1_J.2.B__ZPICZone4AwardFeePlan.doc

DRAFT

MEDICARE INTEGRITY PROGRAM (MIP)

Zone Program Integrity Contractor (ZPIC)

AWARD FEE PLAN

I. Overview and Award Fee Performance Evaluation Periods

This document provides the Award Fee Evaluation Plan for contract number ________, task order ______. Evaluation criteria contained in this plan will be used to determine the amount of Award Fee that will be earned by the contractor.

Prerequisite for Eligibility for Award Fee: In order to participate in the Award Fee program described in this plan, the contractor must obtain at least a minimum score of “3” or “Good” in each of the four (4) individual perspectives (Quality, Timeliness, Cost Control and Business Relations) for the most recent National Institutes of Health (NIH) Contractor Performance System (CPS) evaluation completed.

Annual Award Fee Evaluation Periods: The annual Award Fee Evaluation Period will correspond with the task order period of performance as follows:

II. Organizational Structure for Award Fee Administration

The following organizational structure is established for both CMS and the Contractor for administering the Award Fee provisions of the contract:

A. Fee Determination Official (FDO): The FDO is the Director, OFM, Program Integrity Group, or, should the program be moved to a different CMS component, the current Director for the Program Safeguard Contractor (ZPIC) program. The FDO shall review the recommendation of the Performance Evaluation Panel (PEP) and make a final determination of Award Fee earned and payable to the Contractor for each evaluation period. The FDO may determine a different Award Fee than the PEP recommendation. However, such determinations shall be substantiated by written documentation. The FDO determination shall be made within 45 calendar days following an Award Fee Evaluation Period. The final determination will be forwarded to the Contracting Officer for contractor notification.

B. Performance Evaluation Panel (PEP): The PEP is a panel comprised of the ZPIC Project Officer, Government Task Leader (GTL), Associate GTL, Contracting Officer (CO), Contract Specialist and other Government officials as necessary. The responsibilities of the PEP are as follows:

· Monitor the Contractor’s performance during the Award Fee Evaluation Period;

· Perform an in-depth review of the Contractor’s performance at the end of each Award Fee Evaluation Period.

· Prepare an Award Fee Recommendation Report to be submitted to the FDO no later than 30 calendar days after the close of each evaluation period. The report shall include, at a minimum,

· A contractor performance analysis against the evaluation criteria identified herein;

· Recommendation for an Award Fee amount to be earned by the Contractor; and,

· Signatures of all PEP members.

C. Contractor: The Contractor shall submit an Award Fee performance evaluation self-assessment in accordance with the Umbrella SOW Appendix A, and shall make available all information discussed in the self-assessment for Evaluation Criteria 2 to the PEP within 15 calendar days following the completion of each Award Fee evaluation period. The self-assessment shall provide substantiating documentation and analysis for the evaluation criteria and shall assess the contractor’s performance against the provided evaluation criteria. The contractor may submit a voucher for the final Award Fee as determined by the FDO at any time after written CO notification.

D. Contracting Officer Notification: The Contracting Officer shall provide the Contractor with written notification of the final Award Fee earned within 50 calendar days of the end of each performance evaluation period.

III. Summary of Tasks & Timeframes:

IV. Award Fee Criteria and Award Fee Pool Distribution

A. Award Fee Criteria: The Contractor shall be evaluated using two evaluation criteria as follows:

EVALUATION CRITERIA 1: QUALITY OF SERVICE

60% of the total available award fee pool is dedicated to Evaluation Criteria 1. Award Fee will be earned for those ZPIC’s with a score of 4 (Excellent) or 5 (Outstanding) in the individual Quality of Service key elements listed in the table below from the most recent National Institutes of Health (NIH) Contractor Performance System (CPS) evaluation completed during the award fee evaluation period. The ZPIC annual performance evaluation for Quality of Service is evaluated as shown below:

CMS will use, at a minimum, the following Control Objectives and Key Elements from the ZPIC’s performance evaluation within the Quality of Service perspective. A numerical score will be determined for each key element using the following scoring key:

Scoring Key

0 – Unsatisfactory

1 – Poor

2 – Fair

3 – Good

4 – Excellent

5 – Outstanding

The goal of the award fee plan is to determine award fee dollars earned for excellence in performance. Therefore, award fees will be earned for those key elements where the score is greater than 3 (Good).

Control

Objective

For Reference: The ZPIC is considered meeting the requirements (3-Good) if objectives are met in 85% - 94% of the investigations.

a)prioritizes all investigations to ensure that resources available are devoted primarily to high-priority investigations;

b) provides evidence that investigation files demonstrate an appropriate and ongoing prioritization process 12%

2. Investigation Files For Reference: The ZPIC is considered meeting the requirements if objectives are met in 85% - 94% of the investigations.

a) documentation supports a logical investigatory plan;

b) maintains files on all investigations and documents the action they are taking to substantial all allegations;

c) Investigations are not initiated on complaints that should have been returned to the AC or MAC;

d) the files are organized by provider or supplier with a system for assigning and controlling numbers and shall contain either in hard copy or the case management system all pertinent documents;

e) If the investigation demonstrates a pattern of fraud, discusses it with the OIG at the onset of the investigation, and obtains OIG’s recommendation on whether or not the investigation should be further developed for possible case referral to OIG/OI;

12%

3. LE Referrals For Reference: The ZPIC is considered meeting the requirements (3-Good) if the objectives are met in 85% - 94% of the cases.

a) If ZPIC does not hear from the OIG/OI within the first 90 calendar days following referral, and repeated attempts by the ZPIC to find out the status of the case are unsuccessful, the ZPIC contacts the FBI and/or refer the case to any other investigation agency with interest in the case.

b) follows up with this second referral to the FBI and any other investigative agency within 45 calendar days;

c) prepares complete and thoroughly documented case referral packages for OIG and the state Medicaid agency, if applicable, and the cases are not returned by law enforcement due to being incomplete or poorly documented.

10%

4. FID

For Reference: The ZPIC is considered meeting the requirements (3-Good) if the objectives are met in 85-94% of the investigations and cases.

5. Administrative Actions For Reference: The ZPIC is considered meeting the requirements (3-Good) if the objectives are met in 85%-94% of investigations and cases.

a) on a case by case basis, makes informed decisions on the need for administrative action. As appropriate, the ZPIC makes recommendations for suspension of payment, exclusion of providers, CMPs, prepayment review, postpayment review;

b) develops administrative action, but withholding final action until after consulting with OIG or other law enforcement agencies when taking such measures;

c) continues to monitor the need for administrative action prior to the elapsing of the 90 days and thereafter, and consults with OIG or other law enforcement agencies before taking such measures;

d) if law enforcement is unwilling to render a decision on administrative action or advises the ZPIC against taking administrative action, contacts the primary GTL, Associate GTL and SME with a recommendation;

e) refers all identified overpayments to the AC or MAC to recoup the overpayment.

12%

For Reference: The ZPIC is considered meeting the requirements (3-Good) if the objectives are met in 94% of the claims reviewed.

a) medical review considers all allegations identified in the complaint/investigation that could be validated through review of medical records;

b) MR decisions are consistent with national and local coverage determinations, statutory coverage provisions, and sound clinical judgment and includes reference to CFR, IOMs, and LCDs, patterns and trends, alterations, the service was actually provided, and the whether the service was medically reasonable and necessary.

12%

For Reference: The ZPIC is considered meeting the requirements (3-Good) if there are no, or very minimal, quality problems in meeting the objectives.

a) information is shared with only those that have a “need to know”;

b) mailroom maintains confidentiality;

c) access to sensitive material is restricted and shall never be left unattended;

d) when not being worked on, sensitive material will be kept in locked repository;

e) limited access to keys, codes, and passwords;

f) discarded sensitive information shall be shredded or stored in a locked container for subsequent shredding on a daily basis;

g) in compliance with HIPAA.

6%

2. Facility Security For Reference: The ZPIC is considered meeting the requirements (3-Good) if there are no, or very minimal, quality problems in meeting the objectives.

a) limits access;

b) ensures location of discussions of sensitive information cannot be heard by surrounding units;

c) monitors entrance and exit 6%

For Reference: The ZPIC is considered meeting the requirements (3-Good) if there are no, or very minimal, quality problems in meeting the objectives.

For Reference: The ZPIC is considered meeting the requirements (3-Good) if there are no, or very minimal, quality problems in meeting the objectives.

a) uses a variety of data from a variety of sources;

b) uses AC or MAC data, as appropriate;

c) uses proactive data analysis for potential fraud cases that result in BI MR review and case referrals;

d) is innovative in data analysis;

e) has a process for evaluating the effectiveness of its data analysis to ensure it results in valid outcomes.

12%

For Reference: The ZPIC is considered meeting the requirements (3-Good) if there are no, or very minimal, quality problems in meeting the objectives.

Total

100%

Evaluation Methodology for Criterion 1:

Award fee earned for evaluation criteria 1 is as follows:

PEP Evaluation Considerations: The PEP shall utilize a wide array of resources when reviewing ZPIC performance for Award Fee determination purposes. These resources include, but are not limited to:

1. A complete review of Quality of Service from the most recent annual NIH Performance Evaluation to determine the amount of award fee earned for each key element.

2. Obtaining Government Task Leader (GTL) and Subject Matter Expert (SME) input.

EVALUATION CRITERIA 2: ADMINISTRATIVE ACTIONS

40% of the total available award fee pool is dedicated to Evaluation Criteria 2. Award Fee will be earned based on the ZPIC’s ability to make continuous improvements in the area of administrative actions. The ZPIC is not being assessed award fee earned based on the number of administrative actions nor the amount of funds recovered as a result of administrative actions.

Award Fee Administrative Action Plan (AFAAP) Within the first three (3) months of the award fee evaluation period, the ZPIC shall submit an Award Fee Administrative Action Plan (AFAAP) to the Contracting Officer, GTL and Associate GTL. At a minimum, the AFAAP shall include the following:

· An outline of its plan to improve the volume, timeliness and dollar value of administrative actions.

· A plan to develop a method of tracking receipts of overpayments collected by the AC or MAC that were initiated by the ZPIC.

Reporting and Tracking Requirements:

The contractor shall track all administrative actions on a monthly basis and demonstrate continuous improvement throughout the award fee evaluation period. These administrative actions shall be broken out by type, i.e., Payment Suspension, Pre-pay Edits, Auto Denial Edits, etc. Overpayments sent to an AC or MAC for collection shall be listed along with the amount of the identified overpayment that was actually collected. This will require close coordination and collaboration with the AC or MAC. Progress on the achievements of the AFAAP shall be included in ZPIC monthly CMS ART workload reporting and discussed on GTL calls and regularly scheduled AC or MAC calls.

Self Assessment for Evaluation Criteria 2:

The contractor’s self-assessment for Evaluation Criteria 2 shall provide CMS with the following:

1. Summary of the goals outlined in the AFAAP along with accomplishments achieved for each goal. For example:

2. Summary outlining the accomplishments of the implementation and maintenance of the process developed with the AC/MAC to track the collection of overpayments calculated by the ZPIC.

3. A log of all administrative actions and subsequent results broken out by type of administrative action, i.e., Payment Suspension, Pre-pay Edits, Auto Denial Edits, etc. Overpayments sent to an AC or MAC for collection shall be listed along with the amount of the identified overpayment that was actually collected.

4. Documentation of any overpayments that were identified and sent to the AC or MAC that could not be collected due to reasons beyond the control of the ZPIC, AC or MAC. For example, the provider is no longer operating the business for which the overpayment was calculated.

Award Fee earned for Evaluation Criterion 2 is as follows:

The Award Fee Administration Action Plan submitted by the ZPIC is thorough and complete, timely, and updated during the award fee evaluation period as necessary. Progress on this initiative should be noted in each ZPIC monthly narrative in CMS ARTS and discussed on a regular basis with the GTL.

Successful implementation of this process will account for up to 25% of the award fee pool for Evaluation Criteria 2.

Continuous improvement of administrative actions throughout the award fee evaluation period as set forth in the Award Fee Administrative Action Plan. (If CMS determines that improvements were made outside the Award Fee Administrative Action Plan, CMS may take these improvements into consideration).

Accomplishment of these improvements will account for up to 50% of the award fee pool for Evaluation Criteria 2

PEP Evaluation Considerations: The PEP shall utilize and consider the following when reviewing the ZPIC’s performance on Evaluation Criterion 2:

1. A review of the AFAAP and CMS ART workload reporting monthly updates.

2. A review of the ZPIC’sZPIC Self Assessment of Evaluation Criterion 2 and;

3. Obtain Government Task Leader (GTL) and Subject Matter Expert (SME) input.

B. Award Fee Pool and Distribution:

1. Award Fee Pool: The total amount of Award Fee Pool available is as stated in Section B “Supplies or Services Prices/Costs” of the task order:

2. Distribution of Award Fee Pool: The Award Fee pool is distributed among the two Criterion in the following way:

Example of Award Fee Determination Total Award Fee Pool is $100,000 allocated as follows:

60% or $60,000 – Evaluation Criterion 1 40% or $40,000 – Evaluation Criterion 2

Step 1: Determine Eligibility:

The ZPIC has achieved at least a minimum score of “3” or “Good” in each of the four (4) individual perspectives (Quality, Timeliness, Cost Control and Business Relations) for the most recent National Institutes of Health (NIH) Contractor Performance System (CPS) evaluation completed during the evaluation period. The ZPIC is, therefore, determined eligible to participate in the award fee program.

Step 2: Determine Award Fee Earned for each criterion:

Evaluation Criterion 1 – The ZPIC received the following scores under each key element within Quality of Service in the most recent NIH/CPS evaluation completed during the evaluation period:

Scoring Key

0 – Unsatisfactory, 1 – Poor, 2 – Fair, 3 – Good, 4 – Excellent, 5 – Outstanding

TOTAL

$60,000

$35,880

Evaluation Criterion 2 – It was determined that the ZPIC achieved the following in the continuous improvement of administrative actions.

1. The project plan is thorough and complete, timely and updated as necessary during the award fee period and is duly noted in the CMS ART system – ZPIC earns 25% of the award fee pool or $10,000.

2. The ZPIC has an established process with the AC/MAC to track the collection of overpayments calculated by the ZPIC – ZPIC earns 25% of the award fee pool or $10,000.

3. The ZPIC has made and achieved continuous improvement of administrative actions throughout the award fee evaluation period as set forth in the AFAAP – ZPIC earns 50% of the award fee pool or $20,000.

Attachment J.2.B

Zone 4 A/B/DME/HHH Task Order 0001 Award Fee Plan