1_J.2.A__ZPICZone4ABDMEHHHTOSOW.doc

Attachment J.2.A

ZONE PROGRAM INTEGRITY CONTRACTOR (ZPIC) TASK ORDER

STATEMENT OF WORK

Zone 4 - Parts A, B, DME and HH +H

I. SCOPE

The ZPIC shall perform fraud, waste and abuse detection, deterrence and prevention activities for Medicare claims processed within Zone 4 for the states of Colorado, New Mexico, Oklahoma and Texas.

A. Background

As a result of contracting reform, seven zones have been created based on the newly established Medicare Administrative Contractor (MAC) jurisdictions. As a result of the seven zones, new entities entitled Zone Program Integrity Contractors (ZPICs) have been created to perform program integrity functions for Medicare Parts A, B, C, D, Durable Medical Equipment (DME), Home Health + Hospice (HH + H) and the Medicare Medicaid Data Match Project (Medi-Medi). Of the seven zones, the Centers for Medicare and Medicaid Services (CMS) have designated five zones as having high risk areas. This task order statement of work (SOW) is for all benefit integrity (BI) work for Medicare Parts A, B, DME, and HH + H in Zone 4.

The following provides background information on the current workload by claim type:

CMS Workload by Provider State from the National Database for the period January 1, 2006 through December 31, 2006 Demographic Statistics for Zone 4 Part A

Demographic Statistics for Zone 4 Part B

Demographic Statistics for Zone 4 DME

Demographic Statistics for Zone 4 Part A (HH + H only)

B.

Purpose The purpose of the ZPIC under this Task Order (TO) Statement of Work (SOW) is to perform comprehensive problem identification and research to identify potential fraud, waste and abuse in Zone 4. Additional responsibilities shall include coordination of benefit integrity activities among the AC and MAC and other applicable Medicare and Medicaid Entities (MMEs) within its zone, and dissemination of relevant benefit integrity information to the respective MACs. The ZPIC shall also coordinate benefit integrity activities among other ZPICs as applicable.

This task order shall have the following outcomes:

· Perform the potential fraud, waste and abuse detection, deterrence and prevention workload within the zone specified within this SOW;

· Establish and maintain a positive working and networking relationship with the AC and MAC and other internal or external stakeholders;

· Identification of appropriate corrective actions;

· Performance of quality investigations;

· Refer quality potential fraud cases to the Office of Inspector General (OIG);

· Develop and introduce innovative data analysis methodologies for the early detection and prevention of abusive use of services, as well as possible fraud, waste and abuse schemes.

· Become fully operational for the BI workload for Medicare Parts A, B, DME, and HH + H on November 1, 2008.

· Address high risk areas in the Dallas and Houston areas in the State of Texas IAW with the Program Integrity Manual (PIM).

· Coordinate with the appropriate AC and MAC.

· Coordinate with other ZPICs as applicable

C. Technical Considerations

· The ZPIC shall assume that they will have read only access into the AC’s and MAC’s shared claims processing system(s), with the exception of DME for which they will have read and write access, as well as access to the Medicare Parts A, B, DME, and HH + H data available through the National Claims History File for the zone defined in this Task Order.

II.

REQUIREMENTS

The ZPIC umbrella SOW (USOW) is incorporated into this TO with the same force and effect as if it were provided in full text. Independently and not as an agent of the Government, the ZPIC shall furnish all of the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the Government, as needed to perform the ZPIC USOW requirements and TO SOW requirements for this workload.

NOTE: This TO SOW may be modified to incorporate additional workload not currently identified herein, as well as incorporate umbrella SOW section exceptions below. The addition of such workload is in the interest of economy and efficiency and considered a logical follow-on to the work identified herein. Additionally, ZPIC workload reconfigurations may be necessary in order to comply with the efficient and effective implementation of Medicare contractor reform or other programs that may be enacted by legislation. For example, workload for a certain state may be eliminated or added in order to realign the ZPIC with a Medicare claims processing contractor's workload.

The ZPIC may utilize all of the ZPIC USOW requirements EXCEPT FOR THE FOLLOWING SECTIONS, at this time:

Section 1.1.7.2.4 – Cost Report Audit/Reimbursement Manager

Section 5 (entire section), Cost Report Audit, Settlement and Reimbursement

Section 1.7.1 Only letter C applies, A, B, D, E and F are exempt.

Appendix A, Deliverables - Items 29 – 31, 40 & 41 Appendix G, Uniform Desk Review

Appendix I, ZPIC Edit Differentiation Chart Appendix L, Medi-Medi Polices and Procedures Manual

Appendix M, Part C and Part D Integrity Manual

Appendix N, Prescription Drug Event Data

Appendix P, Instructions for Completing the Medicare Prescription Drug Plan Bid Form for Contract Year 2006

Appendix Q, PDP Bid Pricing Tool

Appendix R, MARx User Information

Appendix S, Weekly Workload and Complaint Activity Report

Appendix T, Earned Value Management Industry Standard EIA – 748 Monthly EVMS Performance Reports

Appendix CC, Instructions for MA Bids

Appendix DD, MA-PD Bid Pricing Tools A. General Requirements:

The ZPIC shall ensure that the workload identified in this Task Order is transitioned from the outgoing contractor(s) in accordance with the requirements identified herein and the ZPIC USOW by October 31, 2008, and that the ZPIC is fully operational no later than November 1, 2008.

The Houston and Dallas areas in the State of Texas are CMS designated high risk areas. For requirements in high risk areas, follow the PIM chapter 4, §§4.32-4.32.1 and chapter 10, §§10.20-10.20.1.

Because fraud in Texas has demonstrated itself in numerous and diverse ways, differing counter approaches must continually change to anticipate and react if the fraud moves to other areas.

As such, the ZPIC shall assume all workload associated with these high risk areas from the outgoing contractor(s) and coordinate with the AC and MAC through the JOA process for addressing high risk areas.

Constraints/Assumptions:

· The ZPICs are constrained by the fact that CMS cannot make any changes to the shared claims processing systems at this time to support ZPIC activities. The AC currently operates using the FISS shared claims processing system for Part A, MCS for Part B, and VMS for DME. The MAC will use the same shared systems.

· Given the rampant fraud in the Dallas and Houston areas of Texas, the ZPIC shall have a physical office in close proximity to the designated high risk areas.

B. Specific Requirements:

Specific tasks to be performed, which are not identified in the umbrella SOW, provide more detail, or are changed from the umbrella SOW, are as follows:

1. Transition activities:

The ZPIC shall work with the AC and MAC and the outgoing PSC to transition the fraud and abuse detection and prevention activities. As part of the transition period, the ZPIC shall develop a project plan, conduct a kick-off meeting, and submit deliverables in accordance with the Umbrella SOW. The ZPIC shall lead regular transition meetings with CMS, the outgoing PSC, and the appropriate AC and MAC and maintain minutes for those meetings.

The transition period shall begin May 1, 2008 and end October 31, 2008.

2. Special Studies The ZPIC shall perform Special Studies as required by CMS. Special Studies will be delineated in a separate SOW and incorporated as an Appendix to this task order SOW. All Special Studies will be funded and billed separately from the basic task order SOW. Special Studies costs will be tracked in a separate column in the basic task order cost structure in the CMS Analysis, Reporting & Tracking (CMS ART) system.

3. Zone Specific High Risk Area Projects and Demonstrations The ZPIC shall perform Zone Specific Projects and Demonstrations for high risk areas as required by CMS. Zone Specific Projects and Demonstrations for high risk areas may require periodic reporting to designated CMS individuals.

C.

Personnel Requirements

Key Personnel:

The Key Personnel requirements for this Task Order are IAW ZPIC USOW Section 1.1.7. Key Personnel required for this Task Order are as follows:

· Task Order Program Director - The Task Order Program Director must be full-time and on-site where the majority of the work is being performed.

· Benefit Integrity (BI) Manager – The BI Manager must be full-time and on-site where the majority of the work is being performed.

· Chief Legal Counsel - Chief Legal Counsel is not required to be full-time.

· Medical Review (MR) for BI Manager – The MR for BI manager must be full-time and on-site where the majority of the work is being performed.

· Medical Director – The Medical Director is not required to be full-time.

In addition, Essential Personnel requirements for this Task Order are IAW ZPIC USOW Section 1.1.8. Essential Personnel required for this Task Order are as follows:

· BI Analyst

· Senior BI Analyst

· Data Analyst

· MAC Liaison

· Lead Claims Review Analyst

IV. Appendices to this Task Order SOW

Appendix A – See ZPIC IDIQ Deliverables Schedule