor be deemed to conflict with the interests of VA, or in the event performance is deemed to be unsatisfactory at any time during the life of the contract/task order, the VA CO will notify the contractor and request the person be immediately removed from the assignment. The reason for removal shall be documented and a request to receive personnel replacement within three (3) business days of the notification shall be made. Replacement personnel qualifications shall be equal to or greater than those of the personnel being replaced. Employment and staffing difficulties shall not be justification for failure to meet established schedules.

Staff Qualifications:

The contractor shall thoroughly train its staff. The contractor shall maintain a sufficient number of staff dedicated to operations, administration, customer service, and support of services under this contract/task order to include, at a minimum, key personnel listed below. The contractor may propose additional staff beyond the minimum listed below, with specific expertise to fully meet the requirements outlined in this PWS.

• Program Director: A Program Director will be assigned who has documented skills and experience in directing the accomplishment of work equal or comparable to the requirements under this contract/task order.

o Experience: The PD shall have at a minimum of 5 years of professional work experience in the healthcare industry supporting either Federal Government agencies or Commercial

Healthcare market as a project manager, project leader, operations manager, technical project manager, or product manager

The Risk Designation for this position (non-IT personnel) has been designated as a Tier 1 (Low) and they will require a Tier 1 BI.

• Certified coding specialists and clinical staff (nurses or physicians) to perform recovery audits internally and perform first level disputes.

• Information Technology Security Analyst (ITSA): The ITSA will be knowledgeable of the regulations and requirements related to obtaining and retaining an ATO and able to provide continuous Assessment and Authorization (A&A) support. The ITSA will be required to obtain VA network access in order to input information into the Governance Risk and Compliance (GRC) tool initially, then as maintenance.

The Risk Designation for this position (IT personnel that will be obtaining and maintaining the ATO) has been designated as Tier 2 (Moderate) and they will require a Tier 2 BI.

2.9 Public Communications

The contractor must receive prior approval from VA for all contractors press releases or information sharing with any outside entities related to contract efforts. The contractor shall not respond to requests from industry publications, newspapers, and journals for information involving the VA RA Program.

These requests shall be forwarded to the VA COR.

VA internal working documents shall not be released to the public without approval from the VA COR. VA will handle all congressional inquiries with support from the contractor if needed.

2.10 Provider Outreach

The contractor will be required to obtain access to VA systems and locate needed documentation to audit claims. In the event the medical documentation in the VA systems is not sufficient to make a determination, the contractor is allowed to contact providers to request additional medical documentation when such documentation is necessary to complete auditing, unless otherwise instructed by VA.

The contractor will only request documentation needed to substantiate a payment was made in a correct amount for authorized services. The contractor shall make every effort to minimize contacts with providers. When requesting medical documentation, the contractor shall also ask for any evidence of an agreed-upon rate outside of the applicable CMS rate or VA fee schedule.

The contractor shall draft a standardized letter requesting documentation; this letter must receive approval by the VA COR prior to being issued. If the contractor does not receive any response from the provider after a letter has been sent, the contractor may call the provider.

Should the contractor obtain information from a provider that impacts collections (e.g., change of address, provider death, dissolution of practice), such information will be reported to the VA in the Weekly Report.

3.0 SPECIFIC TASKS

3.1. - TASK 1 – AUDITING MANAGEMENT PLAN (AMP):

The AMP is a dynamic document that the contractor will create to document how they will manage the audits of this contract.

Within thirty (30) calendar days of following the Kick-Off Meeting, the awardee will be required to create an overarching AMP and integrate understandings and direction received from the Kick-Off Meeting.

This overarching plan will describe the sequence of audits and the contractor’s approach to ensuring all required audits are completed during the contract’s period of performance.

The AMP will be updated and maintained throughout the contract/task order POP. The contractor will validate or correct assumptions they had prior to the Kick-Off Meeting and incorporate the current processes, internal controls, staffing and resources used to conduct the audit activities. The AMP will also need to be updated to reflect obstacles presented, solutions proposed and selected and the progress of how well the implemented solution works.

Additionally, under this task, the contractor shall create a specific audit plan for each of the audit universes identified as an audit task (Tasks 7-16). These audit plans shall address the following subject areas:

3.1.1. Auditing Plan:

The contractor shall develop an audit plan that details how audits will be conducted. The audit plan will include, at minimum:

• A defined objective and scope

• The type(s) of claim(s) to be audited

• The payment methodology used to audit the claims

• How the contractor will review and submit sample test claims

• Types of documents reviewed

Due to the unique nature of the universe of claims associated with each task, an audit plan for each task will be required.

The contractor’s audit plans will ensure that all overpayments for a provider for a fiscal year are reported to VA in a single instance. For example, if a single tax identification number (TIN) has one hundred (100) claims associated with it in a single fiscal year, the contractor will audit all one hundred (100) claims prior to reporting any overpayments to VA for collection. This will allow VA to streamline communications with providers.

3.1.2 Audit Plan Approval Process:

The following approval process will ensure a contractor’s claim review does not conflict with VA policies or reimbursement methodologies used to assess payment accuracy. It will also deconflict the contractor’s efforts against other VA claims audits, investigations, litigation or similar activities.

As the audit plan for each task is submitted, the VA OF Program Lead or COR will review and approve or suggest revisions. Once approved, the contractor will post the audit plan to a public facing website for comments for no less than thirty (30) calendar days.

The contractor will be provided with a test sampling for the universe to be audited during the thirty (30) calendar day comment period to complete and return to the VA. The VA will assess the accuracy of the contractor’s findings. After reviewing the test samples a conference call will be established to discuss findings and any remediation needed to the contractor’s process. During this conference call, the contractor will present comments received from the public. VA will provide guidance on how to address those comments.

Within five (5) business days of the conference call or the date VA provides the final guidance needed, the contractor will submit a final audit plan to VA. The audit plan will include VA-directed revisions. A separate document will contain the public comments and how they have been addressed.

VA will have five (5) business days to approve or deny the contractor’s final audit plan. Upon VA approval, the contractor will post the final audit plan and the response to public comments to the public website and the contractor will begin the audit.

If the audit plan is rejected by VA, the contractor will have five (5) business days to make corrections. VA will approve or reject this revised plan within five (5) business days. This process shall be repeated until the audit plan is approved by VA. Multiple resubmissions will be viewed negatively in performance evaluations.

Deliverable:

1. AMP, within thirty (30) calendar days following Kick-Off Meeting

3.2 - TASK 2 – REPORTING:

The contractor will develop a reporting system that will support production of the following reports of audit findings to OF or designee. The contractor shall provide report templates for OF approval within twenty-one (21) calendar days after the Kick-Off Meeting.

The VA shall have ten (10) business days to review each document and provide feedback if necessary.

The contractor shall have five (5) business days to incorporate any comments. Multiple resubmissions will be viewed negatively in performance evaluations.

Deliverable:

2. Report templates; Twenty-one calendar days (21) following Kick-Off Meeting

3.2.1 Weekly:

Two weekly reports will be required: 1) the Weekly Status Report (WSR) and 2) the Weekly Batch Transmission (WBT) report.

3.2.2 WSR:

The WSR will include data from the week prior and will include data for the fiscal year to date. The following information will be required in the WSR for each VA Program, RAC task and VA payer (e.g., VA, third party):

• Audits completed

• Estimated % completion of the entire task

• Number of overpayments identified

• Overpayments by provider

• Dollar value of overpayments identified

• Number of improper payments pending for fiscal year (no payment received by VA)

• Dollar value of pending payments

• Information obtained from providers that impacts collections

• For auditing tasks nearing completion, the contractor shall begin highlighting when the contractor achieves 75% estimated completion and 90% estimated completion and when the contractor is 2 weeks from 100% completion.

The WSR will be due by close of business (COB) every Monday.

Deliverable:

3. Weekly Status Report: COB the first (1st) business day following the end of the week.

3.2.3 WBT Report:

The WBT will include data required for collections, as instructed by VA after contract kick- off. The WBT will be transmitted directly to the VA or designee in the format they require for collections.

The WBT will be due on the same day of the week on a recurring basis. The specific due date will be determined after contract kicks off.

Deliverable:

4. Weekly Batch Transmission (WBT) report: WBT will be due on the same day of the week on a recurring basis. Specific due date will be determined after contract kicks off.

3.2.4 Monthly Reports:

The Monthly Reports will be in Excel format and include the following data from the prior month.

• Provider name

• Provider Tax ID Number (TIN)

• Case number

• Case creation date

• VISN and station numbers for each case

• Breakdown by task/VA program type

• Audits completed

• Number of overpayments identified

• Dollar value of overpayments payments identified

• Number of improper payments pending for fiscal year Number of disputes received by provider and results

(overturned, upheld or pending) and dollar amount

• Number and dollar amount of underpayments identified, if any, and identified root causes

Unless the VA COR approves alternative arrangements, each Monthly Report shall be due by COB on the fifth (5th) business day following the end of the month. The Monthly Report shall be sent via e-mail to the VA COR.

Deliverable:

5. Monthly Report: COB on the fifth (5th) business day following the end of the month.

3.2.5 Quarterly Reports:

The Payment Integrity Information Act of 2019 (PIIA) (PL 116-117) and OMB Circular A- 123, Appendix C, requires quarterly and annual reporting. With respect to improper payments identified in a recovery audit, the contractor will:

Provide quarterly reports on conditions giving rise to overpayments identified by the contractor and recommendations on how to mitigate those conditions

Notify VA of any overpayments identified by the contractor pertaining to the VA or to any other executive agency that are beyond the scope of the contract

Report to the VA credible evidence of fraud or vulnerabilities to fraud and conduct appropriate training of personnel of the contractor on identification of fraud

Deliverable:

6. Quarterly Reports: Determined after contract kick-off to align with Payment Integrity Information Act of 2019 (PIIA) requirements

3.2.6 Annual Reports:

The Annual Report will include a summary of data and any important events or highlights from the Monthly Reports from the current fiscal year and is due to VA by October 2nd each POP the contract is active. If October 2nd is a Saturday, Sunday or federal holiday, the report will be due by Noon MST the next business day.

At a minimum, the Annual Report will include:

• Lessons learned

• Recommendations to mitigate root causes

• Suggested corrective actions

• Trends

Deliverable:

7. Annual Report: COB October 2 each year the contract is active.

3.2.7 Ad Hoc Reports:

Ad Hoc Reports are requests due to a unique or urgent need for specific information in a specified format.

The VA will request any Ad Hoc Reports by email to the contract point of contact. The contractor shall provide Ad Hoc Reports five (5) business days after the request or by the date indicated by the VA COR.

Deliverable:

8. Ad Hoc Reports: COB five (5) business days after the request or by the date indicated by the VA

COR.

3.2.8 Final Report:

When the contract is scheduled to end, regardless of reason, the contractor shall submit a Final Report.

The Final Report shall include a synopsis of the entire contract project by Base and Option Years. This includes reporting the final amounts of all debt identified, collected and outstanding amounts at the end of the contract by provider, by year and by VA Program or RAC task. The Final Report will also include:

• Lessons learned

• Recommendation to mitigate root causes

• Suggested corrective actions

• Trends identified.

The Final Report shall be due by COB 60 calendar days after the end of the contract.

Deliverable:

9. Final Report (when contract ends): COB 60 calendar days prior to the end of the contract.

TASK 2 – REPORTING DELIVERABLES

2. Report templates; Twenty-one calendar days (21) following Kick-Off Meeting

3. Weekly Status Report: COB the first (1st) business day following the end of the week.

4. Weekly Batch Transmission (WBT) report: WBT will be due on the same day of the week on a recurring basis. Specific due date will be determined after contract kicks off.

5. Monthly Report: COB on the fifth (5th) business day following the end of the month.

6. Quarterly Reports: Determined after contract…