RFP-11-18 - 3rd Party Collection Area Wide 2.pdf

SECTION B

PRICE SCHEDULE

ABERDEEN AREA WIDE

MEDICAL RECORD CODING, DATA ENTRY, 3RD PARTY BILLING,

ACCOUNTS RECEIVABLES & CODING QUEUE PROJECT

ITEM

BASE YEAR:

DESCRIPTION

ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1.

Inpatient Coding, Data Entry

2,675

PCC/EHR

2.

Outpatient Coding, Data

Entry

245,303

3.

Surgical Coding, 2,100

4.

Accounts Receivable

5,070

Hour

5.

Outpatient Billing

116,827

6.

Inpatient Billing

1,057

Record

7.

Printing, Mailing, & Submission of

Claims

Per Claim

8.

Auditing & Coding Queue

Review

3,720

9.

Compliance Auditing

10.

Revenue Generation Cycle

Consultative Services

GRAND

TOTAL

FOR

BASE YEAR:

OPTION YEAR ONE (1):

UNIT OF

OPTION YR

ONE (1):

OPTION YEAR TWO (2):

UNIT OF

TWO (2):

OPTION YEAR THREE (3):

UNIT OF

THREE (3):

OPTION YEAR FOUR (4):

UNIT OF

FOUR (4):

GRAND TOTAL

FOR BASE + ALL FOUR (4) OPTION YEARS: $ __________________

SECTION C

PERFORMANCE BASED STATEMENT OF WORK

FOR THE ABERDEEN AREA WIDE

MEDICAL RECORDS CODING, DATA ENTRY, THIRD PARTY BILLING, ACCOUNTS

RECEIVABLE AND CODING QUEUE PROJECT

C-1. GENERAL:

This performance based statement of work describes the requirements for Third Party Collection Services for the Aberdeen Area Indian Health Service. Prospective Contractor shall begin performance within 24 hours from the date of award of this contract.

C-2. BACKGROUND:

To ensure proper reimbursement as well as regulatory compliance, the Centers of Medicare/Medicaid Services (CMS) and other third party payers have initiated precise guidelines for all providers. These guidelines include documentation requirements that demonstrate medical necessity, correct coding, and billing that depend on data integrity. The Office of Inspector General (OIG) of the United States Department of Health and Human Services (DHHS) believes that all participants in the Medicare and Medicaid programs have an ethical and legal duty to ensure the integrity of their transactions with CMS, Federal and State rules and regulations. These services will permit service units to move towards strict adherence to CMS, Federal and State compliance guidelines and maintain consistency with the highest standards of business and professional ethics. Coding and billing compliance are key components of Medicare’s condition of participation in fostering and monitoring improved health care outcomes.

Indian Health Service (IHS) uses the official coding guidelines for clinical classification systems such as, but not limited to, current editions of International Classification of Disease-Clinical Modification (ICD-CM), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and complies with the Indian Health Service’s Third Party Resource and Internal Control Policy, and the Indian Health Service’s statistical and reporting systems for all departments.

C-3. OBJECTIVE:

The purpose of the contract is for the provision of medical record coding, data entry, third party billing, Coding Queue /Incomplete/errors, and Accounts Receivable services for participating service units of the Aberdeen Area Indian Health Service. All services will be guided by CMS, Federal and State regulations and will ensure third party billing compliance in all AAIHS Service Units.

C-4. SCOPE:

The fifteen (15) Service Units that will be utilizing the third party resource billing, accounts receivable/follow-up, coding, data entry and coding queue reports, will individually coordinate the work schedule with the contractor. Each Service Unit will be responsible to ensure payment through a task order method.

The fifteen (15) Service Units that will utilize the services under this contract are: Standing Rock Service Unit/McLaughlin SU, Cheyenne River Service Unit, Rapid City Service Unit, Rosebud Service Unit, Sisseton Service Unit, Spirit Lake Service Unit, Lower Brule Service Unit, Winnebago Service Unit, Belcourt Service Unit, Wagner Service Unit, Pine Ridge SU/Kyle SU/Wanblee SU and Ft. Thompson SU.

The below grid sheet shows estimated amounts for each line item, for each service unit.

1. Standing Rock Service Unit Inpatient Coding/Data Entry= Record/EHR 0 Outpatient Coding/Data Entry=PCC/EHR 9000 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 500 Billing- Outpatient =PCC/EHR 2500 Billing –Inpatient = Record/EHR 70 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 240 Compliance Auditing= Hourly 0 Revenue Generation Cycle Training/Education= Hourly 0

2. McLaughlin Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 17000 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 480 Billing- Outpatient =PCC/EHR 900 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 100 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

3. Cheyenne River Service Unit Inpatient Coding/Data Entry= Record/EHR 150 Outpatient Coding/Data Entry=PCC/EHR 14403 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 100 Billing- Outpatient =PCC/EHR 1000 Billing –Inpatient = Record/EHR 70 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 100 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

4. Rapid City Service Unit Inpatient Coding/Data Entry= Record/EHR 0 Outpatient Coding/Data Entry=PCC/EHR 1500 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 0 Billing- Outpatient =PCC/EHR 0 Billing –Inpatient = Record/EHR 0 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 1500 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

5. Ft. Thompson Service Unit Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 1800 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 200 Billing- Outpatient =PCC/EHR 1000 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 100 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

6. Rosebud Service Unit Inpatient Coding/Data Entry= Record/EHR 1200 Outpatient Coding/Data Entry=PCC/EHR 90000 Surgical Coding/Data Entry =PCC/EHR 500 Accounts Receivable= Hourly 1680 Billing- Outpatient =PCC/EHR 63350 Billing –Inpatient = Record/EHR 800 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 600 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 128

7. Belcourt Service Unit Inpatient Coding/Data Entry= Record/EHR 900 Outpatient Coding/Data Entry=PCC/EHR 60000 Surgical Coding/Data Entry =PCC/EHR 1000 Accounts Receivable= Hourly 200 Billing- Outpatient =PCC/EHR 5002 Billing –Inpatient = Record/EHR 17 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 400 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

8. Winnebago Inpatient Coding/Data Entry= Record/EHR 125 Outpatient Coding/Data Entry=PCC/EHR 3000 Surgical Coding/Data Entry =PCC/EHR 0 Accounts Receivable= Hourly 150 Billing- Outpatient =PCC/EHR 6200 Billing –Inpatient = Record/EHR 50 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 30 Compliance Auditing= Hourly 32 Revenue Generation Cycle Training/Education= Hourly 24

9. Lower Brule Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 15000 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 960 Billing- Outpatient =PCC/EHR 15000 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 200 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

10. Sisseton Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 18000 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 200 Billing- Outpatient =PCC/EHR 10000 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 200 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

11. Spirit Lake Service Unit Inpatient Coding/Data Entry= Record/EHR 100 Outpatient Coding/Data Entry=PCC/EHR 1000

The overall combined total minimum for service will be:

PCC encounters to be coded and data entered: 10,000 A/R and Coding Queue Audit: 500 hrs Inpatient visits to be coded and data entered: 100 Billing of claims: 5,000

Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 200 Billing- Outpatient =PCC/EHR 2000 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 50 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

12. Wagner Service Unit Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 3500 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 0 Billing- Outpatient =PCC/EHR 7800 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 0 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

13. Pine Ridge Service Unit Inpatient Coding/Data Entry= Record/EHR 200 Outpatient Coding/Data Entry=PCC/EHR 10000 Surgical Coding/Data Entry =PCC/EHR 600 Accounts Receivable= Hourly 200 Billing- Outpatient =PCC/EHR 2000 Billing –Inpatient = Record/EHR 50 Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 0 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

14. Kyle Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 1000 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 100 Billing- Outpatient =PCC/EHR 50 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 100 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

15. Wanblee Inpatient Coding/Data Entry= Record/EHR N/A Outpatient Coding/Data Entry=PCC/EHR 100 Surgical Coding/Data Entry =PCC/EHR N/A Accounts Receivable= Hourly 100 Billing- Outpatient =PCC/EHR 25 Billing –Inpatient = Record/EHR N/A Printing, Mailing, & Submission of Claims = Per Claim 0 TX’er Report/Error Report/Coding Queue= Hourly 100 Compliance Auditing= Hourly 40 Revenue Generation Cycle Training/Education= Hourly 32

C-5. The contractor will comply with all Federal and State Regulations and comply with Indian Health

Service’s Third Party Resource and Internal Control Policy, the Debt Collection Policy, and the Indian Health Service’s statistical and reporting systems for all departments. The contractor will comply with the American Hospital Association (AHA) Official Coding Guidelines for ICD9-CM and the Current Procedural Terminology (CPT) Guidelines, and any specific IHS coding and data entry policies and procedures. The run around timeframes that the contractor will be held to will be those listed in the Internal Control Policy for all processes of the revenue cycle.

The contractor will have access, with restrictions as defined by the Service Unit, to the following Service Unit RPMS modules and other access as requested by the contractor and agreed upon by the Service Unit for revenue enhancement purposes.

a. Patient Registration System

b. Third Party Billing System

c. Accounts Receivable System

d. Patient Care Component/EHR, Dental and Pharmacy

e. Other as deemed necessary by Service Unit/Area Staff

C-6. In order to meet Aberdeen Area Service Unit needs in the revenue cycle and Medical records management, contractor will be required to provide the following:

a. Contractor will work in partnership with the Service Unit to assure continuity of support services, either through direct performance of necessary functions or in sharing responsibilities with service unit staff. Contractor will be expected to serve as an auxiliary resource to the service unit in support services. Contractor must be prepared to provide medical coding and data entry services, third party billing service, accounts receivable posting and follow-up, and coding queue corrections/audits. Contractor will perform along with Area Staff, an initial on site /video conference visit to discuss the contract and contract requirements addressing what functions will be performed by each entity.

b. Contractor will provide onsite training and technical support to assigned facilities in business office and medical records tasks and functions, including but not limited to coding and data entry, third party billing, denial management, accounts receivable posting and follow-up, and other important techniques and procedures. Contractor will perform a minimum of one (1) site visit for duration of at least two (2) days per quarter for assigned service units.

c. Contractor will provide off-site training services quarterly through Webex, Go-to-meeting or video conference to deliver basic entry-level revenue cycle training to IHS employees on an as needed basis. Training plan will include introductory medical coding, data entry (PCC and EHR), third party billing, accounts receivable services, and denial management. Contractor will provide instruction, facilitation and resources for each site participating in the training. If sites are agreeable, the contractor can hold training with more than one service unit at a time.

C-7. THIRD PARTY RESOURCE BILLING SERVICES – SCOPE OF WORK:

Contractor Responsibilities:

a. Shall provide third party resource billing services. Direct access and use of the current RPMS

(Resource Patient Management Systems) via VPN approval and access will be required. The Government will provide access to the RPMS and technical and program support when required.

b. Utilize the current IHS-RPMS Third Party Billing System.

c. Editing and approving (exporting is optional) (Electronic or Hardcopy) inpatient/outpatient

(including Dental and Pharmacy) third party resource claims/bills.

d. Visit data from PCC/Superbill/EHR will be reviewed for accuracy and completeness for appropriate level of reimbursement based on codes and provider documentation.

e. The contractor shall process and submit claims directly to the appropriate carrier or clearinghouse via modem or other communication means in a format acceptable to the appropriate carrier. Electronic submission of claims, in the HIPAA formats, will be the mode of choice when accepted by the carrier/clearinghouse. The electronic submission of claims is optional and must be per request of the Service Unit contact person.

f. Claims not processed electronically shall be processed and printed on paper and on the proper standard form (ADA,CMS-1500,UB-04, etc.). The contractor shall send the processed paper claims to the carrier. Copies of the form shall be provided to the location originating the claims.

This is an optional function and must be per request of the Service Unit contact person.

g. Claims rejected by the carrier for any reasons other than inappropriate format of the claim, and claims rejected by the contractor shall be returned to the service location for correction and resubmitted back to the contractor for processing. The contractor shall not charge for any claims rejected prior to submission to the carrier. Rejected claims from carrier will be corrected and resubmitted to carrier by entity that prepared the claim.

h. Errors in processing or submission of transactions shall be limited to reprocessing and resubmission at the contractor’s expense.

i. Reports shall be generated and provided to each service unit on a monthly basis and each Business Office Manager shall be responsible for distribution of same reports. Reports generated will be at the discretion of the Business Office Manager (e.g., PCC’s generated, A/R hours used, rejected/denial claims, etc. that the facility would want to track for invoicing).

j. Provide on-site support as needed and requested by Service Unit representative.

k. Provide the Service Unit with CMS-1500 and UB-04 data as generated by the contractor for current and past electronic health record. All electronic transactions generated by the contractor shall be HIPAA compliant.

l. There shall be no additional charges for reports generated by the contractor. The Service Unit will receive a standard list of reports that include the following:

1. Monthly accounts receivable aging schedule

2. Monthly summary of charges, payments and adjustments

3. Monthly insurance percentage report

4. The contractor shall submit, as a written report, Accounting Disclosures of Protected Health Information (PHI) made on individuals. Upon request, the report(s) shall be submitted on or within 15 days to the requesting IHS facility.

m. Schedule weekly/bi-weekly/monthly conference calls/management meetings or as needed to discuss project needs. Minutes of meetings shall be provided to the Contract Officer Technical Representative (COTR).

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

o. The contractor shall be responsible for recording, keeping and securing backup of any transaction information provided by the contractor for a maximum of three (3) years and not less than one (1) year.

p. The contractor shall bear the expense of all forms, envelopes, printer ribbon, postage and other supplies/equipment (except at the service locations) necessary in the performance of the contract.

q. The contractor will be responsible for their own travel, lodging and other miscellaneous travel arrangements.

r. The contractor will comply with industry standards, applicable I.H.S. rules and regulations, state and federal law, including but not limited to the OIG recommendations on compliance programs and HIPAA requirements.

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

t. In the event of an overpayment by an Insurance company, the billing office will prepare a refund documentation letter and this will be sent to the Service Unit/Area Office so that a payment can be processed immediately.

u. With respect to audit requests, subpoenas and summonses, the contractor will provide all documentation requested by the insurance payor. A representative from the contractor and the coders and/or physicians will then review this information. Once all information is gathered, it will be sent to whoever requested it. Any money that may be due in the event of an audit will be repaid by the Service Unit and the contractor will credit the Service Unit account for their billing fees. If the audit should arise after the cancellation of this contract, the contractor will still prepare any documentation that may be necessary to complete the audit.

v. The contractor shall provide personnel as to perform billing duties at each service location as required. Personnel shall have basic knowledge of the State Medicaid programs in Iowa, Nebraska, South Dakota, and North Dakota. Personnel shall have prior experience in billing outpatient visits, ambulatory surgeries, inpatient stays, et cetera and have prior experience in medical records coding (ICD-9-CM and CPT-4), preferably Certified Coders, and the use of applicable computer technology to accomplish duties required.

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

x. All remittance/receipts from the carrier shall be mailed to the appropriate Lock Box for the particular facility in which the services were performed.

C-8.

a. Contractor will utilize the RPMS Accounts Receivable System.

PATIENT ACCOUNTS RECEIVABLE – SCOPE OF WORK:

The contractor will provide accounts receivable posting and follow-up services as an optional service to the Aberdeen Area Indian Health Service- Service Units. The purpose of this contract is to allow contractor to provide accountability and follow-up services for previously submitted, yet unpaid, private insurance claims as identified by facility staff.

b. Contractor will assist Service Unit with actual posting of payments and adjustments in the RPMS Accounts

Receivable System, utilizing the HIPAA Standard Reason Codes only.

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

d. Contractor will follow up on all accounts that have an outstanding balance, with the parameters being set by the Service Unit Chief Executive Officer and Business Office Supervisor.

e. Contractor will submit collection letters to private insurance companies using data generated by the RPMS Accounts Receivable Package. The Indian Health Service Office of Information Technology (OIT) has a program written into our RPMS Accounts Receivable Package to allow our staff to automatically transmit outstanding accounts directly to a contractor with the capabilities of receiving, with no additional programming requirements or software needed to accomplish this task. While maintaining the highest levels of integrity, compliance, and ethics, the contractor shall obtain for the Service Unit the full financial reimbursement to which they are legally entitled for services provided.

f. The Contractor submits outstanding account third party collection letters to insurance companies and non-eligible patients based on information transmitted to them by RPMS. A minimum of three letters is submitted to the insurance company for each account allowing ample time for them to respond.

g. Contractor will submit collection letters to private insurance companies for all outstanding accounts with information received from the RPMS Accounts Receivable Debt Collection Program. Where applicable, the written demands when contacting an insurance company will list the applicable state insurance statutes for reimbursement. The demand letters should mirror those provided to the Indian Health Service through the Debt Collection Policy, utilizing preset language in those letters.

h. Contractor will complete all tasks utilizing the data generated by the RPMS Accounts Receivable

Program. Facility staff will generate start and stop records utilizing the RPMS Accounts Receivable Debt Collection Program.

i. Start records are claims that need to be sent to Contractor for first time collection action. These records initiate the collection process.

j. Stop records are claims that have previously been sent to Contractor for collection action but have had a change in balance. These records either stop the collection action because the balance has been paid in full or written off, or these records cause an update in information being sent to the payer.

k. The contractor will provide a written response and status report on all contacts (verbal and written) made on behalf of the entity, stating what was the result of that contact, such as the status of the account, and what further action is to be taken, if any. This response will be given to the Service Unit staff no less than on a weekly basis.

l. The contractor will also serve as a technical advisor to the Service Unit multi-disciplinary revenue enhancement teams at the Service Units in addressing the accounts receivable processes, changes, and necessary enhancements.

C-9. CONSULTANT SERVICES/AUDITING FOR REVENUE GENERATION CYCLE

FUNCTIONS AND PROCESSES – SCOPE OF WORK:

The contractor will provide consultative services on-site as an optional service to the Aberdeen Area Indian Health Service- Service Units and Area Office on revenue generation cycle functions and processes. The contractor will provide on the job training for individual staff and program development on the various functions of revenue generation. The contractor will also serve as a technical advisor to the Service Unit multi-disciplinary revenue enhancement teams at the Service Units in addressing the revenue enhancement work plan.

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

b. The contractor will identify key management objectives and accountability in the revenue generation cycle. Develop timelines to accomplish key management objectives and develop methods for accountability.

c. Eliminate redundancy of work within the revenue generation cycle, refine and implement new workflow processes. Identify best possible physical location of staff who are in the revenue generation process. Provide staff training to accommodate new tasks for each job per workflow process changes.

d. In the implementation of new work flow processes, training provided and other consultative services provided, the contractor must comply with industry standards, applicable I.H.S. rules and regulations, state and federal law, including but not limited to the OIG recommendations on compliance programs and HIPAA requirements. Service Unit compliance plans will be adhered to.

e. Work with pertinent staff and programs to initiate a process change and develop evaluation criteria for the effectiveness of the change.

f. The contractor will develop a concurrent program for providers and other staff to improve documentation to ensure proper and accurate coding for revenue generation purposes.

g. Perform audits on individual processes of the Service Unit staff per request of the Service Units or Area Office, in accordance with Standard Auditing Practices. Contractor will not audit their own processes.

h. Develop audit program and measurements for coding, billing and provider documentation.

Develop baseline metrics and measurable standards to measure current state of coding for effectiveness and to build in accountability. Train staff on the use of various audit techniques and measurements.

i. Address, define, and implement the use of automated systems as it applies to the revenue generation cycle.

j. Provide staff training on techniques of gathering up front information pertaining to third party resources, i.e. patient registration, benefits coordination, etc.

k. At the request by the Area Office the contractor will perform a Service Unit revenue generation cycle assessment that will include auditing and monitoring of coding, provider documentation, billing processes, and collection processes.

l. The contractor will be responsible for their own travel, lodging and other miscellaneous travel arrangements.

m. The contractor may assist the Area Office with planning, implementing, and facilitating Training/Workshops within the scope of Third Party Revenue Processes.

C-10. CODING, DATA ENTRY, COMPLIANCE AUDITING AND REPORTING – SCOPE OF

WORK:

a. Shall code and make complete and accurate all medical visits (ambulatory, inpatient, pharmacy, laboratory, dental with medications, radiology and others) via the IHS RPMS EHR, PCC and Admission/Discharge/Transfer (ADT) systems. Apply IHS and National Reporting and Coding Guidelines.

b. Shall have access to the IHS E.H.R. system to view notes and critical information for correct visit information and coding of all evaluation & management, diagnoses, CPT, HCPCS, modifiers and apply medical significance matching of diagnoses to services.

c. Assignment of E/M, CPT, HCPCS will be completed and modified/appended via the RPMS system using the mnemonic CPE.

d. The IHS “visit verification coding queue” (VVQ) will be accessed for review, accuracy, and completion of all medical visits before a claim can be generated. When a visit cannot be completed in the coding queue, the vendor needs to access the PCC data entry and supervisor options to complete the visit.

e. A report of findings via the VVQ will be documented and presented via phone and a written report as a tool of communication and education for all physician and ancillary staff.

f. Editing, appending, merging, moving data elements, and deleting duplicate entries will be part of the process with application of reporting requirements via the RPMS system.

g. Visit data from PCC/Pick Lists1/EHR will be reviewed (VVQ) for accuracy and completeness to the highest allowable level so the facility receives the appropriate level of reimbursement.

National Coding Guidelines will be applied via PCC. When there is an application of “billing/claims” guidelines based on the payer – the guideline should be applied via the Third Party Billing (TPB) system with feedback to staff.

h. Provide on-site support as needed.

i. There shall be no additional charge for reports generated by the contractor.

j. Schedule monthly management meetings or as needed to discuss project needs.

k. The contractor shall provide personnel as to perform on-site coding and coding queue duties at each service location as required. Personnel shall have prior experience in reporting and billing outpatient visits, ambulatory surgeries, inpatient stays, et cetera and have prior experience in medical records coding (ICD-9-CM and CPT-4), (DRG assignment), Certified Coders preferred, and the use of applicable computer technology to accomplish duties required.

l. Contractor, when working incomplete visit in EHR, will send provider “Notifications” for any record deficiencies (coding, DE, documentation), utilizing the EHR Coding Notification Template and/or Coding Question Template in the EHR.

m. The contractor shall have a minimum of three (3) years experience and/or be a certified coder

(copy of certification) (AHIMA and/or AAPC – etc.). Will apply National Coding Guidelines, IHS Guidelines and Other for both inpatient and outpatient services.

n. The contractor shall have a minimum of one year (1) experience with the RPMS PCC Operator and Supervisor, including the Coding Queue, in order to process all contracted medical documents as required.

o. The contractor will also serve as a technical advisor to the Service Unit multi-disciplinary revenue enhancement teams at the Service Units in addressing medical services coding and reporting and any recommended necessary enhancements.

p. Contractor shall provide on-site training and consultation at least two days quarterly for each service unit that is contracted.

q. Compliance auditing for E&M, ICD-9CM, HCPCS (supplies) and CPT procedures/services will be based on the facility’s number providers, (MD, DO, PA, CNP, all specialty services). No more than 5% of each provider’s annual number of inpatient/outpatient, emergency room, same day surgery, etc. visits. The only visits that will be audited are those done by service unit staff and are third party visits that have 3rd party eligibility (Medicare, Medicaid, & Private Insurance). The accuracy formula shall be the number of records audited divided by the number of coding errors found. (Errors can be wrong principle/primary diagnosis (sequencing), wrong E/M code selected based on provider documentation in the visit (HPI,ROS, etc.) wrong code requiring 4th or 5th digit, acute and chronic conditions coded incorrectly, manifestation codes not coded, injury and poisoning codes not coded, sign and symptoms codes in ICD will be scrutinized to determine if a more specific diagnosis should have been coded and/or the provider queried. A final summary for each provider will be completed and the auditor will meet with each provider and/or the medical staff to discuss the coding and provider documentation findings and recommendations. The auditor will meet with the Service Unit coding staff to discuss coding errors and recommendations.

C-11. MINIMUM QUALIFICATIONS:

The contractor must have at least three (3) years of experience working with health care facilities in developing revenue enhancement initiatives. Must have three years or more of experience in medical records coding (ICD-9 and CPT-4). Must have knowledge of revenue enhancement cycle processes, private insurance carriers and Medicare reimbursement practices and requirements and be able to demonstrate knowledge. Must have knowledge of a compliance program and HIPAA requirements.

Must be familiar with the third party billing RPMS. Must have basic knowledge of Nebraska, Iowa, North Dakota and South Dakota Medicaid programs.

Government Responsibility:

a. The Government will provide proper in-service to the contractor so to become familiar with the

Privacy Act and HIPAA requirements. All necessary documents pertinent to the Privacy Act , HIPAA Privacy rule and HIPAA Security Rule. Security clearances will be on file with the service locations and other offices that require such documentation. Contractor will be provided the Third Party Internal Control Policy and instructed on IHS billing policies and procedures.

b. Work space will be made available for the Contractor. The Service Unit staff will be responsible for retrieving, copying, and returning appropriate medical records, according to hospital policy.

c. The Service Unit will provide proper in-service to the contractor to become familiar with the facility, Privacy Act, and other I.H.S. requirements.

d. The Government shall perform random audits no less than two (2) times per year on coding and claim transactions, record keeping/security backup to ensure contract compliance. Service Unit along with Area Office staff will perform the random audits.

e. Further action is taken by facility staff based on the responses received from the insurance companies.

f. The facility staff will be responsible for working all responses received from the private insurance companies. The facility will resubmit, complete the required research for each of the responses received and/or adjust the open account accordingly.

g. The facility staff will be responsible for setting the parameters in the Debt Collection Program which will specify which claims will be submitted to the contractor. Once a stop record is initiated, Vendor will be responsible for updating the collection letter to the private insurance company or stopping further collection letters once an account has been closed.

h. The Government shall at their option perform an onsite courtesy visit to the contractor facility within the contract year.

C-12. BUSINESS ASSOCIATE AGREEMENT CLAUSE:

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996; its implementing regulations, the Standards of Privacy of Individual Identifiable Health Information at 45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and 45 C.F.R. Parts 160 and 164, Subparts A and C (“Security Rule”); and the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), Title XIII, Subtitle D of the American Reinvestment and Recovery Act of 2009, Pub.

L. No. 111-5, 123 Stat. 115 (2009) (“ARRA”), the Indian Health Service is required to enter into an agreement with the Business Associate, pursuant to which the Business Associate shall comply with and appropriately safeguard Protected Health Information (“PHI”) that it will use and disclose when performing functions, activities or services (“Services”) for the Indian Health Service pursuant to Contract No. HHSI241_____________ (“Contract”). The Business Associate by signing the Contract shall comply with the following terms in addition to other applicable Contract terms and conditions relating to the safekeeping, use and disclosure of PHI.

Section 1 – Definitions

Terms used in this Agreement, if not otherwise defined, shall have the same meaning as those terms contained within the Privacy Rule and the HITECH Act.

a. Breach: “Breach” shall mean the unauthorized acquisition, access, use, or disclosure of Protected

Health Information (defined hereinafter) which compromises the security or privacy of such information, except where an unauthorized person to whom such information is disclosed would not reasonably have been able to retain such information;

b. Covered Entity: “Covered Entity” shall mean the Indian Health Service (IHS);

c. De-identified protected health information: “De-identified protected health information” shall have the same meaning as the term “de-identified protected health information” in 45 C.F.R. § 164.514;

d. Designated Record Set: “Designated Record Set” shall mean (1) a group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider, (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan, or

(ii) Used, in whole or in part, by or for the covered entity to make decisions about individuals. (2) For purposes of this paragraph, the term records means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity; (45 C.F.R. § 164.501)

e. Electronic Health Record: “Electronic Health Record” shall mean an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff;

f. Individual: “Individual” shall have the same meaning as the term “individual” in 45 C.F.R. §

164.501 and shall include a person who qualifies as a personal representative in accordance with 45 C.F.R. § 164.502(g);

g. Limited Data Set: “Limited Data Set” shall have the same meaning as the term “limited data set” in

45 C.F.R. § 164.514(e)(2);

h. Privacy Rule: “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. Parts 160 and 164, Subparts A and E;

i. Protected Health Information: “Protected Health Information” or “PHI” shall have the same meaning as the term “protected health information” in 45 C.F.R. § 160.103;

j. Required By Law: “Required By Law” shall have the same meaning as the term “required by law” in 45 C.F.R. § 164.501;

k. Secretary: “Secretary” shall mean the Secretary of the United States Department of Health and

Human Services or her designee;

l. Unsecured Protected Health Information: “Unsecured Protected Health Information” or Unsecured PHI” shall mean protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of a technology or methodology specified by the Secretary in guidance on the HHS website issued under section 13402(h)(2) of the HITECH Act.

Section 2 – Compliance

The Business Associate agrees to comply with the business associate contract requirements under the Privacy Rule, the HITECH Act and the provisions of this Agreement throughout the term of this Agreement. The Business Associate agrees that it will require all of its agents employees, subsidiaries, affiliates and subcontractors, to whom the Business Associate provides PHI, or who create or receive PHI on behalf of the Business Associate of the IHS, to comply with the Privacy Rule and the HITECH Act, and to enter into written agreements with the Business Associate that provide the same restrictions, terms and conditions as set forth in this Agreement.

In the event the Business Associate awards a subcontract under the Contract pursuant to which the Business Associate will disclose PHI to the subcontractor, notwithstanding any clause to the contrary contained in the Contract, the Business Associate agrees to obtain the IHS Contracting Officer’s written consent prior to awarding such subcontract.

Section 3 – Permitted Uses and Disclosures

The Business Associate shall not use or disclose PHI except to perform functions, activities or services for or on behalf of the IHS as provided for in this Agreement, the Privacy Rule, the HITECH Act or other applicable law. The Business Associate agrees that it may use or disclose PHI on behalf of the IHS only (1) upon obtaining the authorization of the patient to whom the PHI pertains (45 C.F.R. §§ 164.502(a)(1)(iv) and 164.508(b)); (2) for the purpose of treatment, payment or health care operations (45 C.F.R. §§ 164.502(a)(1)(ii), and 164.506)), unless disclosure has been restricted pursuant to the HITECH Act at § 13405(a), or (3) without an authorization or consent, if in accordance with 45 C.F.R.

§§ 164.506, 164.510, 164.512, 164.514(e), 164.514(f) or 164.514(g). The Business Associate shall use and disclose PHI in compliance with each applicable requirement of 45 C.F.R. § 164.504(e), which section is fully incorporated herein. Except as otherwise limited in this Agreement, the Business Associate may use PHI for the management and administration of the Business Associate or to carry out responsibilities that are required of it by law (45 C.F.R. § 164.502(e)(4)(i)).

Section 4 – Safeguards

The Business Associate shall develop and use appropriate procedural, physical and electronic safeguards to protect against the use or disclosure of PHI in a manner not permitted by the Privacy Rule or this Agreement. The Business Associate will limit any use, disclosure or request for use or disclosure of PHI to the minimum amount necessary to accomplish the intended purpose of the use, disclosure or request in accordance with the applicable requirements of the Privacy Rule. As mandated by the HITECH Act, Privacy Rule sections 164.308 (administrative safeguards requirements), 164.310 (physical safeguards requirements), 164.315 (technical safeguards requirements) and 164.316 (policies and procedures and documentation requirements) shall apply to the Business Associate in the same manner that such sections apply to covered entities under the Privacy Rule.

Section 5 – Minimum Necessary

Prior to the Secretary issuing guidance on what constitutes “minimum necessary” for purposes of the Privacy Rule, the Business Associate will limit, to the extent practicable, any use, disclosure or request for use or disclosure of PHI (other than those uses, disclosures or requests for use or disclosure of PHI set forth at 45 CFR section 164.502(b)(2)), to the Limited Data Set, or if needed, to the minimum amount necessary to accomplish the intended purpose of such use, disclosure or request, respectively. Upon the effective date of the Secretary’s “minimum necessary” guidance, the Business Associate will limit any use, disclosure or request for use or disclosure of PHI, to the minimum amount necessary as set forth in such guidance.

Section 6 – Safeguards for Electronic PHI

The Business Associate shall implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of any electronic PHI that it creates, receives, maintains, or transmits on behalf of the IHS as required by 45 C.F.R. Part 164, Subpart C, Security Standards for the protection of Electronic Health Information. Section 4 above shall apply in full to this Section 6.

Section 7 – Reporting of Unauthorized Uses or Disclosures

The Business Associate shall promptly report to the IHS any knowledge of uses or disclosures of PHI that are not in accordance with this Agreement or applicable law. In addition, the Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to the Business Associate of a use or disclosure of PHI by the Business Associate in violation of the requirements of the Privacy Rule or the HITECH Act. For those uses or disclosures that involve a breach of the security of any unsecured PHI received from, or created or received on behalf of, the IHS, the Business Associate shall comply with the requirements set forth in Section 8 below.

Section 8 – Reporting of Breach of Unsecured PHI

The Business Associate shall notify the IHS of a breach of the security of any unsecured PHI that the Business Associate received from, or created or received on behalf of, the IHS within thirty (30) calendar days after the discovery of the breach by the Business Associate, its employees, officers and/or other agents unless a law enforcement official has determined that such notification would impeded a criminal investigation or caused damage to national security, in which case the notification shall be delayed in accordance with the requirements of 45 C.F.R. § 164.412. Such notice shall include, to the extent possible, the identification of each individual whose unsecured PHI has been, or is reasonably believed by the Business Associate to have been, accessed, acquired, or disclosed during such breach;

a brief description of the circumstances of the breach of security, including the date of the breach and the date of the Business Associate’s discovery of the breach; and the type of unsecured PHI involved in the breach. In the event notification is delayed, evidence demonstrating the necessity of the delay shall accompany the notification. A breach shall be treated as discovered as of the first day on which such breach is known to Business Associate (including any person, other than the individual committing the breach that is an employee, officer or other agent of Business Associate) or should have reasonably been known to Business Associate (or person) to have occurred.

Section 9 – Maintenance of Records and Accounting of Disclosures

The Business Associate shall maintain records of PHI received from or created or received on behalf of the IHS and shall document subsequent uses and disclosures of such information by the Business Associate. The Business Associate shall, within 5 calendar days after receiving a request from the IHS, provide to the IHS such information as the IHS may require to fulfill its obligations to provide access to, provide a copy of, and account for disclosures with respect to PHI pursuant to the Privacy Rule (e.g. 45 C.F.R. § 164.528)(individual request for an accounting of PHI disclosures), the HITECH Act and other applicable law.

In accordance with the requirements of HITECH Act Section 13405(c), beginning on [need to determine if BA already has EHR system and then put in applicable dates based on requirement of HITECH Section 13405(c)(4)], the Business Associate shall account for all disclosures of PHI for treatment, payment and health care operational purposes.

Section 10 – Maintenance of Records and Accounting: Individual Access The Business Associate shall maintain a Designated Record Set for each patient for which it has PHI.

In accordance with a patient’s right to access his/her PHI under the Privacy Rule, the Business Associate shall make available all PHI in the patient’s Designated Record Set to the patient to whom that information pertains, or, upon the request of the patient, to the patient’s authorized representative, in compliance with 45 C.F.R. § 164.524. Availability shall be made within 5 calendar days of receipt of a request.

Section 11 – Disclosure for Purposes of Verifying Compliance

Upon request, the Business Associate shall make available to the IHS or to the Secretary, PHI and the Business Associate’s internal practices, books and records, including its policies and procedures and any agreements required by Section 2 herein that it has with subcontractors, vendors and other agents relating to the use and disclosure of PHI received from the IHS, or created or received by the Business Associate on behalf of the IHS, for purposes of determining both the Business Associate’s and the IHS’s compliance with the Privacy Rule and the HITECH Act and its implementing regulations. The Business Associate shall not disclose PHI to any requesting party other than as provided for in this Section and Sections 3 and 10 above. The Business Associate shall forward all other disclosure requests to the IHS for processing, except those it receives directly from individuals in accordance with Section 10 above.

Section 12 – Amendments of Information

The Business Associate shall, within 5 calendar days of a request by the IHS, make PHI available to the IHS for the IHS to fulfill its obligations pursuant to the Privacy Rule to amend PHI and shall, as directed by the IHS, within 5 calendar days of receipt of such direction, incorporate any amendments into PHI held by the Business Associate. The Business Associate shall ensure incorporation of any such amendments into PHI held by its agents or subcontractors within 10 days of its request that they do so, and shall notify the IHS within 5 calendar days of when those agents or subcontractors have completed the incorporation of the amendments. The Business Associate shall not make any amendments to PHI except upon request of the IHS. the Business Associate shall forward to the IHS Contracting Officer for approval all requests to amend PHI that it may receive directly from individuals within 5 calendar days of its receipt of the request.

Section 13 – Obligations of IHS The IHS Contracting Officer shall provide the Business Associate with its notice of privacy practices, produced under 45 C.F.R. § 164.520 and any changes to the notice. The IHS Contracting Officer shall also provide the Business Associate with any changes in, or revocation of, individuals’ authorizations to use or disclose PHI of which the IHS becomes aware, if such changes affect the Business Associate’s permitted or required uses or disclosures of PHI.