Medical Claims Review of Cost-Based Medicare Managed Care Organizations (MCO)

Amendment 000003

RELEASE OF SOLICITATION HHSM-500-2015-RFP-0113
See attachments

Medical Claims Review of Cost-Based Medicare Managed Care Organizations (MCO)

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This synopsis is a pre-solicitation notice and is not a Request for Proposal (RFP).

The Centers for Medicare & Medicaid Services (CMS), Office of Financial Management, Division of Capitated Plan Audits (DCPA), has responsibility for the financial oversight of cost-based Managed Care Organizations (MCOs). DCPA conducts the examination of MCOs, and as a function of these audits, the medical services processed by the MCO must be reviewed. CMS is seeking qualified contractors to provide services in support of the CMS in determining whether Medicare service costs, codes and statistics claimed on the MCO's cost report are accurate and allowable to ensure fair apportionment and proper reimbursement from Medicare.

The Contractor shall assist CMS in determining the accuracy of medical costs and statistics on the final annual cost report, and to identify overpayments related to improper medical coding and/or insufficient medical documentation. To achieve this objective, the contractor will perform statistical data analysis, develop a defensible statistically valid sampling and extrapolation procedure (in accordance with guidance and documents provided by CMS), and conduct medical coding and coverage review. The outcome CMS will achieve from obtaining a centralized support Medical Record Contractor for sampling and medical claims review for all MCO examinations is a consistent approach, improved accuracy in reimbursement to MCOs, as well as increased efficiency in performing these reviews. The Contractor's evaluation will determine whether Medicare claims were paid in accordance with CMS coverage, coding, payment and billing policies, and allow for the recoupment of any overpayment as a result of identified errors. In addition, the Contractor will provide consistent calculation and reporting of payment errors and overall error rates.

This procurement will be a competitive total small business set-aside under NAICS code 541990, All Other Professional, Scientific, and Technical Services, with a size standard of $15 million. This RFP will be issued under HHSM-500-2015-RFP-0113. CMS anticipates award of an Indefinite Delivery Requirements contract with fixed-price type task orders for a one-year Base Period, and four (4) one-year Option Periods that can be exercised at the unilateral discretion of the Government. All prospective offerors must be registered in the System for Award Management at http://www.sam.gov.

The solicitation will be available on or about April 17, 2015, and it will be distributed solely through the Federal Business Opportunities (FBO) website at http://www.fbo.gov. Proposals are expected to be due 30 days from the RFP issue date. All future information about this acquisition, including solicitation amendments, will also be distributed solely through this site. Interested parties are responsible for monitoring this site to ensure that they have the most up-to-date information about this acquisition. No telephone requests or written requests for the RFP will be accepted.

Contractors must be free of conflicts of interest or prepare an OCI mitigation plan to address any actual, potential or apparent organizational conflicts of interest that could arise. One potential conflict identified is the awardee of this proposed contract and a Cost Report Audit Contractor (anticipated to be re-solicited through GSA) cannot be the same. One entity cannot both review and audit the cost plan.

Medical Claims Review of Cost-Based Medicare Managed Care Organizations (MCO)

This synopsis is a pre-solicitation notice and is not a Request for Proposal (RFP).

The Centers for Medicare & Medicaid Services (CMS), Office of Financial Management, Division of Capitated Plan Audits (DCPA), has responsibility for the financial oversight of cost-based Managed Care Organizations (MCOs). DCPA conducts the examination of MCOs, and as a function of these audits, the medical services processed by the MCO must be reviewed. CMS is seeking qualified contractors to provide services in support of the CMS in determining whether Medicare service costs, codes and statistics claimed on the MCO's cost report are accurate and allowable to ensure fair apportionment and proper reimbursement from Medicare.

The Contractor shall assist CMS in determining the accuracy of medical costs and statistics on the final annual cost report, and to identify overpayments related to improper medical coding and/or insufficient medical documentation. To achieve this objective, the contractor will perform statistical data analysis, develop a defensible statistically valid sampling and extrapolation procedure (in accordance with guidance and documents provided by CMS), and conduct medical coding and coverage review. The outcome CMS will achieve from obtaining a centralized support Medical Record Contractor for sampling and medical claims review for all MCO examinations is a consistent approach, improved accuracy in reimbursement to MCOs, as well as increased efficiency in performing these reviews. The Contractor's evaluation will determine whether Medicare claims were paid in accordance with CMS coverage, coding, payment and billing policies, and allow for the recoupment of any overpayment as a result of identified errors. In addition, the Contractor will provide consistent calculation and reporting of payment errors and overall error rates.

This procurement will be a competitive total small business set-aside under NAICS code 541990, All Other Professional, Scientific, and Technical Services, with a size standard of $15 million. This RFP will be issued under HHSM-500-2015-RFP-0113. CMS anticipates award of an Indefinite Delivery Requirements contract with fixed-price type task orders for a one-year Base Period, and four (4) one-year Option Periods that can be exercised at the unilateral discretion of the Government. All prospective offerors must be registered in the System for Award Management at http://www.sam.gov.

The solicitation will be available on or about April 17, 2015, and it will be distributed solely through the Federal Business Opportunities (FBO) website at http://www.fbo.gov. Proposals are expected to be due 30 days from the RFP issue date. All future information about this acquisition, including solicitation amendments, will also be distributed solely through this site. Interested parties are responsible for monitoring this site to ensure that they have the most up-to-date information about this acquisition. No telephone requests or written requests for the RFP will be accepted.

Contractors must be free of conflicts of interest or prepare an OCI mitigation plan to address any actual, potential or apparent organizational conflicts of interest that could arise. One potential conflict identified is the awardee of this proposed contract and a Cost Report Audit Contractor (anticipated to be re-solicited through GSA) cannot be the same. One entity cannot both review and audit the cost plan.