MODIFICATION
R -- Medicaid Integrity Provider Review
- Notice Date
- 6/15/2007
- Notice Type
- Modification
- 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-SS-MIC-ProviderReview
- Response Due
- 6/29/2007
- Description
- SOURCES SOUGHT/REQUEST FOR INFORMATION The Centers for Medicare & Medicaid Services (CMS) is seeking to identify businesses, in particular Small Business sources, (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that can provide the activities required by the Medicaid Integrity Program provisions in the Deficit Reduction Action. Background: Medicaid was enacted in 1965 as Title XIX of the Social Security Act (hereinafter referred to as the Act). Title XIX of the Act is a Federal/State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid is a cooperative venture jointly funded by the Federal and State governments (including the District of Columbia and the Territories) to assist States in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America?s poorest people. Within broad national guidelines governed by Federal statutes, regulations, and policies, each State: (i) establishes its own eligibility standards, (ii) determines the type, amount, duration, and scope of services, (iii) sets the rate of payment for services, (iv) and administers its own program. While State participation in Medicaid is voluntary, all States have chosen to participate. The federal government supports state administration by providing matching funds and establishing general programmatic guidelines. In accordance with the statute, the Medicaid program by law is the payer of last resort. Third party liability (TPL) refers to the legal obligation of third parties to pay all or some of the health care costs of Medicaid services provided under a State Plan. Examples of third parties are: private health insurers, employer-sponsored health insurance, Medicare, workers? compensation, liability settlement, medical-support orders, long-term-care insurance, and estate recovery. Billions of dollars each year are reported by states to CMS as Medicaid savings attributed to third party liability activities. These programs are complex and include activities associated with the eligibility-determination process, claims-payment system, and reimbursement methodologies developed by state Medicaid programs. The TPL policies and procedures are governed by both federal and state laws. Section 6034 of the Deficit Reduction Act (DRA) of 2005, signed February 8, 2006, established the Medicaid Integrity Program (MIP). Under this contract, MIP functions are to be performed by the MIC. The integrity program offers a unique opportunity to identify, recover, and prevent overpayments. It will also support the efforts of State Medicaid agencies through a combination of oversight and technical assistance. While CMS has a wealth of experience in the financial management of the Medicaid program, the auditing of those who provide direct services to Medicaid beneficiaries has always been the responsibility of the States. The DRA defines four main objectives of Medicaid integrity as follows: (i) Review of the actions of individuals or entities furnishing items or services for fraud, waste or abuse; (ii) Audit of claims for payment for items or services furnished, or administrative services rendered; (iii) Identification of overpayments to individuals or entities receiving Federal funds under this title; and, (iv) Education of providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care. Please note, this sources sought notice refers only to the review of the actions of individuals or entities furnishing items or services for fraud, waste or abuse. THIS IS STRICTLY MARKET RESEARCH. THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) WILL NOT ENTERTAIN QUESTIONS REGARDING THIS MARKET RESEARCH. Based on the market research, CMS anticipates soliciting for multiple award Indefinite Delivery Indefinite Quantity (IDIQ) contracts with the following activities to be performed: A. Review the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk or other basis) for which payment may be made under the State plan approved under Title XIX (or under any waiver of such plan approved under section 1115) to determine whether fraud, waste, or abuse has occurred, or is likely to occur; and to determine if such actions have any potential for resulting in an expenditure of funds under Title XIX in a manner which is not intended under the provisions of Title XIX. B. Conduct data mining analysis and perform risk assessment of Medicaid data including, but not limited to, claims for payment under a State plan under Title XIX; C. Propose or develop (only one contractor from the IDIQ will be selected to perform this function) a data mining tool and support testing of the tool. The data mining tool will be used by the Medicaid Integrity Contractors (MIC) to analyze claims data; D. The contractor shall provide a data-mining tool that uses Medicaid data to develop a discreet neural network model combined with Medicaid specific business rules to dynamically identify payments at the greatest risk of being fraudulent or inappropriate. E. The contractor shall provide an evaluative risk assessment tool that, upon demand, provides a risk assessment of any provider at any location within the Medicaid system. The risk based assessment tool will provide, on demand, a report card on the status of the internal controls of the Medicaid program. At a minimum, the risk assessment tool shall identify high risk/problem areas of providers. F. The contractor shall conduct simulations of the neural network model and the business rules in real world conditions and provide enhancements as new data and technology becomes available. G. The contractor shall provide training materials and a training plan for Medicaid use of the data mining and risk assessment tools. CMS requests capability statements, not to exceed 10 pages, to this Sources Sought/RFI from particularly Small Businesses. At a minimum, your capability statement shall include the following information: 1. Business Information: a. DUNS: b. Company Name; c. Company Address; d. Type of Company (i.e. small business, 8(a) woman owned, veteran owned, etc.) as validated via the CCR. All offerors must register on the Central Contractor Registration located at http://www.ccr.gov/index.asp. e. Company Point of Contact, Phone and E-mail address of individuals who can verify the capabilities/experience identified in the responses. 2. The contractor(s) shall be familiar with and use of the Government Auditing Standards, commonly known as the Yellow Book, and audit work paper documentation. 3. Please identify key personnel and a sampling of their education and experience that will be able to perform the functions identified in A through G above. 4. Please provide a statement of the experience and capability of your company with regard to performing the Medicaid activities described above as well as your knowledge and understanding of Title XIX of the Social Security Act and Section 6034 of the Deficit Reduction Act of 2005. 5. CMS anticipates the contractor possessing knowledge of the auditing process in order to coordinate activities with the MIC audit contractors. Please provide a statement of the experience and capabilities your company exhibits in providing this type coordination. 6. Please provide a statement demonstrating your knowledge of the different types of Medicaid providers and your experience in analyzing their trends and patterns within the Medicaid claims and cost reports. A PRESOLICITATION NOTICE HAS ALSO BEEN ISSUED FOR THIS REQUIREMENT DUE TO TIMELINE RESTRAINTS----SMALL BUSINESSES SHOULD RESPOND TO THIS SOURCES SOUGHT NOTICE IN THE EFFORT TO DETERMINE SMALL BUSINESS SET ASIDE. PLEASE SEND ALL RESPONSES TO THE FOLLOWING e-MAIL ADDRESS: "mic-sow@cms.hhs.gov".
- Record
- SN01319948-W 20070617/070615220600 (fbodaily.com)
- Source
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