J.3.A__ZPICZone4M-MTOSOW.doc

Attachment J.3.A

ZONE PROGRAM INTEGRITY CONTRACTOR

ZONE 4 MEDI-MEDI TASK ORDER

STATEMENT OF WORK

I. SCOPE

The ZPIC shall perform fraud, waste, and abuse detecting and prevention activities for Medicare and Medicaid claims in the following states: Colorado, New Mexico, Oklahoma, and Texas.

The Medicare / Medicaid Data Analysis Center (herein after referred to as Medi-Medi) shall support the Centers for Medicare & Medicaid Services’ (CMS) efforts to combat fraud and abuse in the Medicare and Medicaid programs by performing computerized matching and analysis of Medicare and Medicaid data. Support shall also include fraud investigation services, to identify, develop, and refer to law enforcement aberrant activities in the Medicare and Medicaid programs in the above listed states. The results of Medi-Medi analyses shall be shared with the participating states.

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 and 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.

CMS has increased its efforts to use advanced technology to detect and prevent fraud and abuse and to ensure that CMS pays the right provider the right amount, for the right service, on behalf of the right beneficiary. Combining claims data from two major payers for health care services, Medicare and Medicaid, to search for aberrancies indicative of fraud or abuse, should increase the likelihood of detecting activity that may fall below the detection threshold in either program individually. Reasons for this include the fact that many providers serve both the Medicare and Medicaid-eligible populations, and that there are a large number of beneficiaries eligible for both Medicare and Medicaid benefits.

The following charts provide background information on Zone 4’s Medicaid program by state:

Zone 4 has a combined total of 5,295,000 Medicaid eligibles from 2003 and $25,137,246,000 in Medicaid payments from fiscal year 2005.

In 2006, Zone 4 had a combined total of 4,021,536 Medicare Beneficiaries and $29,750,524,277 in Fee For Service (FFS) Medicare payments. Data for 2007 shows 679,315 Medicare Part C Enrollees and 1,624,745 Medicare Part D Enrollees.

B.

Purpose The purpose of the ZPIC under the Medi-Medi Task Order for Zone 4 is to perform comprehensive problem identification and research to identify potentially fraudulent Medicaid and Medicare providers in its zone. Additional responsibilities shall include coordination of benefit integrity activities among participating states in its zone, and dissemination of relevant benefit integrity information to the respective participating states.

The expected outcomes for this Statement of Work are:

· Establishment and maintenance of good working relationships and extensive networking with both internal components and external partners, particularly with participating states and other Program Integrity Partners;

· Combining the most recent three years worth of health care claims data from the Medicare and Medicaid programs;

· Identification and use of data matching and analysis methods and techniques to detect and develop potential fraud cases;

· Statistical analysis and trending activities;

· Identification of appropriate corrective actions;

· Performance of quality investigations; and

· The development of appropriate and quality potential fraud cases for referral to appropriate health care oversight or law enforcement agencies.

II.

REQUIREMENTS

The ZPIC umbrella SOW is incorporated into this Task Order (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 umbrella SOW requirements and the TO SOW requirements for Zone 4.

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.

The ZPIC shall utilize all of the ZPIC umbrella SOW requirements EXCEPT FOR THE FOLLOWING SECTIONS, at this time:

Section 2 Part A, B, DME and HH+H

Section 3 Part C and Part D (Medicare Advantage and Medicare Prescription Drug Benefit) Section 5 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 1-12, 15-19, 41, 54-55, 58-83

Appendix G, Uniform Desk Review

Appendix I, ZPIC Edit Differentiation Chart

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 TO is transitioned from the outgoing PSC(s) in accordance with the requirements identified herein and the umbrella ZPIC SOW by September 30, 2008, and that the ZPIC is fully operational no later than October 1, 2008.

Constraints/Assumptions:

· The ZPIC shall assume the Texas Medi-Medi workload from the outgoing contractor(s) on Oct 1, 2008.

· For proposal purposes only the ZPIC shall assume the other states in Zone 4 will be implemented as follows: Colorado (May 1, 2008), Oklahoma (May 1, 2008), New Mexico (May 1, 2010).

· The ZPIC shall assume that claims will only be matched with A / B / DME / HH+H until such time as C & D Task Orders are awarded. For proposal purposes, please do not include the matching of C & D data after October 2009.

B. Specific Requirements:

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

Task 1

- Texas

ZPIC shall work in partnership with the Texas Health & Human Services Commission (HHSC), Office of Inspector General (OIG) to reduce potential fraud, waste, and abuse in the Medicare and Medicaid programs as set forth in the ZPIC Umbrella SOW.

Task 1a - Transition Activities Texas The ZPIC shall work with the HHSC and the outgoing PSC to transition the fraud and abuse detection and prevention activities. As a part of the transition period, the ZPIC shall develop a project plan, conduct a kick off meeting, and submit deliverables in accordance with the ZPIC Umbrella SOW. The ZPIC shall lead regular transition meetings with CMS, the outgoing PSC, and HHSC and maintain minutes for those meetings.

The duration of the transition period shall be May 1, 2008 through September 30, 2008. October 1, 2008 through April 30, 2009 is considered the Base Year.

Task 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 ART system.

Option 1 - Colorado

The ZPIC shall work in partnership with the Colorado Department of Healthcare Policy & Financing to reduce potential fraud, waste, and abuse in the Medicare and Medicaid programs as set forth in the ZPIC Umbrella SOW.

Option 2 - Oklahoma

The ZPIC shall work in partnership with Oklahoma Healthcare Authority to reduce potential fraud, waste, and abuse in the Medicare and Medicaid programs as set forth in the ZPIC Umbrella SOW.

Option 3 - New Mexico

The ZPIC shall work in partnership with the New Mexico Human Services Department OIG to reduce potential fraud, waste, and abuse in the Medicare and Medicaid programs as set forth in the ZPIC Umbrella SOW.

C. Reporting Requirements The ZPIC shall follow reporting requirements in the ZPIC Umbrella SOW.

D.

Personnel Requirements

The ZPIC personnel shall have data analysis and mining experience using healthcare data in support of fraud, waste and abuse detection. In addition ZPIC personnel shall have experience and knowledge of Medicaid and Medicare programs.

Key Personnel:

The Key Personnel requirements for this TO are IAW ZPIC Umbrella SOW Section 1.1.7. Key Personnel required for this TO are as follows:

· Task Order Program Director - The Task Order Program Director is required to be full time and on-site.

· Benefit Integrity (BI) Manager – The BI Manager is not required to be full-time.

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

· Medical Review (MR) for BI Manager – The MR for BI manager is not required to be full time.

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

· Chief Statistician – The Chief Statistician is required to be full time but not on-site.

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

· Lead Claims Review Analyst

IV. Appendices to this Task Order SOW

Appendix A – See ZPIC IDIQ Deliverables Schedule