Attachments2-4.pdf

Attachment II

Client Authorization Letter

Dear “Client”:

We are currently responding to RFP BAS-0001 issued by the Federal Bureau of Prisons for the procurement of Comprehensive Medical Services. They are placing increased emphasis in their procurements on past performance as a source selection factor. They are requiring that clients of entities responding to the solicitations be identified and their participation in the evaluation process be requested. In the event you are contacted for information on work we have performed, you are hereby authorized to respond to those inquires.

We have identified Mr/Ms. (insert name) of your organization as the point of contact based upon his/her knowledge concerning our work. Your cooperation is appreciated. Any questions may be directed to (insert name).

Sincerely, ATTACHMENT III

PAST PERFORMANCE QUESTIONNAIRE

I. REFERENCE IDENTIFICATION

A. Name of Reference/Activity __________________________________________

(Include point of contact/ __________________________________________

Phone #/FAX #/Address) __________________________________________

II. CONTRACT IDENTIFICATION

A. Contractor __________________________________________

[INSERT NAME OF OFFEROR]

B. Contract Number __________________________________________

C. Contract Type __________________________________________

Competitive [ ] Yes [ ] No

Follow-on [ ] Yes [ ] No

D. Period of Performance __________________________________________

E. Estimated Contract Total __________________________________________

(Including all option periods)

F. Description of Services Provided: __________________________________________

G. Geographic distribution of services under this contract (i.e. local, nationwide, worldwide):

H. Number of locations serviced by this contract: _________________________________.

III. EVALUATION

Below are listed specific questions relating to the following five categories of contractor performance:

quality, timeliness, cost control, business relations, and customer satisfaction. Please rate the contractor for each question on a scale from 1 to 5, 5 being the best rating and 1 being the worst rating, or N/A for not applicable. There is a comment section provided below each question. Please document any responses receiving a rating of 2 or 1.

[ ] 5 - Considerably surpassed minimum requirements

[ ] 4 - Exceeded minimum requirements

[ ] 3 - Met minimum requirements

[ ] 2 - Less than minimum requirements

[ ] 1 - Efforts had a negative effect

A. QUALITY OF PRODUCT OR SERVICE

1. To what extent did the health services provider comply with the specific contract requirements?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

2. How effective has the health services provider been in providing the required health care services?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

3. To what extent did the health services provider respond to technical directions, quality improvement recommendations, contract change orders, etc.?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

4. To what extent was the health services provider's evaluation and treatment completely documented, accurate, legible, and of appropriate content?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

5. Were the discharge instructions by the attending physician in sufficient detail to allow subsequent care of the patient?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

6. Did the health services provider commit adequate resources in timely fashion to the contract for continuity of care and to render diagnostic evaluations and treatment successfully?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

B. TIMELINESS OF PERFORMANCE

1. To what extent did the health services provider adhere to contract delivery or performance schedules?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

2. To what extent did the health services provider submit required inmate medical records, evaluation and treatment reports and/or discharge summary reports in a timely manner?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

3. To what extent did the health services provider provide timely medical assistance, both on-site and off-site, when responding to emergency situations?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

4. To what extent did the health services provider submit change orders and other required proposals to promote quality health care in a timely manner?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

5. To what extent did the health services provider meet the response times in the contract?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

C. COST CONTROL

1. To what extent did the health services provider provide current, accurate, and complete billings?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

2. To what extent did the health services provider ensure only the services ordered by the Government were provided (unless required for intervention in life threatening emergencies)?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

3. To what extent did the health services provider exhibit efforts to control costs while providing quality health care services?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

D. BUSINESS RELATIONS

1. To what extent was the health services provider able to solve contract performance problems without extensive guidance from Government counterparts (COTR)?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

2. To what extent was the health services provider effective in interfacing with Government Health

Services staff?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

3. What level of integration experience has the health services provider demonstrated using medical supplies/equipment provided by the Government?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

4. To what extent did the health services provider coordinate, integrate, and provide for their designated personnel on an as-needed basis?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

5. To what extent did the contractor achieve effective logistics support, i.e., personnel, etc.?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment: ___________________________________________________________________________

E. CUSTOMER SATISFACTION

1. Has this contract been partially or completely terminated for default or convenience?

[ ] Yes for: [ ] Default [ ] Convenience

[ ] No

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules). _______________

2. Are there any pending terminations?

[ ] Yes [ ] No

If yes, please explain and indicate the status. ________________________________________________

3. How would you describe the level of health care services provided by the contractor?

[ ] Excellent [ ] Good [ ] Fair [ ] Unacceptable

Comment: ___________________________________________________________________________

4. Would you recommend this contractor for the award of additional contracts?

[ ] Yes [ ] No

Comment: ___________________________________________________________________________

NARRATIVE SUMMARY

Use this section to explain additional information not included above.

Attachment IV Computation of Basic DRG Payments (i.e., Operating Federal Rate)

CBSA 12420 -Austin, Texas

Urban Area Payment Formula

Labor-related portion of the National Adjusted Operating Standardized Amount (NAOSA)(Full Update)(Table 1a or 1b, Federal Register)

X Wage Index for the Area (Table 4A for Urban Areas, Federal Register )

= Wage adjusted labor related portion

+ Nonlabor-related portion of the NAOSA (Full Update)(Table 1a or 1b, Federal Register )

= Wage Adjusted Rate

X DRG Relative Weight (Table 5, Federal Register )

= Basic DRG Payment for CBSA 12420 - Austin, Texas Hospitals

Index Figures

Obtained from the Federal Register, VOL 72, No. 162, Wednesday, August 22, 2007 for discharges on/after October 1, 2007.

National Adjusted Operating Standardized Amounts (NAOSA) - Table 1b (full update)

Labor-related portion: $3,077.46 Nonlabor-related portion: $1,886.18

Wage Index for Urban Areas by CBSA - (Table 4A)

Austin, Texas (12420): 0.9501

DRG Relative Weight (Table 5)

DRG 75, Viral Meningitis w CC/MCC: 1.5369

Application For DRG 21 (example)

$3,077.46 (Labor-related portion of the NAOSA) X 0.9501 (Wage Index for the Area) + $1,886.18 (Nonlabor-related portion of the NAOSA) = $4,810.07 (Wage Adjusted Rate) X 1.5369 (DRG Relative Weight) = $7,392.60 (Basic DRG Payment for Austin, Texas Area Hospitals, DRG 21)

Payment for DRG 75 under the contract would be $7,392.60 plus or minus any premium or discount established as the contract rate.