RFP 2024-13 IBR & DRG Billing Services

CareOregon, on behalf of Health Share of Oregon and CareOregon Advantage, is issuing Request for Proposals (RFP) #2024-13 for Itemized Bill Review (IBR) and Diagnosis Related Grouping (DRG) Billing Services in Multnomah County, Oregon. The procurement seeks to outsource payment integrity services for high-dollar inpatient hospital claims to meet regulatory requirements from the Centers for Medicare and Medicaid Services (CMS) and the Oregon Health Authority (OHA). Key deliverables include implementation of DRG audit review, overpayment recovery, and IBR forensic review services, with an anticipated contract start date of January 1, 2025, and an initial term through October 31, 2025. The RFP allows for two additional two-year renewal options. Evaluation criteria will encompass the proposer's general background, qualifications, scope of work, equity/diversity/inclusion efforts, and fees. Proposals are due by September 26, 2024, at 2:00 PM Pacific Time, with pricing structures accepted as either a set fee per claim reviewed or a percentage of recovered claim overpayments. The expected claim review volume is approximately 500 per month, including 150-200 DRG claims and 50-70 IBR claims.

CareOregon encourages proposals from minority, women, service-disabled veteran, and emerging small businesses, demonstrating a commitment to diverse vendor participation. The organization will require successful proposers to comply with nondiscrimination requirements. While specific budget ranges are not explicitly stated, the RFP indicates the potential for multiple vendor awards. The current contract covers services for approximately 500,000 total members, suggesting a substantial potential contract value. OptumInsight, Inc. has been identified as the apparent successful proposer pending contract negotiations, though CareOregon treats the RFP process as confidential and does not share detailed vendor proposal information. The procurement will require vendors to integrate with existing claims review infrastructure and demonstrate capabilities in medical record analysis, claim selection processes, and payment integrity methodologies. No specific incumbent vendor details beyond the current service provider are disclosed in the documentation.