J-06 Award Fee Sample.docx

RFP- RRB-11-R-001- Attachment J-06

Award Fee Plan For RRB Part B Specialty Medicare Administrative Contractor

(RRBSMAC)

Nationwide Jurisdiction

Effective Date

TBD

Evaluation Period

TBD

I. OVERVIEW

This document provides the Award Fee Evaluation Plan for the Nationwide Jurisdiction Part B Specialty Medicare Administrative Contractor (MAC) contract awarded to Contractor X. The performance criteria contained within this plan will be used, along with other performance-related information, to determine the amount of award fee that will be earned by the Contractor.

The purpose of utilizing the award fee process is to motivate and reward Contractor excellence in the performance of contract requirements critical to program success, while the Contractor meets at least minimum acceptable performance levels in all other areas.

The award fee may be awarded in whole, in part, or not at all based on evaluated performance exceeding minimum contract requirements.

II. THE AWARD FEE PLAN

The award fee plan describes how the Contractor will be evaluated and how the award fee will be administered. The plan identifies the criteria to be used to evaluate the Contractor’s performance as it relates to the award fee for the performance period. The plan also identifies the roles and responsibilities of those who will participate in the evaluations.

The Award Fee Plan:

· Is approved by the RRB Contracting Officer, In consultation with CMS and the RRB Performance Evaluation Board (PEB), and the RRB Fee Determining Official (FDO);

· Allocates the fee pool among performance categories;

· Specifies the evaluation cycle;

· Identifies the roles and responsibilities of those who will participate in the evaluation; and

· Describes criteria for evaluating the Contractor’s performance.

The FDO may unilaterally change the award fee plan prior to the beginning of an evaluation period. The Contractor will be notified of changes to the plan by the Contracting Officer, in writing, before the start of the affected evaluation period. Changes to this plan that are applicable to a current evaluation period will be incorporated by mutual consent of both parties.

1.0 Fee Arrangement

The fee arrangement is negotiated based on the total estimated cost of the contract. There are regulatory limitations on total fee (cumulative base fee and award fee) for a Cost Plus Award Fee contract. The fee consists of two parts, the base fee and the earned award fee.

1.1 Base Fee. The base fee can be viewed as the minimum compensation for the resources a Contractor uses or the investment it may undertake in order to perform the contract.

1.2 Earned Award Fee. The earned award fee is the amount of fee set aside in the contract that is available to be earned by the Contractor for exceeding minimum contract requirements. The Contractor is not guaranteed a minimum amount of award fee. Consequently, some, none, or the entire maximum available award fee may be earned. The amount of the fee awarded to the Contractor is unilaterally determined by the Government’s evaluation of the Contractor’s performance which exceeds contract requirements.

1.3 Prerequisite for Eligibility for Award Fee: In order to participate in the Award Fee program described in this document, the Contractor must obtain at least a minimum score of “Fair” in each individual perspective/evaluation criterion for the most recent Department of Defense (DOD) Past Performance Information Retrieval System(PPIRS) evaluation during the evaluation period.

2.0 Performance Evaluation Period

Please note however, that the base year evaluation period begins with the first full month, and ends with the last full month of the contract year, unless otherwise specified. The final determination of the fee earned will be accomplished within 90 days after the end of the contract year.

3.0 Organizational Structure for Award Fee Administration

The award fee organizational structure is established for administering the award fee provisions of this contract. The organization consists of the following:

Fee Determining Official (FDO). The FDO is the Director of Programs. The responsibilities of the FDO are to:

· Approve the award fee plan and any significant changes;

· Review the Performance Evaluation Board (PEB) report, Contractor input, and other pertinent performance data; and

· Make a final determination of award fee earned and payable for each evaluation period.

Performance Evaluation Board (PEB). The PEB is comprised of the RRB Project Officer; RRB Contracting Officer; RRB Contract Administrator; RRB Medicare (SMAC) COTR and the Medicare Program Operations Specialists; RRB Director, Unemployment and Programs Support Division; and designated CMS Medicare Award Fee Program Specialists. The responsibilities of the PEB are to:

· Review Performance Monitors’ evaluation of the Contractor’s performance;

· Consider all evaluation information from pertinent sources;

· Prepare a report to the FDO on the recommendation of an award fee to be earned by the Contractor; and

· Substantiate the recommended award fee to the FDO.

The PEB report is due to the FDO 70 days after the end of the evaluation period.

Performance Monitors. Performance Monitors are RRB staff, who maintain written records of the Contractor’s performance in their assigned evaluation area(s), so that a fair and accurate evaluation is obtained. Performance Monitors will review and consolidate periodic monitoring information for inclusion in their performance monitor reports, which are due to the PEB no later than 45 days after the end of the evaluation period.

Contractor Input. The Contractor shall provide a written award fee performance evaluation self-assessment to the RRB Project Officer and RRB Contracting Officer within 30 days of completion of the award fee evaluation period. The Contractor should provide as much detail as is necessary to assist the evaluators in making their final determination; however, any written self-assessment shall not exceed 20 pages in length. When preparing the self-assessment, the Contractor shall use the attached Award Fee Evaluation template. The self-assessment should be submitted in MS Word. (See Attachment J6A)

Notification to the Contractor. The Contractor shall receive written notification of the award fee determination within 90 days of the end of the contract year.

III. AWARD FEE CRITERIA - SCORING

1.0 Award Fee Categories:

1.1 Implementation Evaluation Period (if applicable)

RRB in conjunction with CMS will assess the Contractor’s performance against the stated metrics in the following areas:

-Successful Claims Workload Cutover -Risk Mitigation

1.2 Operational Evaluation Period

RRB in conjunction with CMS will assess contractor performance against stated metrics in the following areas:

A. Contract Administration B. Provider Customer Service Program C. Claims Processing Timeliness D. EMC Claim Increase E. Appeals Redetermination Timeliness F. Beneficiary Customer Service Program G. Medical Review H. Reduction in Paper Remittance Advice I. Electronic Funds Transfer (EFT) J. Provider Enrollment (PE)

2.0 Distribution of Award Fee Pool

2.1 Implementation – if applicable

The award fee will be distributed in the following manner for the implementation period:

2.2 Operational

The award fee will be distributed in the following manner for this evaluation period:

Award FEE Pool Distribution

60%

In the event that an award fee metric is no longer applicable, RRB reserves the right to reallocate the award fee pool associated with that metric among the remaining award fee criteria and disperse accordingly.

In addition, RRB will provide an overall adjectival rating for the Contractor’s award fee performance based on the percentage of award fee earned in compliance with the following chart:

3.0 Award Fee Process

At the end of the award fee period, the RRB Project Officer reviews the work performed during that period. The RRB Project Officer and Performance Monitors evaluate the Contractor’s performance in accordance with the Performance Metrics and the Statement of Work. The Project Officer and the Performance Monitors make a recommendation regarding the percentage of fee to be awarded. This recommendation is subject to the Contracting Officer’s review of the Contractor’s performance of the contract.

This recommendation is provided to the PEB and finally, the FDO. The FDO will take into account the Contractor’s overall performance on the contract, when making an earned award fee determination. The FDO, may at his or her discretion, increase or reduce the amount of the award fee under the contract, or determine not to make payment of any award fee, for example, if the Contractor exceeds its budget amount or if the Contractor otherwise has not managed its costs under the contract in an efficient and effective manner.

4.0 Performance Metrics

4.1 Implementation Award Fee Metrics

The Contractor shall be evaluated by the Project Officer and the Implementation Lead using the following evaluation criteria:

Award Fee Criterion 1: Successful Claims Workload Cutover

The Contractor successfully implements each workload segment on the final approved implementation plan cutover date. Successful implementation means that 95% of clean claims are processed within the claims payment floor and ceiling specified in IOM Pub. 100 – 04, Chapter 1, sections 80.2.1.1 and 80.2.1.2

Award Fee Criterion 2: Risk Mitigation

The Contractor appropriately mitigates and/or takes action when segment risks affect segment implementation and/or operations. In addition, the Contractor proactively communicates with RRB and CMS regarding any impending problems during the implementation period.

4.2 Operational Award Fee Metrics

The Contractor shall be evaluated using the following evaluation criteria:

Award Fee Criterion 1: Contract Administration

This award fee metric measures overall contract management. RRB and CMS will consider at a minimum the Contractor’s performance in the areas of cost and project management.

· The SMAC proactively proposes innovative and cost effective solutions to problems that are implemented in the Contractor’s own jurisdiction (e.g., automating manual operations).

· The SMAC focused on identifying and solving problems, with no negative impact to RRB and CMS.

· The SMAC is consistently under budget.

· Collaboration with other entities, including other MACs and Law Enforcement agencies is evidenced by positive program improvements and problem-solving that has broad program benefit, as well as prevention of Fraud, waste, and abuse of Medicare Trust funds.

80% - 100%

· The SMAC proactively proposes innovative and cost effective solution(s) to problems that have the potential to be “piloted” or implemented in the contractor’s jurisdiction (e.g., automating manual operations).

· Problem solving only requires guidance and does not consume additional government resources.

· The SMAC does exhibit cost savings.

60% - 79%

· Problem solving consumes minimal additional government resources.

· Quality end results are consistently delivered according to schedule.

40% - 59%

The data source for this metric is the Contracting Officer and Project Officer who will evaluate on an ongoing basis.

Award Fee Criterion 2.1: Provider Customer Service Program – Accuracy

This criterion measures the accuracy with which the Contractor’s Customer Service Representatives (CSRs) respond to Medicare policy questions. In order to earn the award fee for this metric, the Contractor will respond to policy questions with a 90% accuracy rate for the award fee period. The data source for this metric is CMS monthly initiated calls to the Contractor with a summary score reported for the period of performance. The response must be provided by the CSR that was originally posed the question, even if the response is provided as a call back within ten business days of the inquiry. If the call is returned by a different CSR, unless demonstrated extenuating circumstances exist, the call will be scored as incorrect.

Award Fee Criterion 2.2: Provider Customer Service Program – Self-Service Utilization Rate

This criterion measures the rate at which providers and beneficiaries in the contractor’s jurisdiction use the Interactive Voice Response (IVR) system and the Internet Portal (if the contractor has one). For this award fee metric, the utilization rate shall average at least 75% in the last two months of the evaluation period. If the contractor proposed an IVR handle rate greater than 75% during the procurement process, RRB and CMS will adjust this award fee metric to be greater than the proposed IVR handle rate. If the contractor does not have an Internet Portal, the utilization rate is the IVR handle rate. If the contractor has both an IVR and an Internet Portal, the utilization rate is the (# of Calls Handled in IVR + Internet Portal Sessions) / (IVR Only Completed Calls + CSR Only Completed Calls + Internet Portal Sessions) *100. The data used to determine this metric will be taken from the data reported into the Provider Inquiries Evaluation System (PIES).

Award Fee Criterion 2.3: Provider Customer Service Program - Listserv

The Contractor shall actively market and promote the benefits of being a member of the provider listserv(s). No later than 15 days prior to the end of the operational award fee period, the total of unique, individual members of its provider listserv(s) shall be at 15% or higher of its active provider count for the entire jurisdiction, as supplied by the Contractor.

Award Fee Criterion 3: Claims Processing Timeliness (CPT)

This criterion measures the timeliness of processing clean, electronic claims within statutorily specified timeframes. Specifically, clean electronic claims are to be paid as early as the 14th day after receipt and must be paid by the 31st day of receipt. Part B CPT only will be evaluated for purposes of this award fee criterion.

In order to be eligible for participation in this criterion, the Contractor shall process at least 95.0% of clean, electronic claims within statutorily specified timeframes. If the Contractor has one or more months during the period in which the Contractor does not achieve the 95.0% performance threshold, then the Contractor is not eligible for participation in this criterion.

Award fee for this metric, will be earned based on the number of months the Contractor achieves a 99.0% performance level for processing clean, electronic claims within statutorily specified timelines. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 99.0% CPT rate by the number of months in the operational period. For example, if there are six (6) months in the operational period and the Contractor achieves the 99.0% CPT rate for four (4) of the six (6) months, the Contractor would earn 67% of the award fee for this metric. The data source for this metric is the Contractor Reporting Operational Workload Data (CROWD) system which reflects monthly performance.

The RRB rounding convention for this metric is to one decimal place. Values of five (5) and above are rounded up and values of four (4) and below are rounded down. For example, a CPT score of 98.95% would be rounded to a 99.0% and a score of 98.94% would be rounded to 98.9%. Please note, because the data in CROWD is already rounded to one decimal place, a score of 98.9% in CROWD would NOT be rounded up to 99.0% for purposes of award fee evaluation.

Award Fee Criterion 4: EMC Claims Increase

This criterion measures the contractor’s efforts to increase the number of electronic claims received monthly.

In order to be eligible for participation in this criterion, the Contractor must receive over 91% of its monthly claims electronically. The Award fee for this metric will be earned based on the number of months the Contractor achieves a 91.0% EMC Rate. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 91.0% EMC Rate by the number of months in the operational period. For example, if there are six (12) months in the operational period and the Contractor achieves the 91.0% EMC Rate for eight (8) of the twelve (12) months, the Contractor would earn 67% of the award fee for this metric.

Award Fee Criterion 5: Appeals Redetermination Timeliness

This criterion measures the Contractor’s timeliness in processing and sending 100% of redetermination notices within 60 calendar days of receipt. In order to be eligible for participation in this criterion, the Contractor shall process at least 90% of redeterminations within 60 calendar days of receipt for all months of the period of performance.

The percentage of Award Fee earned will be calculated by dividing the number of months that the metric was met by the total number of months in the evaluation period.

The data source for this metric is the CROWD, CMS-2592 Appeals Workload Report and data submitted in the monthly report. Redetermination timeliness is calculated by dividing the sum of redeterminations cleared in 60 days (line 15) by the total cleared (lines 15 + 16). For validation purposes, the sum of lines 15 + 16 should equal line 6 (requests cleared) – line 7 (requested cleared where evidence is submitted after request). Redeterminations subject to the 74-day processing timeframe, because documentation is submitted later in the process (as reported on lines 7, 18, 19, and 20), are not to be included in the calculation for this metric. For this metric, timeliness is calculated to two (2) decimal places, with a hundredth value of five (5) and above rounded up, and hundredth value of four (4) and below rounded down. Therefore, a value of 99.95% or above would be rounded to 100%, and a value of 99.94% would be rounded to 99.9%.

Award Fee Criterion 6.1: Beneficiary Customer Service - Inquiries

This criterion measures the timeliness of responses to complex inquiries forwarded from 1-800-Medicare/Beneficiary Contact Center (BCC) or from CMS or RRB Regional Offices.

In order to be eligible for participation in this criterion, the Contractor shall respond to beneficiary telephone and written inquiries within 25 business days for at least 75% of inquiry cases and within 45 business days for 95% of inquiry cases referred by 1-800-Medicare/Beneficiary Contact Center via the Next Generation Desktop. Both timeliness standards must be met to be eligible for participation in this award fee criterion. Timeliness will be calculated using Next Generation Desktop summary (i.e., not monthly) data for the entire award fee evaluation period. The National Data Warehouse Complex Inquiry materialized view is to be used as the single source for reporting. Please review JSM/TDL-09256 for information on how this metric is calculated.

Award fee for this criterion will be based on the number of months in the award fee period that the Contractor responds to 80% of beneficiary telephone and written inquiries within 10 business days. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 80% performance level by the number of months in the award fee period. For example, if there are 12 months in the award fee period and the Contractor achieves the 80% rate for seven of the 12 months, the Contractor would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 6.2: Beneficiary Customer Service – Average Speed to Answer (ASA)

This criterion measures the average speed to answer beneficiary phone calls. Currently 99% of the beneficiary phone calls are to be answered within 120 seconds. This data is summarized on monthly statistical phone data reports.

The award fee for this criterion will be based on the number of months in the award fee period that the Contractor answers to 99% of beneficiary telephone calls within 120 seconds. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 99 performance level by the number of months in the award fee period. For example, if there are 12 months in the award fee period and the Contractor achieves the 99% rate for seven of the 12 months, the Contractor would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 6.3: Beneficiary Customer Service – Call Completion Rate

This criterion measures the call completion rate; currently the call completion rate must equal or be less than 70%. This data is summarized on monthly statistical phone data reports.

The award fee for this criterion will be based on the number of months in the award fee period that the Contractor’s beneficiary call completion rate was equal to or greater than 70 percent. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the performance level by the number of months in the award fee period. For example, if there are 12 months in the award fee period and the Contractor achieves the 70% or higher rate for seven of the 12 months, the Contractor would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 7 Medical Review

This criterion measures the annual Medicare Review Strategy Report as outlined in the Medicare Program Integrity Manual, Chapter 7, MR Reports Annual MR Strategy with the goal of reducing the claims payment error rate.

The award fee for this criterion will be based on 100% of the contractor reviews conducted and completed on all prioritized problems as stated in the MR Strategy Report in both prepay and post pay review. This also includes all probe reviews that have been identified through data analysis and earmarked as part of the medical review activities. A probe review is a random sample of 20 to 40 claims in the case of a provider-specific problem, or 100 randomly sampled claims for a widespread or service-specific problem.

Award Fee Criterion 8: Decrease in the Number of Paper Remittance Advices

This criterion measures the Contractor’s ability to decrease the number of paper remittance advices sent to providers in its jurisdiction. The contractor shall include the number of paper and electronic remittance advices sent in its monthly status reports.

Award fee earned will be based on the percentage decrease in the number of paper remittances sent during the last three months of the award fee period compared to the baseline. The baseline will be calculated based on the percentage of remittances sent in the first three full months of the award fee period. The data source for this metric, for Part B, will be line 8 in the CROWD 3.2.19 5 List report.

Award Fee for Part B (decrease in number of paper remittances) will be earned as follows:

Award Fee Criterion 9: Increase in Use of Electronic Funds Transfer (EFT)

This criterion measures the Contractor’s ability to increase the use of EFT payments to existing Medicare providers. The contractor shall include EFT statistics in its monthly status reports. Specifically, the contractor should include the number of EFT payments made to providers, as well as, the number of paper checks sent to providers by month, broken out for Part B only. The data source for this metric, for Part B, will be line 9 in the CROWD 3.2.19 5 List report. Award fee earned will be based on the increase in the % of EFT transactions made in the last full month of the award fee period compared against the % of EFT transactions made in the first full month of the award fee period (which will be the baseline).

Award Fee Criterion 10: Provider Enrollment Calls

This award fee criterion measures the Contractor’s call completion rate for provider enrollment calls. In consideration of the large number of active RRB providers a monthly call completion rate of 50% or higher is eligible for award participation based on the following:

This data is summarized on monthly statistical phone data reports.

The award fee for this criterion will be based on the number of months in the award fee period that the contractor’s call completion rate is 51% or more. The percentage of the award fee earned will be the total percentage by assigning each month in the award period with the applicable monthly Award fee percentage rate as shown above.

Sample Specialty MAC Award Fee Plan Page 3