AttachmentJ.1ZPICUSOWAmendment1.doc

Zone Program Integrity Contractor

Statement of Work

Centers for Medicare & Medicaid Services September 2007

81. GENERAL & ADMINISTRATION

81.1 – General

81.1.1 – Scope

81.1.1.1 - Background

101.1.1.1.1 - Medicare Integrity Program in the Health Insurance Portability and Accountability Act

111.1.2 - Purpose

111.1.3 - Basic Requirements

121.1.4 - Fundamental Activities

131.1.5 - Coordination

131.1.5.1 - Affiliated Contractors/Medicare Administrative Contractors

131.1.5.2 – One Program Integrity Project (One PI)

141.1.5.3 - Other Zone Program Integrity Contractors

141.1.5.4 - Working with Other Affiliated Contractors and Medicare Administrative Contractors Outside the Zone Program Integrity Contractor Zone

151.1.5.5 - Office of the Inspector General

151.1.5.6 - Department of Justice

151.1.5.7 - Federal Bureau of Investigation

151.1.5.8 - Medicaid State Agency and Medicaid Fiscal Agents

161.1.5.9 - Medicaid Fraud Control Units (MFCUs)

161.1.5.10 - State Agencies for Survey and Certification

161.1.5.11 - Law Enforcement Health Care Task Forces

161.1.5.12 - State Licensure Agencies

161.1.5.12.1 – State Licensure of Agents and Brokers

161.1.5.12.2 - State and Local Licensure and Enforcement Agencies

171.1.5.13 - Professional Societies

171.1.5.14 - Quality Improvement Organizations

171.1.5.15 - Managed Care Organizations

171.1.5.16 - Private Health Insurers

171.1.5.17 - Other Specialty Contractors

171.1.5.18 - Other Federal and State Agencies

181.1.5.19 – Appropriate CMS Staff

181.1.5.20 – Data Analysis Coordination

181.1.6 - Workload

181.1.7 - Key Personnel

181.1.7.1 - General Requirements

191.1.7.2 - Key Personnel

191.1.7.2.1 – Zone Program Director

191.1.7.2.2 – Task Order Program DirectorFee-for-Service Task Order Manager

1.1.7.2.3 - Medi-Medi Task Order Manager

201.1.7.2.3 4- Medical Director

211.1.7.2.4 5 - Cost Report Audit/Reimbursement Manager

211.1.7.2.5 6 – MMA Audit Manager

221.1.7.2.6 7 - Benefit Integrity Manager

221.1.7.2.7 8 - Medical Review Manager

221.1.7.2.8 9 - Chief Legal Counsel

221.1.7.2.9 10 - Chief Statistician

231.1.7.2.10 11 – Pharmacy Specialist

231.1.7.2.11 12 - Chief Actuary

231.1.8 - Other Essential Personnel

231.1.8.1 - Labor Category Personnel

241.1.8.1.1 - Benefit Integrity (BI) Analyst

241.1.8.1.2 - Senior Benefit Integrity (BI) Analyst

241.1.8.1.3 - Supervisor - Audit/Reimbursement (S-A/R)

251.1.8.1.4 - Senior Auditor/Reimbursement Specialist (SARS)

251.1.8.1.5 - Auditor/Reimbursement Specialist (ARS)

251.1.8.1.6 - Accounting/Reimbursement Technician (A/RT)

251.1.8.1.7 - Lead Claims Review Analyst

261.1.8.1.8 - Senior Claims Analyst

271.1.8.1.9 - Junior Claims Analyst

271.1.8.1.10 - Claims Review Analyst – Therapy

281.1.8.1.11 - Clinical Information Specialist

281.1.8.1.12 - Coding Analyst

281.1.8.1.13 - Coding Coordinator

281.1.8.1.14 - Data Analyst

291.1.8.1.15 - MAC Liaison

291.2 - Zone Program Integrity Contractor Administration

291.2.1 - Project Management

291.2.1.1 - Project Phases

291.2.1.1.1 - Transitional Phase

301.2.1.1.2 - Implementation Phase

301.2.1.1.3 - Fully Operational Phase

301.2.1.2 - Project Management Plan

311.2.1.3 - Kickoff Meeting

361.2.2 – Financial Management

361.2.2.1 - CMS Analysis, Reporting, and Tracking System (CMS ARTS)

361.2.2.2 - Payments from Providers or Beneficiaries

371.2.2.3 - Funding for Coordinated Zone Program Integrity Contractor/Appropriate MMEs

371.2.3 - Deliverables

371.2.3.1 - Deliverables

371.2.3.2 – Reporting Requirements

371.2.3.2.1 - Project Management Plan

381.2.3.2.1.1 - Transition Phase

391.2.3.2.1.2 - Implementation Phase

391.2.3.2.1.3 - Fully Operational Phase

401.2.3.2.2 – Transition Deliverables List

401.2.3.2.3 – Implementation Deliverables List

401.2.3.2.4 – Fully Operational Deliverables List

401.2.3.2.5 - Joint Operating Agreement - Draft and Final

401.2.3.2.6 - Public Relations Plan

411.2.3.2.7 - Lessons Learned Reports

411.2.3.2.8 - Cost Report

421.2.3.2.9 - Self-Assessment Report

421.2.3.2.9.1 - Annual Self-Assessment Report

431.2.3.2.9.2 - Award Fee Plan Evaluation

431.2.3.2.10 - Information Technology Systems Plan

441.2.3.2.11 - Systems Security Reporting

441.2.3.2.12 - Freedom of Information Act Reports

441.2.3.2.13 - Law Enforcement Requests Report

451.2.4 – Award Fee/Zone Program Integrity Contractor Performance Evaluation

451.2.4.1 - Award Fee

451.2.4.2 - Zone Program Integrity Contractor Performance Evaluation

451.2.4.2.1 - Evaluation Overview

451.2.4.2.2 - Objectives

451.2.4.3 - Evaluation

461.2.4.3.1 - Annual Performance Evaluation Process

461.2.4.3.2 - Performance Evaluation Data Sources

471.3 – Benefit Integrity

471.3.1 - General

471.4 – Requests for Information

471.4.1 - Customer Service

471.4.1.1 - Zone Program Integrity Contractor Denial Inquiries

481.4.1.2 - Telephone, Written, and Misdirected Inquiries

481.4.1.3 - Other

481.4.2 - Requests from Law Enforcement Agencies and Other Entities

481.4.3 - Freedom of Information Act Requests

491.4.4 - Ad Hoc Requests from the Centers for Medicare & Medicaid Services

491.5 – Information & Technology Systems and Security

491.5.1 - Access to Systems

491.5.1.1 - Data Use Agreement

491.5.1.2 - Other Systems Access Requirements

501.5.1.3 – Data Analysis Tools Available to the ZPIC at No Cost

511.5.2 - Systems

511.5.2.1 - General System Requirements

511.5.2.2 - Functions to be Performed on a Specific System

521.5.2.2.1 - Functions to be Performed Using the Shared Claims Processing Systems

521.5.2.2.2 - Functions to be Performed Using the ZPIC System

531.5.2.2.3 - Functions to be Performed Using Either System

541.5.2.2.4 - Imaging

541.5.2.3 - Hardware and Software Testing

541.5.2.3.1 - Affiliated Contractor and Medicare Administrative Contractor Shared Claims Processing System

541.5.2.3.2 - Zone Program Integrity Contractor Systems

541.5.2.3.3 - Other Systems

541.5.2.3.4 - Test Plan Guidelines

561.5.3 - Information Technology Systems Plan

571.5.4 - Telecommunications

581.5.4.1 - General Requirements

591.5.4.2 - Service Request Process Requirements

591.5.5 - Secure E-mail System

601.5.6 - Print/Mail Capability

601.5.7 - Security

601.5.7.1 - Physical and Operational Security

601.5.7.2 - System Security

611.5.7.2.1 - Certification for Compliance with CMS Systems Security Requirements

611.5.7.2.2 Administer Security Program

621.5.7.2.3 Correct Deficiencies

631.5.7.2.4 Corrective Action Attestation

631.5.7.2.5 Security Review and Verification

641.6 – Quality Assurance and Improvement

641.6.1 - Quality Assurance

641.6.1.1 - Zone Program Integrity Contractor Quality Assurance Program

641.6.1.1.1 - Cooperation/Coordination

641.6.1.1.2 - Quality

651.6.1.1.3 - Innovation

651.6.1.1.4 - ISO Registration

661.6.1.2 – Continuous Improvement Program

661.6.1.3 – Earned Value Management System

661.6.2 - Conflict of Interest

671.7 – Medical Review

671.7.1 - Medical Review

672. PART A, B, DME AND HH+H

672.2 – General

682.3 – ZPIC Administration

682.4 - Benefit Integrity

682.4.1 – Purpose

682.4.2 – Field Office Support

692.4.3 - Workload

692.4.4 – Reporting Requirements

692.4.4.1 – Joint Operating Agreement (JOA)

702.4.4.2 – Other

702.5 – Requests for Information

702.6 – IT Systems and Support

712.7 – Quality Assurance and Improvement

723. PART C AND PART D (MEDICARE ADVANTAGE AND MEDICARE PRESCRIPTION DRUG BENEFIT)

723.1 – General and Administration

723.1.2 - Assumptions and Constraints

723.2 - Administration

723.2.1 - Kickoff Meeting and Transition Activities

723.2.1.1 - Kickoff Meeting with Law Enforcement Agencies

733.2.2 – Deliverables and Reporting Requirements

733.2.2.1 - Law Enforcement Meeting Notes

733.2.2.6 - Audit Report

733.2.2.7 - Executive Summaries of Law Enforcement Referrals

733.2.2.8 - Improper Payments Report

733.2.2.9 - Deceased Beneficiary Postpayment Review Report

743.3 - Benefit Integrity

743.4 - Requests for Information

754. MEDICARE-MEDICAID (MEDI-MEDI)

754.1 - Background

754.1.1 – Vision

754.1.2 - Functional Statement

754.1.3 – Purpose

764.2 - General Requirements

764.3 - Workload

774.4 – Administration

774.4.1 - Transition Phase

774.4.2 - Implementation Phase

774.4.2.1 - Project Initiation Meeting

774.4.2.2 - Implementation Project Management Plan

774.4.2.3 - Coordination and Information Sharing

784.4.2.4 - Establish Medi-Medi Steering Committee

784.4.2.5 - Monthly Reporting

784.4.3 - Fully Operational Phase

784.4.3.1 - Coordination and Information Sharing

784.4.3.2 - Medi-Medi Steering Committee

784.4.3.5 - Monthly Reporting

794.5 - Data/IT Systems

794.5.1 - Transition Phase

794.5.2 - Implementation Phase

794.5.3 - Fully Operational Phase

794.6 - Data Matching

794.6.1 - Transition Phase

794.6.2 - Implementation Phase

804.6.3 - Fully Operational Phase

804.7 - Data Analysis

804.7.1 - Transition Phase

804.7.2 - Implementation Phase

804.7.3 - Fully Operational Phase

814.8 - Investigations and Cases

814.8.1 - Transition Phase

814.8.2 - Implementation Phase

814.8.3 - Fully Operational Phase

824.9 – Deliverables

824.9.1 - Monthly Status Report

824.9.2 - Cost Reports

834.9.3 - Project Management Plans

834.9.4 - Joint Operating Agreement

834.9.5 - Information Technology (IT) Plan

834.9.6 - Data Analysis Plan

834.9.7 - Data Matching Protocol

834.9.8 - Cross Claims Analysis Catalog Entries

834.9.9 - Medi-Medi Steering Committee Charter

834.9.10 - Medi-Medi Steering Committee Minutes

855. COST REPORT AUDIT, SETTLEMENT, AND REIMBURSEMENT

855.1 - Background and Purpose

865.2 - Requirements

885.3 - Coordination with Benefit Integrity Staff

885.4 - Types of Reviews and Cost Report Audits

885.4.1 - Cost Report Review with Benefit Integrity Staff

895.4.2 - Desk Reviews

895.4.3 - Field or In-house Cost Report Audits

915.4.4 - Special Cost Report Audit Initiatives

925.4.5 - Other Cost Report Audit and Reimbursement Related Activities

925.4.5.1 - Update the Health Care Provider Cost Report Information System

925.4.5.2 - Perform Periodic Interim Payment Reviews

925.4.5.3 - Interim Rate Review Process

935.4.5.4 - CMS’ Interim Payment Expectations

935.4.5.5 - TEFRA Exception Requests

935.4.5.6 - Intern and Resident Information Systems

935.4.6 - CMS’ Expectations

935.5 - Settlement of Cost Reports

945.6 - Processing Provider Cost Report Hearing Requests

955.6.1 - For Amounts in Controversy of at Least $1,000 But Less than $10,000

955.6.2 - For Amounts in Controversy of $10,000 or More

965.7 - Cost Report Reopenings and Corrections

975.8 - Improving the Cost Report Audit Process

1. GENERAL & ADMINISTRATIONtc "1.

SCOPE " \l 2

1.1 – General

1.1.1 – Scope

1.1.1.1 - Background tc "A.

Background " \l 3 Medicare was enacted in 1965 as Title XVIII of the Social Security Act (the Act). Medicare has two programs, the Hospital Insurance Program (HI or Part A) and the Supplementary Medical Insurance Program (SMI or Part B). Part A covers certain hospital and related health care services. A person who is entitled to Social Security monthly benefits or is a qualified railroad retirement beneficiary is automatically entitled to Medicare Part A beginning with the first day of the month in which the individual attains age 65. Medicare Part B is a voluntary program that pays all or part of the costs for physician services, laboratory services, ambulance services, durable medical equipment, prosthetics, orthotics, medical supplies, outpatient hospital services, certain home health services, services furnished by rural health clinics, ambulatory surgical centers, comprehensive outpatient rehabilitation facilities, and certain medical and other health services not covered by Part A of Medicare.

Sections 1816(a) and 1842(a) of the Act provide that public or private entities and agencies may participate in the administration of the Medicare program under agreements or contracts entered into with the Centers for Medicare & Medicaid Services (CMS) on behalf of the Secretary of the Department of Health and Human Services. These Medicare contractors are known as Fiscal Intermediaries (FIs) and Carriers. FIs have primarily processed bills and made payments for all facilities (Hospitals, Skilled Nursing Facilities (SNFs), Ambulatory Surgical Centers (ASCs), etc.). Carriers have primarily processed claims and made payments for all Part B services billed by a physician or supplier.

As part of these contractual duties, FIs and Carriers were charged to perform program integrity activities. These activities include, among other things, reviewing claims to make coverage determinations, deterring and detecting potential fraud and/or abuse, and auditing provider cost reports. In addition, FIs and Carriers performed the entire range of claims processing functions, including entering data, establishing computer edits to identify potential duplicate claims, and mailing notices to beneficiaries and providers. FIs and Carriers are referred to as affiliated contractors (ACs) throughout this umbrella SOW.

Approximately 19% or 8.3 million of the 43 million elderly and disabled people on Medicare are enrolled in a Medicare Advantage Plan. While Medicare HMOs have been an option for beneficiaries since the 1970s, it was the passage of the Tax Equity and Fiscal Responsibility Act (TEFRA) in 1982 that allowed Medicare beneficiaries to enroll in HMOs reimbursed on a cost or “risk-contracting” basis. Medicare HMOs were paid on a capitated basis set at 95% of Medicare’s fee-for-service costs in each county.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Public Law 104-191) was enacted on August 21, 1996. Section 202 of Public Law 104-191 adds a new section, §1893, to the Social Security Act that establishes the Medicare Integrity Program (MIP). MIP was established, in part, to strengthen CMS’ ability to deter potential fraud, waste and abuse in the Medicare program. It provides a separate and stable long-term funding mechanism for MIP activities. By expanding CMS’ contracting authority, MIP allows CMS to more aggressively carry out program safeguard functions. As part of this program, CMS created several new entities, including the Program Safeguard Contractors (PSCs). The PSCs were dedicated to program integrity and enhanced data capabilities.

The Balanced Budget Act of 1997 (BBA) added a Part C program to Medicare. At that time, it was referred to as Medicare+Choice (M+C). While health maintenance organizations (HMOs) have been an option under Medicare since the 1970s, the BBA authorized new Medicare plans, including preferred provider organizations, private fee-for-service plans and Medical Savings Accounts (MSA).

Under Medicare Advantage, plans must provide basic Medicare benefits, and plans must use any savings to reduce enrollee premiums or improve benefits. MA plans (excluding Private Fee for Service (PFFS) and cost plans) are required to offer at least one plan that includes the basic Medicare drug benefit or a plan with enhanced alternative drug coverage.

On December 8, 2003, the President signed into law the Medicare Modernization Act (MMA) (Public Law 108-173). Section 911 of MMA directed implementation of Medicare FFS contracting reform. Medicare Contracting Reform requires that CMS use competitive procedures to replace its current fiscal intermediaries and carriers with a uniform type of administrative entity, referred to as Medicare Administrative Contractors (MACs). MMA also establishes a new voluntary outpatient prescription drug benefit under Part D of title XVIII of the Social Security Act (Act). The prescription drug benefit, referred to as Medicare Part D, as well as an employer subsidy for qualified retiree health plans began on January 1, 2006. Coverage for the drug benefit is provided by private prescription drug plans (PDPs) that offer drug-only coverage, or through Medicare Advantage plans that offer both prescription drug and health care coverage (known as MA-PD plans).

The MMA renamed Medicare+Choice to Medicare Advantage and created new regional Preferred Provider Organizations (PPOs) and Special Needs Plans (SNPs) for dual eligibles and other vulnerable populations. In addition, the MMA increased Medicare Advantage payment rates on average to 110 percent of Medicare FFS levels for HMOs and 119 percent of Medicare FFS for private fee-for-service (PFFS) plans. In 2007, due largely by the higher payment rates, Medicare Private Health Plan Contracts increased to 604 and enrollment increased to 8.3 million. From December 2005 to February 2007 there has been a 350% increase of private fee-for-service enrollment; 35% increase in Regional PPOs; and17% increase in local HMOs and PPOs. Today 18% of beneficiaries are enrolled in private plans compared to 11% in 2003.

The final rule implementing the new Medicare Prescription Drug Benefit, and the final rule establishing and regulating the Medicare Advantage (MA) program were published in the Federal Register on Friday, January 28, 2005 and are available from the Federal Register online database at http://www.access.gpo.gov/fr/index.html. Other information on MMA can be found on the CMS website at http://www.cms.hhs.gov/medZPICarereform/.

Section 6034 of the Deficit Reduction Act (DRA) of 2005 created the Medicaid Integrity Program and amended Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). The national expansion of the Medicare-Medicaid (Medi-Medi) Data Match Program was implemented as part of the DRA. Medi-Medi is a partnership between Medicaid and Medicare that enhances collaboration to reduce fraud, waste, and abuse by matching claims data from both programs in order to identify improper billing and utilization patterns that may not be detected when the programs are viewed in isolation.

As result of contracting reform, seven zones have been created based on the newly established MAC jurisdictions. Included in the seven zones are five high risk areas. As a result of the seven zones, new entities entitled Zone Program Integrity Contractors (ZPICs) have been created to perform program integrity for Medicare Parts A, B, C, D, Durable Medical Equipment (DME), Home Health and Hospice (HH+H) and Medi-Medi.

1.1.1.1.1 - Medicare Integrity Program in the Health Insurance Portability and Accountability Act

One way CMS will carry out its authority under HIPAA, MIP and the MMA is through this Indefinite Delivery Indefinite Quantity (IDIQ) contract for work to be performed by a ZPIC. This umbrella Statement of Work (SOW) encompasses all of the fundamental activities that may be required of a ZPIC. However, no work will be performed on the umbrella SOW since individual Task Orders will be awarded under the IDIQ for specific requirements (refer to contract Section G - Contract Administration, for details on task ordering procedures).

Task Orders may be awarded by CMS or other government agencies identified herein for some or all of the activities identified in this umbrella SOW.

For example; a Task Order may be issued for all of the activities identified in this umbrella SOW under a Task Order SOW that may read “The Contractor shall perform all of the requirements of the umbrella SOW as the Zone Program Integrity Contractor for a specified Carrier, FI or MAC.” Or, a Task Order may be issued for some of the activities, such as “generate program safeguard edits,” or “perform cost report audits on specified providers.” Each Task Order will contain an individual statement of work for requirements to be performed that are within the scope of this umbrella SOW.

1.1.2 - Purpose tc "B.

Purpose " \l 3 The purpose of this Statement of Work is twofold.

1. It provides a vehicle to promote the integrity of the Medicare and Medicaid programs by accomplishing the following objectives:

· Identify, stop and prevent Medicare and Medicaid fraud, waste and abuse and refer instances of potential fraud, waste and abuse to the appropriate law enforcement agencies.

· Decrease the submission of abusive and fraudulent Medicare and Medicaid claims.

· Recommend appropriate administrative action (e.g., payment suspension recommendations and CMPs) to CMS as necessary in accordance with Medicare and Medicaid laws and regulations, etc., to ensure that appropriate and accurate payments for services are made, which are consistent with all Medicare and Medicaid rules and regulations.

· Coordinate potential fraud, waste and abuse with appropriate Medicare & Medicaid Entities (MMEs).

2. It establishes the fundamental activities that may be awarded by individual Task Orders under the ZPIC umbrella SOW.

1.1.3 - Basic Requirements tc "A.

Basic Requirements " \l 3 The Zone Program Integrity Contractor (ZPIC) shall:

· Furnish the necessary services and qualified personnel, facilities, equipment, materials, and supplies not otherwise provided by the Government as needed to perform the requirements set forth in this Statement of Work (SOW) as indicated in each individual Task Order. The ZPIC shall have all the necessary resources required for performance as a ZPIC within 90 days of issuance of a Task Order, unless otherwise specified in each Task Order.

· As applicable, work jointly with the appropriate MMEs to perform the tasks and activities identified in this SOW through a Joint Operating Agreement (JOA). The JOA shall be modified and updated to reflect any changes in the project. One hard copy to the appropriate MME, one CD ROM to the CO, and entry into CMS ARTS, identifying the changes through an appropriate means, shall be distributed to the Primary Government Task Leader (primary GTL), associate GTL, the AC(s), the MAC(s) and the Contracting Officer.

· Provide the Centers for Medicare & Medicaid Services (CMS) with complete and accurate information on all actions upon request.

· Perform requirements as defined in this SOW in accordance with applicable Medicare and Medicaid laws and regulations, CMS manuals, the Federal Managers’ Financial Integrity Act (FMFIA), Government Auditing Standards (GAS), the Chief Financial Officer (CFO) Act of 1990 and others as may be identified herein.

· Continuously evaluate the effectiveness of all actions.

· Coordinate with the appropriate MMEs to ensure adequate training of staff on program integrity issues.

· Maintain records and files in accordance with Appendix D, Records Retention.

· Report in accordance with deliverables listed and the deliverables schedule in Chapter 1, §1.2.3 and in Appendix A, Deliverables.

1.1.4 - Fundamental Activities

Fundamental activities of the ZPIC that will help ensure payments are appropriate and consistent with Medicare and Medicaid coverage, coding, and audit policy, and will also identify, prevent, or correct potential fraud, waste and/or abuse may include, but are not limited to, the following:

· performing BI investigations;

· referring cases to law enforcement;

· making coverage and coding determinations;

· review of audit, settlement, and reimbursement of cost reports;

· reviewing bids for participation in the prescription drug program (Part C and Part D only);

· assisting CMS in developing a list of entities that may require future monitoring based upon past history;

· conducting specified audits;

· conducting specified complaint investigations (Part C and Part D only);

· conducting preliminary investigations into entities conducting fraudulent enrollment, eligibility determination and benefit distribution (Part C and Part D only);

· matching and analysis of Medicare and Medicaid data;

· responding to law enforcement requests and providing expertise to law enforcement on ongoing investigations;

· implementing appropriate administrative actions;

· coordinating potential fraud, waste and abuse activities with the appropriate MMEs; and

· complaint screening (Part C and Part D only).

NOTE: The list of activities above is in no special order that is indicative of priority or weight.

The ZPIC shall perform these activities as specified in this SOW in a manner that maximizes resources and produces the most effective and efficient results. See individual chapters for more detail on fundamental activities for specific workloads (e.g. Part A, B, HH+H, and DME; Part C; Part D; Medi-Medi).

1.1.5 - Coordination tc "C.

Coordination " \l 3 The ZPIC’s success in safeguarding the Medicare Trust Fund depends on a close and coordinated working relationship with its internal components and external organizations. The ZPIC and its partners shall work together and communicate frequently in order to keep each other apprised of potential areas of vulnerability and to avoid duplication of efforts. The ZPIC shall work with and coordinate with, as necessary, external entities including, but not limited to, those described in the following sections.

1.1.5.1 - Affiliated Contractors/Medicare Administrative Contractors

Whether a program integrity function is performed by the ZPIC or AC/MAC, it is imperative that both entities work together to achieve the common goal of ensuring the integrity of the Medicare program.

1.1.5.2 – One Program Integrity Project (One PI)

The One Program Integrity (PI) project, begun in FY 2006, will, for the first time, provide streamlined, centralized access and analysis for standardized Medicaid data across multiple states, integrated with data from Medicare Parts A, B, and D. The initial focus of the One PI contract is to obtain and store Medicaid data

The One PI project will address business needs for CMS organizations, such as Program Integrity, Center for Medicaid and State Operations (CMSO), Office of Research, Development and Information (ORDI), and Office of Clinical Standards & Quality (OCSQ); contractors, such as ZPICs; state Medicaid agencies; and law enforcement, to name a few. Expanding business service to these users will consist of adding analytic tools, adding data sources (such as more states), adding additional contractors, and adding new types of contractors. The addition of these new data sources will enable CMS to house a richer data environment that will drive new capabilities such as the identification of episodes of care and identification of potential fraud perpetrated across multiple government programs. Additionally, when completed, this project will provide regional and national norms for the state Medicaid fraud units while reducing the states’ burden of multiple data submissions to CMS. Alternative analysis and cost benefit analysis will be used to select each new unit of business service.

Once One PI is completed, the ZPICs will be provided access to data that is standardized across states. One PI will also provide additional analysis to support potential fraud, waste and abuse by linking records together from the Medicare and Medicaid programs.

1.1.5.3 - Other Zone Program Integrity Contractors

The ZPIC shall coordinate with other ZPICs, when applicable, to ensure that efforts are coordinated to stop Medicare fraud, waste and abuse. The ZPIC shall utilize all available tools (e.g., the Fraud Investigation Database (FID) and CMS Customer Information System (HCIS)) to ensure coordination and the prevention of duplication of efforts. As a part of its coordination activities, the ZPIC shall participate in information sharing sessions, such as the Zone Program Integrity Contractor Data Users Group (ZPIC DUG).

In addition, the ZPIC shall work with other ZPIC contractors as needed when issues cross- zonal boundaries (e.g., when a case is national in scope). As a part of its coordination activities, the ZPIC shall participate in information sharing sessions, meetings, or conference calls as appropriate. The ZPIC shall share lessons learned, best practices and materials to the extent appropriate for greater success and enhanced coordination of the ZPIC program.

1.1.5.4 - Working with Other Affiliated Contractors and Medicare Administrative Contractors Outside the Zone Program Integrity Contractor Zone

The ZPIC shall work with ACs and MACs outside of its zone to share ideas and coordinate its program integrity efforts as necessary (e.g., attend national and Contractor Medical Director (CMD) conferences and participate in national conference calls).

The ZPIC shall also work with other MME organizations that assist Medicare beneficiaries including, but not limited to, the SMPs, which use volunteers to help identify and report Medicare potential fraud, waste and abuse and the Senior Health Insurance Assistance Programs (SHIPs), which provide counseling and assistance to Medicare beneficiaries.

1.1.5.5 - Office of the Inspector General All referrals by the ZPIC for potential Medicare fraud will be made to the Office of the Inspector General, Office of Investigations (OIG OI). The ZPIC shall provide the OIG with access, as needed, to its files, records, and data in accordance with the Memorandum of Understanding (MOU), and other relevant program guidance, among the Department of Justice (DOJ), the OIG, and CMS. (See Appendix F, MOU with Law Enforcement.) The ZPIC shall meet quarterly, or more frequently if necessary, with OIG agents in its zone to discuss pending or potential cases.

1.1.5.6 - Department of Justice

The ZPIC shall provide the DOJ with access as needed to its files, records, and data in accordance with the MOU and other relevant program guidance. (See Appendix F, MOU with Law Enforcement) The ZPIC shall meet with DOJ personnel when needed to enhance coordination between the ZPIC and the DOJ.

1.1.5.7 - Federal Bureau of Investigation The ZPIC shall provide the Federal Bureau of Investigation (FBI) with access as needed to its files, records, and data in accordance with the MOU and other relevant program guidance. (See Appendix F, MOU with Law Enforcement) The ZPIC shall meet with FBI personnel regularly to enhance coordination between the ZPIC and the FBI.

1.1.5.8 - Medicaid State Agency and Medicaid Fiscal Agents

Medicaid State Agencies identify aberrant practices and abnormal patterns that may constitute potential fraud, waste and abuse in the state program. Unlike Medicaid Fraud Control Units, these agencies investigate but do not prosecute potential fraud. Medicaid Fiscal Agents are responsible for processing Medicaid claims for the state. The ZPIC shall meet with the appropriate entity in each state performing the Medicaid program integrity function to coordinate state and local potential fraud cases. The ZPIC shall maintain an ongoing dialogue with these entities and shall coordinate appropriate anti-fraud, waste and abuse initiatives.

1.1.5.9 - Medicaid Fraud Control Units (MFCUs)

Located in the office of the State Attorney General, Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid fraud cases. The ZPIC does not have responsibility for investigating or researching Medicaid fraud per se, but is responsible for coordination with MFCUs. The ZPIC shall meet with MFCUs in order to coordinate state and local potential fraud cases. The ZPIC shall maintain an ongoing dialogue with MFCUs and shall coordinate appropriate anti-fraud, waste and abuse initiatives.

1.1.5.10 - State Agencies for Survey and Certification

The ZPIC shall coordinate information (e.g., quality of care, potential fraud, waste and abuse) with the state agencies that perform under the §l864 agreements that are referred to collectively as the certification process.

1.1.5.11 - Law Enforcement Health Care Task Forces

The ZPIC shall coordinate information about potential fraud, waste and abuse issues/cases with national, state, and local Law Enforcement Health Care Task Forces within its zone.

The ZPIC shall exchange information about potential fraud, waste and abuse issues/matters with national, state and local Law Enforcement Health Care Task Forces within its zone and participate in such task force meetings on a regular and consistent basis.

1.1.5.12 - State Licensure Agencies

The ZPIC shall share information with the state survey and certification agency, or any other administrative agency able to, and interested in, sanctioning providers who either bill inappropriately, fraudulently or mistreat patients.

1.1.5.12.1 – State Licensure of Agents and Brokers

The ZPIC shall share information with the state licensure agencies, or any other administrative agency able to, and interested in, sanctioning agents and brokers who inappropriately or fraudulently enroll Medicare beneficiaries into Medicare Advantage plans.

1.1.5.12.2 - State and Local Licensure and Enforcement Agencies

The ZPIC shall share information with the state survey and certification agency, or any other administrative agency and/or local agency able to, and responsible for, sanctioning providers who either bill inappropriately or fraudulently misrepresent themselves or mistreat patients.

1.1.5.13 - Professional Societies

The ZPIC shall meet as necessary with members of professional societies in order to gain input from the society, particularly with respect to the development of new/revised contractor policies.

1.1.5.14 - Quality Improvement Organizations

The ZPIC shall refer quality of care issues to Quality Improvement Organizations (QIOs) when these issues are discovered as part of the ZPIC’s anti-fraud, waste and abuse activities.

1.1.5.15 - Managed Care Organizations

The ZPIC shall maintain an ongoing dialogue with the appropriate personnel or units in managed care organizations, including Medicare Advantage (MA) and 1876 Cost plans within its zone and shall coordinate appropriate anti-fraud, waste and abuse initiatives with them.

1.1.5.16 - Private Health Insurers

To the extent permitted by statute, CMS, and other government regulations, the ZPIC shall share information and maintain an ongoing dialogue with private health insurers and shall coordinate appropriate anti-fraud, waste and abuse initiatives. The ZPIC shall consult CMS before sharing information with private health insurers, and CMS will advise the ZPIC on the nature and extent of information sharing and coordination it may have with private health insurers.

1.1.5.17 - Other Specialty Contractors

In the future, as CMS develops new types of specialty contractors, the ZPIC will be charged with working with them in an appropriate manner defined by CMS.

1.1.5.18 - Other Federal and State Agencies

The ZPIC shall work with other federal and state agencies not listed above (e.g., Drug Enforcement Agency, Food and Drug Administration, Federal Trade Commission, and Office of Personnel Management) as appropriate. Under these circumstances, the ZPIC shall work with CMS to determine the best method of working and collaborating with other such agencies.

1.1.5.19 – Appropriate CMS Staff

The ZPIC shall work with the Project Officer, primary GTL, associate GTL, and other designated CMS staff to coordinate work that the ZPIC needs to perform to fulfill the tasks under this umbrella SOW.

1.1.5.20 – Data Analysis Coordination

ZPICs shall be prepared to coordinate with other ZPICs and other MMEs, as applicable, to address nationwide data strategies that will integrate and analyze all applicable Medicare Part A, B, C, Medicaid and DMEPOS data, RDS data and Medicare Part D data (including CMS PDE data and retail pharmaceutical script data) to identify national trends. The ZPIC shall also utilize data from other sources, e.g. Medicare Beneficiary Database (MBD), National Counsel of Prescription Drug Programs (NCPDP), MediSpan, First Databank, as appropriate. In addition, the ZPIC shall be prepared to offer a strategy for obtaining and analyzing all data.

This ZPIC should be prepared to perform data analysis, utilizing an integrated database, within their zone, and refer these leads to CMS, CMS contractors (e.g., other ZPICs), and law enforcement as appropriate.

1.1.6 - Workload tc "D.

Workload " \l 3 All work required under this umbrella SOW will be designated by issuance of individual Task Orders. Task Orders awarded under this umbrella SOW are restricted to issuance by CMS and/or the OIG, FBI, DOJ, or other federal government agencies as may be identified by CMS. Task Orders will be issued for some or all of the tasks/requirements identified herein.

Furthermore, the ZPIC’s workload volume designated at the time of award of a Task Order may be increased during the period of performance of the Task Order. The Contracting Officer (CO) will notify the ZPIC reasonably in advance of assuming the increase in workload volume so that the appropriate actions may ensue.

1.1.7 - Key Personnel tc "A.

Organizational Structure and Key Personnel " \l 3

1.1.7.1 - General Requirements

When Task Orders are issued, key personnel positions will be identified in the Task Order Statement of Work (SOW).

1.1.7.2 - Key Personnel

The ZPIC shall maintain a staff of key personnel positions that are dedicated as FTEs, unless otherwise specified in the Task Order. Key personnel may be dedicated less than full time, unless otherwise noted, and may be shared across more than one Task Order as approved by the Contracting Officer (CO). Key personnel shall not serve dual responsibilities in key functions unless approved by the Contracting Officer (CO), e.g., the Program Director may not also serve as the Benefit Integrity Manager. Changes in key personnel positions shall be submitted to the Contracting Officer in writing for approval within 30 days prior to any change.

When key personnel positions are vacated due to unforeseen circumstances, a proposed replacement shall be submitted in writing for approval no later than 30 calendar days from the date the position was vacated. Interim replacements should be identified and approved by CMS when a permanent replacement cannot be identified within this time frame. CMS may consider a 60-day interim replacement until a permanent replacement is secured.

Unless otherwise approved by the Contracting Officer, the key personnel noted below shall possess the following minimum work experience and educational requirements (other key personnel may be identified in a Task Order along with the respective work experience and educational requirements):

1.1.7.2.1 – Zone Program Director

The Zone Program Director shall be full time and employed by the prime contractor and possess:

Work Experience

Tentc " i.

Work Experience " \l 5 or more years of professional experience, with at least 5 years related to healthcare, and at least 3 years as a manager responsible for managing complex systems and work flow.

Educational Requirements

A bachelor’s degree from an accredited institution, plus a master’s degree from an accredited institution or substitution of 4 additional years of related work experience in lieu of the master’s degree.

1.1.7.2.2 – Task Order Program Director

The Task Order Program Director shall possess:

Work Experience

Tentc " i.

Work Experience " \l 5 or more years of professional experience with at least 3 years as a manager responsible for managing complex systems and work flow and experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work.

Educational Requirements

A bachelor’s degree from an accredited institution, plus a master’s degree from an accredited institution or substitution of 4 additional years of related work experience in lieu of the master’s degree.

1.1.7.2.2 Fee-for-Service Task Order Manager

The Fee-for-Service Task Order Manager shall possess:

Work Experience

Tentc " i.

Work Experience " \l 5 or more years of professional experience with at least 3 years as a manager responsible for managing complex systems and work flow and experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work.

Educational Requirements

A bachelor’s degree from an accredited institution, plus a master’s degree from an accredited institution or substitution of 4 additional years of related work experience in lieu of the master’s degree.

1.1.7.2.3 Medi-Medi Task Order Manager

The Medi-Medi Task Order Manager shall possess:

Work Experience

Tentc " i.

Work Experience " \l 5 or more years of professional experience with at least 3 years as a manager responsible for managing complex systems and work flow and experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work.

Educational Requirements

A bachelor’s degree from an accredited institution, plus a master’s degree from an accredited institution or substitution of 4 additional years of related work experience in lieu of the master’s degree.

1.1.7.2.3 4 - Medical Director

The Medical Director shall possess:

Work Experience

Prior work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.

Extensive knowledge of the Medicare program, particularly the coverage and payment rules, as well as experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work.

Public relations experience such as working with physician groups, beneficiary organizations, and/or congressional offices is preferred.

Educational Requirements

Experience practicing medicine for at least 3 years as a board-certified doctor of medicine or a doctor who is currently licensed.

See PIM Chapter 1, §1.4 for further Medical Director requirements.

1.1.7.2.4 5 - Cost Report Audit/Reimbursement Manager

The Cost Report Audit/Reimbursement Manager shall possess:

Work Experience

Three to 5 years management experience in Medicare cost report auditing, settlement, and reimbursement.

Educational Requirements

Bachelor’s degree in accounting or equivalent with a master’s and/or Certified Public Accountant (CPA) certification (or 4 additional years of related work experience in lieu of CPA certification).

Knowledge of Medicare law, regulations, manuals, and instructions, and Government Auditing Standards (GAS).

1.1.7.2.5 6 – MMA Audit Manager

The Audit Manager shall possess:

Work Experience Three to 5 years management experience in the auditing field. Knowledge of Medicare reimbursement principles as they apply to Part D, Retiree Drug Subsidy (RDS) and Medicare Advantage is preferred.

Educational Requirements

Bachelor’s degree in accounting or equivalent with a master’s and/or Certified Public Accountant (CPA) certification (or 4 years of related work experience in lieu of CPA certification).

Knowledge of Medicare law, regulations, manuals and instructions, and Government Audit Standards (GAS). Experience auditing pharmaceutical benefit managers is preferred.

1.1.7.2.6 7 - Benefit Integrity Manager

The Benefit Integrity (BI) Manager shall possess:

Work Experience A minimum of 3 years supervisory experience in the general area of benefit integrity investigation. Medicare and Medicaid knowledge and experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work is preferred.

Educational Requirements

Bachelor’s degree in criminal justice, health science, administration or such areas as specified in the Task Order. Education requirements may be substituted if the applicant has 10 or more years of related benefit integrity experience.

1.1.7.2.7 8 - Medical Review Manager

The Medical Review Manager shall possess:

Work Experience

A minimum of 3 years supervisory experience in the general area of medical/ utilization review.

Educational Requirements

Bachelor’s degree in nursing with an active Registered Nurse license.

1.1.7.2.8 9 - Chief Legal Counsel

The Chief Legal Counsel shall possess:

Work Experience

A minimum of 3 years experience applying Medicare regulations.

Educational Requirements

Must be a licensed attorney.

1.1.7.2.9 10 - Chief Statistician

The Chief Statistician shall possess:

Work Experience

A minimum of 3 years experience using statistics to support corporate/business information needs.

Experience in statistical detection of potential fraud, predictive modeling, development of mathematical models, neural networks, and data mining or other analytical methods.

Demonstrated experience and knowledge of health care information (health claims data, ICD-9-CM codes, physician specialty codes, survey and certification data, pharmaceutical data including NCPDP file formats and codes, provider identifiers, etc.). Requirements may be further defined in the Task Order Statement of Work.

Educational Requirements

A minimum of a master’s degree in statistics or related discipline.

1.1.7.2.10 11 – Pharmacy Specialist

The Pharmacy Specialist shall possess:

Work Experience

Extensive knowledge of how prescription drugs are developed and managed. The Pharmacy Specialist (PS) shall have a minimum of five (5) years experience in prescription drug benefit management with three (3) years experience managing a prescription drug formulary, medication therapy management, and drug interaction program. The PS shall have experience in the development of plans and the review of claims to ensure clinically appropriate utilization. This shall include experience in claims analysis, claims data review for abnormalities, auditing of claims, and setting up edits and audits to ensure proper utilization of benefits. The PS shall also have knowledge and experience concerning the current uses of medications, new or emerging issues, issues related to electronic prescribing, among other general knowledge and experience in the prescription drug benefits.

Educational Requirements

The PS shall be a board trained certified pharmacist with a Doctorate of Pharmacy (Pharm. D) and trained in Biochemistry, Chemistry and Pharmacokinetics.

1.1.7.2.11 12 - Chief Actuary

The Chief Actuary shall possess:

Work Experience

A minimum of 5 years actuarial experience, preferably in the pharmaceutical industry.

Educational Requirements

A four year degree from an accredited institution and shall also be a member of the American Academy of Actuaries.

1.1.8 - Other Essential Personnel

1.1.8.1 - Labor Category Personnel

Although not considered key personnel positions, the following labor category personnel may be required for Task Orders issued under this SOW. When required by the Task Order, the respective job classification requirements are essential for performance under this contract. Waiver(s) from the essential personnel requirements may be submitted in writing to the Contracting Officer for approval. All waiver requests should include a copy of a resume along with supporting rationale for the deviation from these requirements.

1.1.8.1.1 - Benefit Integrity (BI) Analyst

The BI Analyst shall possess:

Work Experience

At least 2 years of experience in benefit integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.

Educational Requirements

At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical courses related to the position (e.g., law enforcement investigation, statistics, data analysis) and those who have met all requirements to be designated a Certified Fraud Examiner.

1.1.8.1.2 - Senior Benefit Integrity (BI) Analyst

The Senior BI Analyst shall possess:

Work Experience

At least 3 years of experience in benefit integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing, and developing information, and making appropriate decisions. At least 2 years of experience in project management.

Educational Requirements

At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical courses related to the position (i.e., law enforcement investigation, statistics, data analysis) and have met all requirements to be designated a Certified Fraud Examiner.

1.1.8.1.3 - Supervisor - Audit/Reimbursement (S-A/R)

The S-A/R shall possess:

Work Experience

A minimum of 2 years in a Medicare audit and reimbursement setting.

Management skills (planning, organizing, controlling) and demonstrated ability to lead a team.

Understanding of Government Auditing Standards, audit procedures, and financial analysis techniques.

Previous supervisory experience in a Medicare audit and reimbursement setting is preferred.

Educational Requirements

Bachelor’s degree in accounting or a related field with a minimum of 24 semester hours in accounting courses. A Certified Public Accountant (CPA) or Certified Management Accountant (CMA) certificate is preferred.

1.1.8.1.4 - Senior Auditor/Reimbursement Specialist (SARS)

The SARS will possess:

Work Experience

A minimum of 2 years of Medicare audit and reimbursement experience.

Educational Requirements

Bachelor’s degree in accounting or in a related field with a minimum of 24 semester hours in accounting. A Certified Public Accountant (CPA) certificate is desirable.

1.1.8.1.5 - Auditor/Reimbursement Specialist (ARS)

The ARS shall possess:

Work Experience

One or more years of Medicare audit and reimbursement experience and training to perform all Medicare desk reviews, audits, and settlements as assigned.

Educational Requirements Bachelor’s degree in accounting or in a related field, with a minimum of 24 semester hours in accounting.

1.1.8.1.6 - Accounting/Reimbursement Technician (A/RT)

The A/RT shall possess:

Work Experience

Bookkeeping and personal computer experience.

Working knowledge of Medicare rules and regulations.

Educational Requirements

High school diploma. Accounting and/or business college courses are desirable.

1.1.8.1.7 - Lead Claims Review Analyst

The Lead Claims Review Analyst shall possess:

Work Experience

At least 2 years utilization/quality assurance review and ICD-9-CM/CPT-4 coding experience.

Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required.

Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.

Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required.

Educational Requirements

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