TOP 2028 Questions for Industry 20240726.docx

TRICARE OVERSEAS PROGRAM

TOP 2028

Questions For Industry

1. Quality Care

(a) What can the contractor do to ensure beneficiaries receive the highest level of quality healthcare in private sector facilities?

(b) How can the contractor effectively measure the quality of health care received in the private sector facilities?

(c) What clinical quality outcome measures and experience measures could be implemented, and how?

(d) What user-friendly, cost-effective methods can be used to provide the Government with information on the quality of care?

(e) How and to what extent can the contractor implement value-based care/purchasing overseas?

2. Private Sector Networks

(a) What factors would be considered in network development and how would these factors ensure a "right sized" network?

(b) How can overseas provider networks be “right sized” and how can “right sized” networks promote quality and reduce costs?

(c) What processes are available to ensure TRICARE beneficiaries can book appointments and receive care within the TRICARE access to care standards (see below standards)?

TRICARE Access Standards: The contractor shall ensure travel time does not exceed 30 minutes from home to primary care delivery site unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area. The contractor shall ensure that travel time for specialty care does not exceed one hour, unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area. The contractor shall ensure that the wait time for an appointment for a well-patient visit or a specialty care referral for enrollees do not exceed four weeks; for a routine visit, the wait time for an appointment shall not exceed one week; and for an urgent care visit the wait time for an appointment shall generally not exceed 24 hours. The contractor shall ensure that emergency services be available and accessible to handle emergencies (and urgent care visits if not available from other primary care providers (PCPs) within the service area 24 hours a day, seven days a week (24/7) for enrollees.

(d) How can the contractor provide behavioral health support to TOP Prime and Prime Remote Beneficiaries given host nation cultural and language barriers?

(e) How can the contractor leverage telemedicine and other technology as part of the overseas networks, recognizing the constraints imposed by the US and host nations?

(f) What processes would the contractor use to ensure that network providers are compliant with TRICARE requirements such as timely medical records collection and cashless claimless services?

3. Direct Care/Private Sector Care Integration

(a) What can the contractor do to assist the Military Treatment Facilities in enhancing the direct care system and optimizing integration between the direct care and private sector care?

(b) MTFs located in Bahrain, Belgium, Guam, Germany, Greece, Italy, Japan, Korea, Puerto Rico, Spain, Turkey, United Kingdom generate approximately 175K outpatient visits and 13K inpatient admissions in the private sector per year. What is the estimated average time to collect medical records in the above countries? What are challenges/barriers to medical record collection in these countries and how can they be overcome?

(c) Most of these records are not in English. What is the average time it would take a contractor to translate a medical record? How can a contractor leverage artificial intelligence or other technology to expediate translation of medical records while ensuring accuracy?

(d) What is the most effective, customer friendly method for delivering collected, translated outpatient medical records to MTFs?

(e) What is the total estimated time to collect, translate, and provide a medical record to an MTF? What is an appropriate record collection standard for collection/translation/delivery?

(f) How will the contractor assure that inpatient admission notes and discharge summaries providing medical updates are shared with the MTF. What is the recommended time frame for providing inpatient admission notes and discharge summaries to ensure continuity of care and patient safety?

(g) How will the contractor assure that outpatient medical updates for routine and urgent cases are shared with the MTF. What is the recommended time frame for providing outpatient medical updates to ensure continuity of care and patient safety?

(h) What can the contractor do to assist medically manage TOP Prime enrollees who are hospitalized in a private sector facility? How can the contractor ensure continuity of care and a seamless transition from a private sector facility to the MTF?

(i) How and to what extent can the contractor work with MTFs to support/implement population health overseas? How can the contractor work with direct care system to enhance population health?

(j) How can the contract leverage AI/technology to process referrals issue authorizations within one business day?

4. Beneficiary Experience of Care

(a) What industry practices drive beneficiary satisfaction and how could those effectively be implemented in an Overseas environment?

(b) How can the contractor engage the beneficiary to participate in their healthcare and measure that success?

(c) What can the contractor do to enhance the experience of care for beneficiaries when they are sent to a purchased care sector provider for care?

(d) How can the contractor ensure beneficiaries are able to effectively communicate in host nation facilities?

(e) What can the Contractor do to manage accurate and efficient interpretation services that will support successful health care delivery for both Overseas providers and beneficiaries?

(f) What video (or other technology) assisted interpretation services can be utilized in the overseas environment to overcome communication barriers between Overseas providers and beneficiaries.

(g) How can the contractor utilize best business practices to implement cost effective, customer focused call center standards?

(h) How can the contractor execute timely service recovery when addressing a beneficiary’s poor experience?

5. TOP Prime Remote Support

(a) What can the contractor do to medically manage patients in remote locations and ensure that the care received is medically necessary, appropriate, and high quality?

(b) How can the contractor ensure cashless, claimless access to medical care in remote locations?

6. Claims

(a) What can the Contractor do to ensure claims are coded accurately?

(b) Given that many of the providers overseas do not utilize U.S. coding, what can the contractor do to ensure claims are processed accurately for only those services or procedures related to a specific care authorization?

(c) Given that the Government pays billed charges in most locations, what can be done to ensure costs are reasonable and customary, and to reduce health care costs?

(d) What can the Contractor do to ensure claims are processed within TRICARE processing timeframes (see below standards)?

· The contractor shall process 98% retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt.

· The contractor shall process 100% of all claims (both retained and excluded, including adjustments) accurately and to completion within 90 calendar days from the date of receipt.

(e) How can AI be leveraged to ensure claims information is reviewed thoroughly to reduce processing delays?

(f) What IT and AI systems can be leveraged to allow beneficiaries and providers access to real-time claim status?

7. Combatant Command/Expeditionary Forces Support

(a) How can the contractor ensure delivery of private sector care to military operational forces deployed in remote locations?

(b) How can the contractor ensure integration of private sector care with military care to operational forces deployed to remote locations?

8. AI and Emerging Technologies

(a) How can the contractor leverage AI and other emerging technologies to improve all aspects of health for the beneficiary population?

(b) How can the contractor leverage automation, AI, and advanced data analytics to deliver healthcare support services?

(c) Given that emerging technologies like Large Language Models and Generative AI are evolving rapidly, how can the contractor evaluate and implement these safely and securely?

(d) What approach will the contractor take for its data products to ensure data quality, interoperability, and accessibility by the Defense Health Agency?

(e) What example use cases does the contractor envision as providing the highest value and ROI to the Government, including but not limited to solutions that address any of the following: private sector provider networks, referral management activities, TRICARE eligibility verification and enrollment, medically necessary evacuations (medevacs), medical documentation, interpretation and translation services, medical management services, customer service/call center activities, beneficiary and provider education and marketing, and claims processing and coding. Please specify whether the example use cases are fully autonomous or require a human-in-the-loop (HITL).

(f) What emerging technologies will the contractor have available on day-one? What technologies would the contractor seek to implement within 12 months, 36 months, and 60 months?

(g) AI poses significant requirements for advanced software, advanced hardware, and significant data; what capabilities does the vendor bring and what capabilities is the Government expected to provide?

(h) What technical safeguards (guardrails, change control plans, etc) does the contractor support for its emerging technologies, given the current lack of standardized oversight within industry? What can the contractor do to ensure adherence to Responsible Artificial Intelligence (RAI) principles and DOD requirements?

HT9402-24-RFI-0218 Page 1 of 5 Attachment 1: TOP28 Questions for Industry image1.png image2.png