Medical_adjudication.pdf

NATIONAL ACQUISITIONS AND SYSTEMS SECTION

JUSTIFICATION FOR OTHER THAN FULL AND OPEN COMPETITION

Pursuant to the Federal Acquisitions Regulation (FAR) Section 13.501(a) and the Bureau of Prisons Acquisition Policy Subpart 6.304(c), the Federal Bureau of Prisons has determined the use of other than full and open competitive procedures is justified for this procurement action. The following is supporting documentation formatted in accordance with FAR Subsection 6.303-2 (Content), as required in FAR Section 13.501(a) (1) (ii).

1. Contracting Agency - United States Department of Justice, Federal Bureau of Prisons (Bureau), Central Office, Administration Division, National Acquisitions and Systems Section. Requiring Office: United States Department of Justice, Federal Bureau of Prisons, Financial Management Section, Health Services Division (HSD).

2. Description of Action - This action is for a modification to a sole source purchase order so that the Bureau may continue to receive medical claims adjudication services, for healthcare service providers/contractors (healthcare providers) paid under Medicare-based rate structures. The modified order will be for the period from December 1, 2014 through January 31, 2015.

3. Description of SupPlies/Services Required to Meet the Agency's Needs - Inclusive of the Estimate Value - The Bureau has a requirement for medical claims adjudication services. These services are to ensure compliance with Medicare Claims processing guidelines/manual in conjunction with the National Correct Coding Initiative edits; for fee schedule healthcare providers, the objective is to ensure compliance with the applicable negotiated fee schedule. The Bureau currently provides healthcare to more than 219,000 inmates in more than 119 institutions geographically dispersed throughout the contiguous United States, Hawaii, and Puerto Rico.

4. Statutory Authority Substantiating this Action - The statutory authority permitting other than full and open competition is 41 u.s.c. 1901. It has been determined that the use of this authority is appropriate pursuant to FAR 13.501(a) (1) (ii), ~Prepare sole source (including brand .name) justifications

-1-using the format at 6. 303-2, modified to reflect an acquisition under the authority of the test program for commercial items at 41 U.S.C. 1901 or the authority of 41 U.S.C. 1903."

5. Determination that proposed Contractor's unique qualifications or the nature of the acquisition requires use of the authority cited- The purpose of medical claims adjudication is to ensure medical claims are arbitrated in accordance with current National Correct Coding Initiative edits in conjunction with Medicare/Centers for Medicare and Medicaid Services (CMS) claims processing guidelines and/or negotiated fee schedules, as applicable to underlying contracts. Medical claims adjudication also inco.rporates internal and systemic controls in the adjudications process to prohibit duplicate payments and ensure that the Bureau complies with the requirements of the Prompt Payment Act and Statement of Federal Financial Accounting Standards {SFFAS).

The Bureau currently has a four-month contract for these services with PGBA, LLC {PGBA) which ends on November 30, 2014 and is in the process of soliciting and awarding a new contract for medical claims adjudication but has encountered unforeseen circumstances and delays due to possible changes in the Bureau's Information Technology (IT) requirements. Also, in order to transition services from PGBA to a potentially new contractor, data rights must be transferred from PGBA to the new contractor (contractor) and the contractor must set up computer access for each institution and establish accounts/passwords for each of the institution's medical staff members to access the contractor's claims system {currently approximately 180 staff). This process requires the contractor to coordinate with the Bureau's IT department to ensure all system/security requirements are adhered to and are in compliance with Bureau guidelines. Also, current staff will need to be retrained to learn the new contractor's system. This will affect staff currently located at approximately twenty-two institutions.

Based on historical training data, training will be for about six people at each of the 22 institutions at 8 hours each for a total of 1,440 man hours in training time. It has been determined that ·a two month purchase order will be beneficial to the government due to the extensive ramp-up process in transitioning from PGBA to another contractor, if necessary.

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6. Efforts to Obtain Competition - The Contracting Officer will publish the Justification for Other than Full and Open Competition on the Federal Business Opportunities website, fedbizopps.gov, in accordance with FAR 13.501(a) (1) {iii).

7. Contracting Officer's Fair and Reasonable Cost Determination

- Based on the historical acquisition data and survey of the market, the Contracting Officer has made the determination that the proposed price shall be fair and reasonable.

8. Market Research - Market research was conducted by both the requiring activity and Contracting Officer. It has been determined that a sufficient number of vendors have bid on the solicitation.

9. Other Factors - A lapse of medical claims adjudication services would be detrimental to the Government since these services ensure compliance with Medicare Claims processing and ensure compliance with the applicable negotiated fee schedule. In a previous audit of Bureau's medical claims conducted by the Office of the Inspector General (OIG) in 2007, it was recommended that processes be put in place to "improve controls over the review of and payments for medical procedures" due to the Bureau being overcharged on several invoices. If services lapse, claims will be required to be adjudicated manually by the Bureau staff and currently the Bureau does not have the staff nor the expertise to adjudicate claims at the current institutions receiving adjudication services from PGBA.

10. List of Sources The contractor for medical claims adjudication services is as follows:

PGBA, LLC

8733 Highway 17 Bypass South Surfside Beach, SC 29575

11. Action to be taken to Promote Future Competition - The Bureau is committed to the competitive acquisition of requirements. It is the Bureau's policy to seek full and open competition to meet Bureau requirements when such competition does not impede mission imperatives. The Contracting Officer will continue to conduct market surveys in preparation of the future acquisition.

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12. Contracting Officer's Certification - I hereby certify this request for a Justification and Approval of Other than Full Competition is made in good faith, the supporting data and information are accurate and complete to the best of my knowledge and belief.

RONDA

MORROW

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Ronda J. Morrow, Contract Specialist Date National Acquisitions & Systems Section

13. Requirements/Technical Certification - I certify that the supporting data under my cognizance which are included in this justification are accurate and complete to the best of my knowledge and belief.

Financial Management Section

14. Concurrence- I certify that the above justification is accurate and complete to the best of my knowledge and belief.

National Acquisitions & Systems Section

C eH:nes: Scott, Chief Acquisitions Branch

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