SOURCES SOUGHT
R -- EVALUATION & OVERSIGHT SERVICES FOR CMS'S QUALIFIED INDEPENDENT CONTRACTORS
- Notice Date
- 6/14/2007
- Notice Type
- Sources Sought
- NAICS
- 541611
— Administrative Management and General Management Consulting Services
- Contracting Office
- Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Acquisition and Grants Management, 7500 Security Blvd. C2-21-15, Baltimore, MD, 21244-1850, UNITED STATES
- ZIP Code
- 00000
- Solicitation Number
- Reference-Number-71307
- Response Due
- 7/5/2007
- Archive Date
- 12/13/2007
- Description
- Introduction: This is SOURCES SOUGHT NOTICE to determine the availability of potential small business (e.g., 8(a), service-disabled veteran owned small businesses, HUBZone small businesses, small disadvantaged businesses, veteran-owned small business, and woman-owned small business) that can provide evaluation and oversight services for CMS in its efforts to monitor the quality, accuracy and consistency of Qualified Independent Contractor (QIC) decisions and operations. The information from this market research will help CMS plan their acquisition strategy. Please be sure to indicate if you have a GSA schedule contract. BACKGROUND: The following provides a general overview of the traditional Medicare fee-for-service (FFS) program as well as the FFS Medicare appeals process and the role of the Qualified Independent Contractors (QICs) in that process. The purpose of the Evaluation and Oversight (E & O) contractor will be to evaluate the accuracy, timeliness, and quality of QIC decisions as well as their overall performance of other contractual duties. A copy of the QICs' umbrella statement of work is attached for more detail. Medicare Part A and Part B: Medicare is a nationwide, federal health insurance program enacted in 1965 as title XVIII of the Social Security Act (the Act). Medicare provides health insurance for people 65 years of age or older, certain younger disabled persons, and persons with permanent kidney failure (end stage renal disease). Medicare serves an estimated 40 million beneficiaries and processes approximately 900 million claims and 7 million appeals per year. Beneficiaries may choose between the traditional, fee-for-service Medicare program, and a private health plan option referred to as Medicare Advantage Program. The Medicare program consists of two primary parts: 1. Hospital Insurance (HI), also known as "Part A;" and 2. Supplementary Medical Insurance (SMI), also known as "Part B." Medicare Part A covers some of the costs of providing medically necessary inpatient hospital care, skilled nursing facility care following a hospital stay, home health care, and hospice care. Individuals entitled to Social Security or Railroad Retirement benefits are automatically entitled to Part A hospital insurance beginning with the first day of the month in which the individual attains the age of 65. Those younger than age 65 who receive Social Security disability benefits and those with end-stage renal disease (ESRD) are also entitled to Part A. Individuals who worked in certain Medicare-qualified federal, state, or local government employment may also qualify for coverage provided certain conditions are met. Medicare Part B helps pay for certain physician services (in both hospital and non-hospital settings,) outpatient hospital services, and many other medical services, equipment, and supplies not covered under Part A. Part B benefits are available to almost anyone age 65 or older regardless of entitlement to Medicare Part A and to disabled beneficiaries entitled to Part A. Part B is an "optional program," meaning that eligible individuals may elect or decline to enroll in the program, which requires payment of a monthly premium. The Department of Health and Human Services (DHHS) has overall responsibility for administering the Medicare Program, with assistance from the Social Security Administration (SSA). The Centers for Medicare & Medicaid Services (CMS), an agency of DHHS, administers the Medicare Program on a day-to-day basis, including formulation and promulgation of Medicare Program policy and guidance; contract execution, operation and management; maintenance and review of utilization records; providing inquirers with basic information; general Medicare financing. The DHHS is responsible for adjudicating ALJ hearing requests of Medicare claim appeals. SSA is responsible for determining whether an individual is entitled to Medicare and for maintaining the Medicare master beneficiary record. Sections 1816 and 1842 of the Act provide that public or private entities and agencies may participate in the administration of the Medicare Program under contracts or agreements entered into with CMS. These Medicare contractors are known as Fiscal Intermediaries (FIs) and carriers. FIs perform Medicare claims processing and benefit payment functions for institutional providers in Part A and Part B of the program. Carriers perform Medicare claims processing and benefit payment functions for Part B. The Medicare Modernization Act required CMS to undergo contract reform in which the Part A and Part B functions would be combined and performed by a Medicare Administrative Contractor (MAC). The MACs are being implemented by jurisdiction on a gradual basis. Therefore, QICs interact with both MACs and as well as traditional Medicare contractors. There are four Durable Medical Equipment Medicare Administrative Contractors (DME MACs or DMACs), each serving approximately one geographic quarter of the nation. CMS has also established separate contracts with four FIs to handle home health and hospice claims. These contracted entities are called Regional Home Health Intermediaries (RHHIs). For the purposes of this document, when referring to FIs, carriers, MACs, DMACs, and RHHIs, in general, we will refer to them as affiliated contractors (ACs). The Medicare FFS Appeals Process: Under the original Medicare plan, a beneficiary may generally obtain health services from any institution, agency, or person qualified to participate in the Medicare program that undertakes to provide the service to the individual. After the care is provided, the provider or supplier (or, in some cases, a beneficiary) submits a claim for benefits under the Medicare program to the appropriate AC. If the claim is for an item or service that falls within a Medicare benefit category, is medically reasonable and necessary for the individual, and is not otherwise statutorily excluded, then the contractor pays the claim. However, the Medicare program does not cover all health care expenses. If the Medicare contractor determines that the medical care is not covered under the Medicare program, it denies the claim. When an AC denies a claim, it notifies the provider, supplier and/or beneficiary of the denial, and, if appropriate, offers the opportunity to appeal this decision. The existing appeals procedures for original Medicare are set forth in regulations at 42 Code of Federal Regulations (CFR) 405 Subpart I-Determinations, Redeterminations, Reconsiderations and Appeals under Original Medicare (Part A and Part B). The section of the regulation specific to the QIC level of appeal begin at 42 CFR 405.960. The CFR can be accessed online by going to the following website: http://www.gpoaccess.gov/cfr/index.html. Once a claim has been denied, the beneficiary, provider, supplier or their authorized representative may appeal the claim to the contractor that made the initial determination. The request must be filed within 120 of the initial determination. This first level of appeal is known as a redetermination. The individual conducting the redetermination must not have been involved in making the initial determination and must issue a decision to all parties to the appeal within 60 days of receipt of the appeal request. If the appellant is dissatisfied with the redetermination decision, then they may request a reconsideration with the QIC within 180 days from the date of the redetermination decision. The QIC then has 60 days from the date of receipt of the reconsideration request to: (1) issue a decision; (2) notify the appellant they will be unable to complete their request within the 60 day timeframe and offer the appellant the option to escalate their appeal to the next level of the appeals process; or (3) dismiss the request. If the appellant is dissatisfied with the QIC's reconsideration, then they may request a hearing before an Administrative Law Judge (ALJ). The appellant has 60 days from the date of the QIC's reconsideration to request a hearing and the ALJ has 90 days to issue a decision. If an appellant continues to be dissatisfied with the ALJ's decision they may request a review with the Medicare Appeals Council at the Departmental Appeals Board. The appellant has 60 days to request a review with the Medicare Appeals Council and if the Medicare Appeals Council accepts the request, the Medicare Appeals Council has 90 days to issue a decision. This is the last stage of the administrative appeals process and appellants who continue to be dissatisfied can appeal to federal district court. WORK & TASKS: 1) Perform an on-site evaluation of each of the fee-for-service (FFS) QICs. 2) Determine if the QIC is performing the functions in their task order statement of work in accordance with CMS rules, regulations, and policy guidance. 3) Perform a minimum of one, annual, on-site evaluation, of not less than one business week in length, at each FFS QIC and the Administrative QIC (AdQIC). There are 6 QICs. 4) Employ a team of individuals that together possess knowledge of the Medicare appeals process, familiarity with Medicare coverage guidelines and the clinical expertise to evaluate the medical necessity determinations made by QIC Panel reviewers. 5) Review a random sample of not less than 100 closed QIC (per QIC) cases adjudicated during the review period. Review periods will differ by QIC and will be provided by CMS. 6) Examine the QICs adherence to CMS procedural requirements, such as acknowledging the reconsideration request within 14 days; issuing a decision, dismissal or effectuation notice within 60 days of receipt of the request; and forwarding effectuation notices timely; etc. 7) Review the QICs adherence to CMS's policy of forwarding decisions and effectuation information to the affiliated contractors (for purposes of this document, affiliated contractors refers to carriers, fiscal intermediaries and Medicare Administrative Contractors including durable medical equipment MACs). 8) Review the QICs' decisions to determine quality, accuracy, consistency and timeliness. Decisions should provide an adequate rationale for the decision and conform to Medicare?s national coverage guidelines, rules and regulations. 9) Develop evaluation protocols that will be used during QIC evaluations and submit them for CMS approval. 10) Develop a report based on the results of each QIC evaluation and submit it to CMS for approval. 11) Recommend process improvements or identified educational needs at each QICs' operation. 12) Develop a master report comparing the QICs' performance and any inconsistencies in QIC decision-making across QICs. 13) Review each QIC's rebuttal to the evaluation finding, if a rebuttal is submitted, and any supporting documentation submitted. 14) Discuss rebuttals with CMS and prepare a response to the rebuttals submitted. REQUIREMENTS (Requirements, Knowledge, Skills/Proficiencies): I. Technical Expertise: I.1. Knowledge of Medicare rules, regulations, manual instructions and policy guidance. I.2. Knowledge of the Medicare?s appeals process. I.3. Knowledge of Medicare?s coverage guidelines. I.4. Ability to hire the necessary clinical staff with knowledge as detailed above to perform reviews. I.5. Proficiency in using Siebel, COGNOS or Content Manager system applications. I.6. Experience performing evaluations or audits of government programs. II. Security: Full understanding and compliance with the following: II.1. Health Insurance Portability and Accountability Act (HIPAA); II.2. Privacy Act of 1974, Public Law 93-579, as amended. CMS/HHS Standards, Policies and Procedures: Security: CMS IT Security (http://www.cms.hhs.gov/InformationSecurity/) III. Non-Compete Restriction: Due to the potential conflict of interest issues, as well as a possibility for unfair competitive advantage, the entity that successfully bids on the E&O contract can not be a current QIC that performs reconsiderations or administrative functions under the QIC Umbrella Statement of Work. Additionally, the entity that is awarded the E&O contract cannot bid on QIC work for the three year (one year with two option years) contract period of performance. The successful offeror will be barred from bidding on any QIC work (FFS as well as Part C and Part D work) for an additional three years after the completion of the period of performance as the E&O contractor. DEMONSTRATED KNOWLEDGE AND EXPERIENCE: Please address your demonstrated knowledge and experience or how you will provide each of the following points (A) through (E) and reference where applicable specific items from the Work and Tasks section or Requirements section. (A) Evaluating or Administering Government Contracts. Please discuss experience with overseeing or evaluating a contractor(s)? performance of a government program or experience overseeing or administering a government program. (B) Performing Compliance Reviews. Please discuss any experience in performing compliance reviews or evaluations to determine an entity?s compliance with contractual, regulatory or statutory requirements. (C) Experience and Understanding of the Medicare Program or government health care programs. Discuss any experience with administering, overseeing or evaluating programs such as Medicare, Medicaid or other federal health care programs. (D) Drafting reports and making performance recommendations. Discuss any experience in drafting reports that dealt with the administration or oversight of a federal program or high level federal documents such as audit reports, regulations, rulings or reports to Congress. Discuss any experience with making recommendations for improvements to performance in the administration of federal health care programs based on evaluation or audit findings. (E) Familiarity with the requirements of HIPAA and the Privacy Act. Please discuss any experience with the requirements of HIPAA and the Privacy Act as they relate to medical records, medical documentation and personally identifiable information. INFORMATION REQUESTED: Interested parties having the capabilities necessary to perform the stated requirements may submit capability statements via email to Aileene Mitchell Ford (Aileene.Mitchellford@cms.hhs.gov). CAPABILITY STATEMENTS MUST DEMONSTRATE THE MINIMUM REQUIREMENTS OUTLINED ABOVE. Please address each in order listed above under Demonstrated Knowledge and Experience. Capability statements shall also include the following information: company name, address, point of contact, phone/fax/email, DUNS Number, and business size and status,(e.g., small business, 8(a), veteran-owned small business, service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, and women owned small business) including any letters, certificates, or similar documentation indicating such status; corporate structure (corporation, LLC, sole proprietorship, partnership, limited liability partnership, professional corporation, etc.); and tax identification number. Capability Statements shall be limited to 15 pages and shall include any/all teaming arrangements. Please include the following: Business Information -- a. DUNS: b. Company Name c. Company Address d. Current GSA Contracts e. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. f. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp . g. Company Point of Contact, Phone and Email address h. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. Teaming Arrangements: All teaming arrangements shall also include the above-cited information and certifications for each entity on the proposed team. Teaming arrangements are encouraged. Responses must be submitted not later than July 5, 2007. Capability statements will not be returned and will not be accepted after the due date. This is not an invitation for bid, request for proposal or other solicitation and in no way obligates CMS to award a contract. The sole intent is for market research to obtain capabilities for set-aside and procurement planning purposes. Contact information: Aileene Mitchell Ford, Contract Specialist 410-786-8147 Debra Hoffman, Contracting Officer 410-786-0517
- Place of Performance
- Address: Contractor facility and/or CMS
- Zip Code: 21244
- Country: UNITED STATES
- Zip Code: 21244
- Record
- SN01318741-W 20070616/070614220559 (fbodaily.com)
- Source
-
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