Statement of Work Sources Sought.pdf

INDIAN HEALTH SERVICE

PHOENIX INDIAN MEDICAL CENTER

Rev 5/2018

Statement of Work

Background Phoenix Indian Medical Center (PIMC) is one of the largest Indian Health Service (IHS) facilities located in the State of Arizona with an estimated accounts receivable (AR) aging total in excess of $10 million.

To ensure all claim revenue is captured, PIMC seeks to contract with a 3rd party to provide accounts receivable, collections and denial management services for this outstanding debt.

Objective To comply with the IHS Internal Controls policy which requires all accounts to be reviewed with 45 days from the date the bill was created. All Commercial/Private Insurance claims greater than 40 days will be reviewed with steps to determine the claim status.

Benefits:

1. Comply with the IHS Internal Control Policy

2. Decrease the volume of aged accounts

3. Reduce the turnaround time for payments

4. Increase revenue by collecting this debt

System Requirements The Contractor will need access to the Resource and Patient Management System (RPMS), Electronic Health Record (EHR) and the Accounts Receivable Folder in order to complete the tasks. The Contractor will also be provided with access to any Commercial Payer Websites that PIMC has access to.

Contract Awardee Responsibilities & Tasks The Contractor shall perform the following work after obtaining RPMS Accounts Receivable aging claims from PIMC staff:

Categorize and prioritize aging reports by Payer, by workgroup Verify eligibility and claim with private insurance company Review denial reasons on rejected claims Resubmit claims or correct rejected claim and submit to appropriate insurer Verifies payment or valid denial on accounts reviewed Submits appeals to insurers Sends collection notices on certain claims Submits data on denials to PIMC for closeout Test and review claims for Quality Control Submit reports to Management

Scope of Work The following scope of work is for Commercial/Private Insurance, greater than 45 days from the claim approved date. The scope set out herein includes 10,000 claims over a 1 year period of time.

If claims are submitted with no response from the payer, they are considered denied and appear on the aging report. The Contractor proposes the following review steps:

1. Obtain AR claims from PIMC. Run system reports as needed to assist with the review. Aging and AR reports including, but not limited to Aged Open Items (AOI), Aged Summary Management (ASM), and Bills Listing (BL).

2. Categorize and prioritize aging reports by Payer, by workgroup

3. Verify eligibility and claim with insurance company and other PIMC resources.

a. If claim not found by the Payer: The Contractor resubmits claim.

b. If claim rejected prior to entering payer’s adjudication system: Review reason

i. If denial valid and cannot be correct: The Contractor adds claim to “Close Out Spreadsheet” and sends to PIMC to adjust the claim to zero.

ii. If denial is valid and able to be corrected by The Contractor:

1. The Contractor corrects and resubmits electronically or manually.

2. The Contractor adds claim to “Resubmitted Spreadsheet”.

3. The Contractor adds comments in RPMS, AR module.

4. The Contractor verifies payment received and posted by PIMC or properly denied.

iii. If denial valid and able to be corrected by PIMC only (billing, coding error, etc.):

1. The Contractor adds claim to PIMC “Billing Spreadsheet” or “Coding Spreadsheet”.

2. PIMC coordinates with billing and coding department to remediate and resubmit.

3. The Contractor verifies payment received and posted by PIMC or properly denied.

c. If claim denied after entering payer’s adjudication system: Review reason

i. If denial code is valid and cannot be correct:

1. The Contractor adds claim to “Close Out Spreadsheet” and sends to PIMC to adjust the claim to zero

ii. If denial valid and able to be corrected by the Contractor:

1. The Contractor corrects and resubmits electronically or manually.

2. The Contractor adds claim to “Resubmitted Spreadsheet”.

3. The Contractor adds comments in RPMS, AR module.

4. The Contractor verifies payment received and posted by PIMC or properly denied.

iii. If denial valid and able to be corrected by PIMC only (billing, coding error, etc.):

Rev 5/2018

1. The Contractor adds claim to PIMC “Billing Spreadsheet” or “Coding Spreadsheet”.

2. PIMC coordinates with billing and coding department to remediate and resubmit.

3. The Contractor verifies payment received and posted by PIMC or properly denied.

iv. If denial code not valid:

1. The Contractor submits an appeal to the payer (attach EOB, appeal reason, computer generator ledger, explanation of why the claim should be paid.) (Appeal threshold > $100)

2. The Contractor adds the claim to the “Appeal Spreadsheet”.

3. Follow-up with payer (online, call)

4. The Contractor verifies payment received and posted by PIMC or properly denied.

d. If claim is resubmitted by PIMC or the Contractor and improperly denied, the Contractor repeats review steps.

4. Pre-Authorization and Out of Network (OON) Denials

a. Add claim to “Pre-Authorization/OON spreadsheet”.

b. PIMC Debt Management Clerk will send collection notice(s), one month apart based on the IHS Debt Collection Policy.

c.

5. Quality Control:

a. Test and review claims for each the Contractor analyst to ensure they are properly handled.

i. Denial codes handled properly

ii. Claims reviewed timely

iii. Educate the Contractor analyst based on findings

Deliverables:

o The Contractor to provide the following schedules on a weekly basis

Close Out Spreadsheet

Resubmitted Spreadsheet

Billing Spreadsheet

Coding Spreadsheet

Appeals Spreadsheet o The Contractor to provide a summary of claims status on a monthly basis (include amount collected).

o The Contractor to provide list of common issues found to PIMC management.

Price/Costs Schedule Based on the complexity of the assignment, availability of information and highly manual process, this is a firm fixed-price requirements type of contract to provide claims research, collection, denial management services, and reporting.

These is a general estimate only and is not a representation to an offeror or contractor that the estimated quantity will be required or ordered, or that conditions affecting requirements will be stable or normal.

Failure of the Government to require services in the quantities described in the Schedule as “estimated” will not entitle the contractor to any equitable adjustment in price.

The following is a schedule of services to be performed during the contract term.

1. Claim research, billing, collection, and denial management services and reporting

Period of Performance (POP) Performance of the contract(s) shall be for one year from the date when the contract is awarded.

Minimum Qualifications Contractor shall have a minimum of ten (10) years’ experience with Indian Health Service’s Resource and Patient Management System.

Preferred Evaluation Method Best Value with Tradeoffs

Delivery Specified reports shall be delivered as listed under deliverables either weekly, monthly, or at the completion of the contract.

Contracting Officer Authority Authority to negotiate changes in the terms, conditions, or amounts cited in this contract is reserved for the Contracting Officer.

Rev 5/2018

Contracting Officer’s Representative (COR) The person identified below is hereby designated as the Contracting Officer's Representative (CO) for this contract.

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Invoice Submission and Payment The Contractor shall submit its original invoice to the Phoenix Indian Medical Center, Finance Dept., Aztec Building 1616 East Indian School Road, Suite 360E, Phoenix AZ 85016 and or via email to PHX_PIMCAPInvoice@ihs.gov. The Contractor agrees to include the following information on each invoice. (1) Contractors name, address; (2) Contract Number (entire contract number must be included);

(3) Invoice number and date; (4) Cost or price; (5) Dates of Service including the number of hours worked; and (6) Remit to address. Phoenix Indian Medical Center, Finance Dept., Aztec Building 1616 East Indian School Road, Suite 360E, Phoenix, AZ 85016, shall make payment.

mailto:PHX_PIMCAPInvoice@ihs.gov

Invoice Submission and Payment