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FBO DAILY - FEDBIZOPPS ISSUE OF FEBRUARY 09, 2013 FBO #4095
SOURCES SOUGHT

99 -- OFFICE OF WORKERS’ COMPENSATION PROGRAMS’ (OWCP) WORKERS' COMPENSATION MEDICAL BILL PROCESSING (WCMBP) SOLUTION - RFI FOR DOL131RI21641

Notice Date

2/7/2013
 

Notice Type

Sources Sought
 

NAICS

518210 — Data Processing, Hosting, and Related Services
 

Contracting Office

Department of Labor, Office of the Assistant Secretary for Administration and Management, Procurement Services Center, S-4306 200 Constitution Avenue, NW, Washington, District of Columbia, 20210-0001, United States
 

ZIP Code

20210-0001
 

Solicitation Number

DOL131RI21641
 

Archive Date

4/9/2013
 

Point of Contact

PATRICIA E. HAMMONS, Phone: 202-693-4591
 

E-Mail Address

HAMMONS.PATRICIA.E@DOL.GOV
(HAMMONS.PATRICIA.E@DOL.GOV)
 

Small Business Set-Aside

N/A
 

Description

SECTION 17 TREATMENT SUITES BUILD SECTION 15 PROVIDER ENROLLMENT AND MANAGEMENT BUILD SECTION 13 EDITS AND AUDITS (PART 2 OF 2) SECTION 13 EDITS AND AUDITS BUILD (PART 1 OF 2) SECTION 10 AND 14 CLAIMANT ELIGIBILITY AND TPL BUILD SECTION 9 BILL PROCESSING BUILD SECTION 8 BILL SCAN DATA ENTRY BUILD PWS RFI FOR DOL131RI21641 REQUEST FOR INFORMATION For OFFICE OF WORKERS' COMPENSATION PROGRAMS' (OWCP) WORKERS' COMPENSATION MEDICAL BILL PROCESSING (WCMBP) SOLUTION The intent of this notice is for informational and planning purposes only and does not constitute a formal Request for Quotes (RFQ), Request for Proposal (RFP), or Invitation for Bid (IFB). This Request For Information (RFI) is not to be construed as a commitment by the U.S. Federal Government (Government). If a formal solicitation is generated at a later date, a solicitation notice will be published through the Government Point of Entry at www.fedbizopps.gov. The Government does not intend to pay for any information provided under this notice. The information submitted by Respondents will not be returned. Respondents are not to provide any information that is considered proprietary, trade secrets, privileged, or confidential as part of the RFI responses. The Government is not obligated to notify respondents of the results of this RFI. Hard copies of this RFI will not be issued. The North American Industry Classification System (NAICS) code for this request is 518210. The small business size is $7 million. Introduction The U.S. Department of Labor's (DOL) OWCP administers workers' compensation medical bill processing programs that mitigate the impact of work-related injury for certain workers and their families. OWCP is seeking a single Contractor to build and operate a centralized WCMBP solution, also referred to as Central Bill Process (CBP), for three OWCP programs: the Division of Federal Employees' Compensation (DFEC), the Division of Coal Mine Workers' Compensation (DCMWC) and the Division of Energy Employees Occupational Illness Compensation (DEEOIC). OWCP's medical bill processing function is currently provided as an outsourced service. The Government does not own an information system that can be transferred to a follow-on Contractor. Only historical data will be transferred. This centralized solution will include the processes associated with receipt of the medical bills and attachments, review of medical bills and attachments against program-specific authorizations, handling of inquiries related to medical services from claimants and providers, and utilization of business rules established by each Program for the adjudication and pricing of medical bills. Specifically, the integrated system will support the following capabilities: • Receipt and accounting for medical bills, attachments and other documents, in both hardcopy and electronic formats • Scanning and data entry of bills, attachments and other documents received. • Processing of bills to payment or denial (the Contractor will not make benefit payments, but will transfer payment files to Treasury for certification and payment) • Processing of requests for adjustment, authorization of services, suspense resolution, and appeals processing • Processing and responding to submitted correspondence received from medical providers and claimants, when applicable, and storing the responses to the correspondence in an imaging system from which the Government can retrieve for review • Enrolling new providers and managing information about existing providers • Providing claimant and provider support via a call center and self-service applications (such as user access portals and IVR) • Processing Point of Sale (POS) pharmacy bills • Providing secure on-line access, available to authorized users, to view images of bills, correspondence, and other documents. Uniqueness of the OWCP's WCMBP OWCP authorizes payments for the medical conditions accepted as being compensable by the OWCP Program under which the claim is filed. Each of the three OWCP Programs provides medical benefits only when the medical care is related to a valid injury/illness claim (case), the medical condition(s) treated are accepted for payment by OWCP Program government claims examiners (CE), and the treatment occurs within time period(s) of eligibility covered by legislative mandates. Each of the OWCP Programs has a unique set of business processes and functional flows that the WCMBP solution must support. The Division of Federal Employees Compensation (DFEC) is the largest program. It accounts for 90% (approximately 4.5 million bills per year) of all medical bills received by OWCP. DFEC has millions of claimants and hundreds of thousands of enrolled providers. Claimant eligibility records for DFEC are maintained by the Government in their case management system (IFECs) and will be provided as input to the WCMBP for bill processing. For each claimant, an eligibility record will be established within WCMBP for each unique case number provided on the eligibility file received from DOL. A claimant can have multiple cases --a DFEC claimant having multiple injuries will have an eligibility record established within WCMBP for each unique case. Eligibility records are associated with claimants by case number, date of injury and date of birth. DFEC does not associate eligibility records to claimants by SSN. The Contractor shall establish an electronic interface between WCMBP and IFECs to receive DFEC claimant eligibility records and send back appropriate responses. Eligibility records loaded into WCMBP will be made available throughout the system for its respective functions. The Division of Energy Employees Occupational Injury Compensation (DEEOIC) accounts for about 9% of all medical bills received by OWCP. Claimant eligibility records for DEEOIC are maintained by the Government in their case management system (DEEOIC ECS) and will be provided to the WCMBP for bill processing. For each claimant, an eligibility record will be established within WCMBP using claimant's SSN as a unique identifier. Each claimant has one case. DOL will send a complete set of eligibility records per accepted condition when an accepted condition is added to the claimant's record. Contractor shall develop an electronic interface between WCMBP and DEEOIC ECS to receive DEEOIC claimant eligibility records and send back appropriate responses. Eligibility records loaded into WCMBP will be made available throughout the system for its respective functions. The Division of Coal Mine Workers' Compensation (DCMWC) is the smallest program and accounts for 1% of all medical bills received by OWCP. Claimant eligibility records for DCMWC are maintained by the Government in their case management system (Automated Support Package or ASP) and will be sent to the WCMBP for bill processing. For each claimant, an eligibility record will be established within WCMBP using the claimant's SSN as the unique identifier. Each claimant has one case. Contractor shall establish an electronic interface between the WCMBP and the DCMWC Automated Support Package (ASP) to receive DCMWC claimant eligibility records and send back appropriate responses. Eligibility records loaded into WCMBP will be made available throughout the system for its respective functions. The concept of an "accepted condition" is unique to DOL's WCMBP. This approach stipulates that claimants are entitled to coverage only by virtue of being accepted by the Government as having a specific work-related illness or injury. The accepted condition(s) is the only condition(s) for which medical bills can be paid. The Government will provide the Contractor with a daily eligibility data file containing claimant eligibility - information that the Contractor will use to process medical bills. Payments are authorized based on the medical conditions (ICD-9/10 codes) accepted as being compensable by the OWCP program under which the claim is filed. This is accomplished by applying OWCP's authorization logic (organized in "treatment suites") to the billing information. The accepted condition(s) on a claim for the DFEC Program is the only condition(s) in which services are payable for that unique case number. Cases under the DFEC program may involve more than one accepted condition and claimants may have more than one case open and active with unique conditions accepted for medical treatment. The accepted condition(s) on claim for the DEEOIC Program are the only conditions for which services are payable for a claimant using the claimant's Social Security Number (SSN) as the unique identifier. Accepted cases under this program may include up to 99 accepted conditions. There is only one accepted condition on a claim for the DCMWC Program for which services are payable for claimants using the claimant's SSN as the unique identifier. The Claims Examiners (CEs) for each Program determine the accepted conditions and authorize certain medical treatments. Data from the WCMBP keep the CEs informed of the nature and quantity of treatment for a given accepted condition and case, and the WCMBP forwards requests for treatment requiring prior authorization by the CE. OWCP medical bill processing assumes the use of industry standard medical bill processing techniques including, but not limited to: validity edits, consistency edits, correct coding initiative (CCI), duplicate checking, service limitations, application of OWCP fee schedules, and financial accounting, auditing, and reporting. OWCP medical bill processing volumes require a high degree of automation of the adjudication process and require the Contractor to support an interface to the OWCP-owned Treatment Suites. Treatment Suites The OWCP uses a set of business rules and decisions, which are logically grouped into "Treatment Suites" to automate certain WCMBP functions. Treatment Suites processing is an automated process for determining if the services associated with a bill are authorized for the accepted condition. The Treatment Suite concept provides for the consistent application of OWCP medical policy across Programs. However, its design is sufficiently flexible to support the application of each Program's individual standards and guidelines. Importantly, it minimizes the need for the manual review of bills to determine whether the treatment is related to the accepted condition prior to payment. Treatment Suites contain a set of diagnosis-driven algorithms that determine authorization requirements and the procedures, drugs, hospitalization, DME, and all other services that are payable for accepted condition(s). Treatment Suites consist of a diagnosis or group of related diagnoses (expressed as International Classification of Disease (ICD)-9/10CM codes) linked to the medical procedures, medications, and other services used in its (their) treatment. Services are identified in terms of Current Procedural Terminology (CPT) codes, Healthcare Common Procedural Coding System (HCPCS) codes, Diagnosis Related Group (DRG) codes, Therapeutic Class (TC) codes, National Drug Codes (NDC), Generic Code Nomenclature (GCN), and other nomenclatures. Common complications are part of the treatment suites and are considered in decision making. OWCP-defined prior authorization requirements for medical procedures are also embedded in the Treatment Suites. Treatment Suites processing includes Government medical benefits policies, clinical guidelines, and medical care ("diagnosis to treatment") management logic. All incoming medical bills are compared to the Treatment Suites of the accepted conditions applicable to a specific case. Bills with services included in the Treatment Suites for the accepted conditions or complications continue processing, while services that are billed but not found in the pertinent treatment suites logic for the accepted conditions are denied or suspended for manual resolution. The Treatment Suites algorithms are contained in reference files and are updated by means of a management toolset (Treatment Suites Builder) provided to the Contractor as GFI. The Contractor will host the Treatment Suites tool, which includes the database. The current version of the treatment suites is a java-based tool with a DB2 database. WCMBP Program Goals The goal of the WCMBP program is to acquire a standards-based bill processing system and processes that implement the following: * Improved mailroom, imaging, and data entry throughput, accuracy, and efficiency * Ensure a smooth and timely transition from the incumbent service provider * Ensure efficient, accurate and timely processing of medical and pharmacy bills * Ensure timely and correctly processed authorizations for covered benefits. * Provide accurate and timely responses to customer inquiries and requests. * Implement advanced medical bill processing technologies and processes * Develop robust fraud and abuse and error detection/protection processes * Use of industry-standard hosting and programming techniques to support portability among platforms * Implement bill processing and auxiliary functionality in a modular manner that allows the DOL to select components that could be Government-owned versus components that are better suited for outsourcing * Implement robust change and configuration management process * Establish a framework for continuous improvement. Current Work Volumes The FY2012 annual volumes of bills, authorizations, and inquiries, processed and the providers enrolled for each program are presented below. 2012 DFEC; DEEOIC; DCMWC Bills Processed 4,503,466; 431,253; 152,927 Bills Returned 420,220; 41,520; 18,344 Lines Items Processed 12,046,904; 1,064,202; 389,727 Call Center Calls 596,428; 48,543; 22,775 Call Center Minutes 353,063; 70,773; 61,265 Authorizations Processed 969,214; 38,332; 70,852 Pages imaged 14,787,298; 2,406,250; 530,881 New Provider Enrollments 13,281; 4,038; 3,012 Number of active user portal accounts 8,627; 2,203; 1,654 Number of authenticated user portal hits 10,064,471; 948,760; 788,377 Number of internal WCMBP user system accounts 3,578; 2,754; 2,042 Bills submitted via user portal 251,334; 17,429; 26 Non-Phar Bills submitted on paper 2,824,691; 253,673; 101,539 Phar Bills Submitted on paper 101,834; 11,609; 190 Bills submitted on paper 2,926,525; 265,282; 101,729 WCMBP Major Functional Requirement Groups The Sections below present high level descriptions of the functional elements of the WCMBP system. These elements are grouped into three major functional groups for ease of organization. This section presents overview information. For more information, please refer to the section in the attached draft PWS and six draft Requirements Specification Documents (RSD) documents. Please note that only six draft RSDs have been provided as examples of the level of detail available in the set of Government-Furnished RSDs. Also, those requirements identified as (New) in the draft PWS will not have corresponding references in the draft RSDs. Group 1 - Inputs and Outputs Input and Outputs Group contains all functional elements associated with accepting bills, transitioning physical artifacts into electronic format and preparing correspondence for mailing. Mailroom (PWS section 5) The mailroom will accept mail from USPS and other mail delivery services for all three OWCP Programs and prepares it for further processing. The mailroom will perform document preparation that encompasses all mailroom, imaging, and data capture services required in preparation for bill processing to include: sorting, imaging, indexing, tracking, return to originator, and warehousing. The Contractor shall securely store and dispose of all PII/PHI hardcopy documents in accordance with the requirements established for each Program. In addition, the mailroom is responsible for preparing mail for delivery to the providers and claimants. To meet the minimum requirement, the Contractor shall establish and operate the mailroom facilities and systems of sufficient size to meet the estimated volume of mail anticipated by this RFI. DFEC Document Imaging (PWS section 6) The Contractor shall establish and operate infrastructure and system to scan and index all DFEC documents (medical bills, attachments, and correspondence, etc.) received by the mailroom in accordance with the rules established by DFEC for particular form/document types and categories (more complete description is provided in PWS Section 6). Indexes and images of DFEC documents are transmitted to DFEC via IFECS daily. Claimant Bill Development (PWS section 7) The Contractor shall implement a process to receive and review each claimant-submitted bill to determine if sufficient information is provided on the bill and attachments to ensure successful processing. If insufficient information is provided on the claimant-submitted bill itself, the Contractor shall review the submitted attachments to determine if required information is included there. If the required information is available, the Contractor shall enter the missing information into the WCMBP via key data entry functionality and process the bill through normal bill processing operations. Claimant submitted bills with insufficient information will be returned to either the claimant or the appropriate Program District Office. Bill Scan/Data Entry (PWS section 8) The Contractor shall determine if bills received have been submitted on a Government-approved form and if so, identify the bill type for each Program. The Contractor shall develop a process of extracting data elements to produce medical bill database records. The Contractor shall capture all required data elements accurately and completely (using automated methods to the extent possible to minimize cost). The Contractor shall correlate each bill with a valid case number (for DFEC) and/or SSN (for DEEOIC and DCMWC) obtained from CBP Claimant Eligibility files. The Contractor shall ensure that Government approved validation criteria are applied to specified fields at the time of input, as part of the data entry process, and shall document all instances in which fields do not satisfy Government validation criteria. RTP/RTC/RTD (PWS section 12) The Return-to-Provider (RTP) and Return-to-Claimant (RTC) processes are associated with sending bills or other materials rejected by the medical bill processing solution to the original submitters. The Return-to-District Office (RTD) process forwards mail that was incorrectly sent to the mailroom as well as bills, forms, and correspondence that the image processing system can't process to the appropriate Program District Office as determined by the business rules associated with this Section. When bill does not meet Government requirements for processing, the Contractor shall return the bill to the provider, claimant or Program District Office within 5 workdays of receipt, with a letter that lists all specific deficiencies. The Contractor shall store images of all RTP/RTC letters and/or RTD checklists when the letter/checklist is created. These electronically stored documents must be in a format that is accessible to authorized staff, at any time. Group 2 - Core The following functions have been selected for Group 2 because they are highly specialized to OWCP and the functionality and inter-dependencies may be tightly coupled. Additionally, the Government estimates that these functions may require a high degree of customization. Bill Processing (PWS section 9) Bill processing includes the processes associated with reviewing medical bills against the established treatment and eligibility criteria established by each of the OWCP programs. The payment acceptance criteria are the input to the Bill Processing function. To successfully support the Bill Processing function, the Contractor shall: * develop workflow and systems to automate the process of bill adjudication utilizing Programspecific rules and criteria * generate outputs contingent on adjudication results-payment files, suspended bills for manual resolution, or denied bills/bill lines Edits & Audits (PWS section 13) The Edit and Audit process involves a series of algorithms (edits and audits) which act as prepayment controls to implement Government policies. The result of the Edit and Audit process is the denial of payments or suspension for manual review when bill data are in conflict with Government policy. Edits are performed on the information within a single bill, while audits additionally compare the current bill data to information in history or other files such as the Authorization File, and/or other bills in process in the same cycle. Although most edits and audits are similar in concept across the three Programs, the specific algorithms and the pay/deny/suspend decisions may vary for each program. Contractor shall implement the Edits and Audits process flow as described in the PWS, maintain its logic throughout its lifecycle and process all bills against this logic. The Contractor shall implement a set of edits and audits that may be customized by OWCP Program with regard to the edit/audit rules, EOB, and bill disposition. Authorizations (PWS section 16) The Government requires that medical services paid on behalf of claimants be medically related to accepted conditions for which compensation can be paid. To meet this criterion, OWCP programs use program-specific authorization processes that require different levels of authorization for services. The Contractor shall implement the Authorization process flows as described in the PWS, maintain its logic throughout its lifecycle and process all bills against this logic. The Contractor shall accept and process authorizations received according to the Program rules and accurately associate the authorization with a valid case or claimant identification number. Treatment Suites (PWS section 17) The Contractor shall implement the Treatment Suites process flow as described in the draft PWS, maintain its logic throughout its lifecycle and process all bills against this logic as an integrated component of the medical bill processing solution. The Contractor shall host and maintain (in the Contractor's environment) the OWCP-owned Treatment Suites Builder and Viewer tools (GFI) Bill Pricing (PWS section 18) Bill Pricing processes use Government-approved fee schedules to calculate allowed fees. Allowed fees are derived from adjusted Metro Statistical Area (MSA) data and are used to price procedures based on national and industry standards. The Contractor shall develop a unique bill pricing logic and process for each OWCP program (DFEC, DEEOIC, DCMWC). The Contractor shall also implement the capability to override a fee schedule based on provider-specific data. The Contractor shall implement the Bill Pricing process flow as described in the draft PWS, maintain its logic throughout its lifecycle and process all bills against this logic. Pharmacy (PWS section 19) The Contractor shall develop a pharmacy process that uses a point-of-sale (POS) prescription drug bill processing methodology, including prospective drug service limitations, the application of programspecific Treatment Suites for bills submitted directly from a pharmacy, and Program specific bill pricing logic. The Contractor shall process paper bills submitted by claimants and pharmacies as well as electronic bills. The Pharmacy processes shall apply to all OWCP programs (DFEC, DEEOIC, and DCMWC). Bill Resolution (PWS section 20) Bill Resolution process refers to the manual review and decision-making required to resolve edits that occur between the identification of bills (or lines) that cannot be processed electronically and the reprocessing of bills to completion. The Contractor shall implement a Bill Resolution process that suspends bills for manual review as instructed by the Government. The Contractor's bill resolution process shall: allow authorized Government personnel to view suspended bills and their attachments; route certain suspended bills to authorized Government personnel for them to make bill resolution decisions; automatically apply fee schedules to bills that are re-processed after suspension and manual resolution; manually price certain bills during the bill resolution process based on Government input; and apply unique Bill Resolution rules based on bill types and provider types. Payment Files Process (PWS section 21) Payment processing provides continuous accountability and control of all bills in the medical bill process. In order for the Government to track the number of bills entered into payment processing, categorized by bill type, the Contractor shall: * Produce reports to ensure bill counts are balanced during each cycle. * Ensure that total bill counts and dollar amounts, processed during a payment cycle, are documented at the end of the payment cycle, and include provider negative balances for all three OWCP programs. * Produces a final payment summary report that balances the preliminary payment and final payment information to help maintain integrity throughout the payment process. The payment cycle is defined as the period beginning 12:00am Saturday through 11:59 pm Friday. Payment cycles are scheduled to run once a week for each program. The Contractor shall transmit payment and EFT files to the Government on a schedule determined by the Government. Additionally, the Contractor shall generate and distribute remittance vouchers (RVs) to the appropriate recipients. The US Treasury Department is responsible for check production, check mailing, and EFT processing for each program. Therefore RVs are mailed separately from checks. The Contractor shall maintain records generated during bill payment processing and document all payments paid to all providers during any tax year. The Contractor shall prepare MISC-1099 forms for all eligible providers per IRS regulations. Provider Enrollment & Management (PWS section 15) The goal of Provider Enrollment and Management is to reimburse only qualified providers that comply with Government program rules and regulations for services rendered to eligible recipients. The Contractor shall develop and implement all Government-approved Provider Enrollment and Management processes including, but not limited to: * Accepting hardcopy provider enrollment forms. * Accepting electronic provider enrollment forms. * Providing the capability for providers to perform the enrollment process electronically. * Providing the capability to handle new and/or different provider types, modify criteria for defining provider classes, develop, and modify processes required for provider enrollment, develop and modify provider enrollment workflows. * Placing providers in an "on-review" status based on Government-provided criteria (e.g., specific services, specific claimants, dates of service, etc.). * Activating and deactivating providers based on Government-provided criteria. * Processing Government-supplied information (e.g., the HHS Excluded Provider File and Internal Revenue Service [IRS] levy file). * Ensuring that enrollment processes operate in accordance with Government instructions. * Maintaining payment histories and outputting IRS 1099 forms This process shall include all functions necessary to enroll new and maintain current information about existing providers. In addition, this process shall maintain user portal accessibility for all providers. The Contractor shall implement all workflows and requirements listed in the draft PWS section. Claimant Eligibility (PWS section 14) The Claimant Eligibility function utilizes eligibility information from the Government to determine whether medical bills are eligible for payment based on the claimant's accepted condition(s). WCMBP differs from other bill processing operations, because it uses the concept of accepted condition. Specifically, claimants are entitled to coverage by virtue of being accepted by the Government as having a specific work-related illness or injury. The accepted condition(s) is the only condition(s) for which services can be reimbursed. In the WCMBP, the Government provides data containing claimant eligibility information that the Contractor uses to process bills. Contractor shall accept claimant eligibility information from each DOL Program, process the eligibility records in accordance with the Program business rules, ensure validity of input claimant eligibility files, and use eligibility files to process bills. Third Party Liability (PWS section 10) The WCMBP incorporates the concept of "Third Party Liability", which is a process of reviewing bills in order to determine whether a party other than the Government is responsible for payment and the processing required by each Program. Each OWCP Program uses specific criteria to identify whether a claimant's medical bills are third party liabilities and the subsequent medical bill and accounting processes that result from that determination. The contractor shall implement third party liability logic into the overall bill processing process, in accordance with Program-specific rules. Prompt Payment Bill Processing (PWS section 11) Certain services mandated by the Government are considered subject to the Prompt Payment Act (PPA). The Prompt Payment Bill Processing identifies bills that qualify under the Prompt Payment Act (PPA) and processes them according to Program-specific regulations, to include payment of interest on bills that are paid outside of the required timelines. The Contractor shall design, develop, and implement a PPA process, reviewed and approved by the Government that shall include, but is not limited to: * Providing accurate identification of all PPA bills. * Implementing workflow management that ensures compliance with the PPA rules and procedures. * Establishing electronic capabilities that can be used by authorized providersto submit bills and reports in electronic format. * Implementing the Government fee schedules for the payment of these services. Fee Schedule Appeals (PWS section 22) The Fee Schedule Appeals process applies to all three OWCP programs. Upon receiving a fee appeal request, the Contractor shall determine and communicate to the Government within one (1) business day of receipt if the fee appeal request meets at least one (1) of the Government's three (3)criteria. These criteria are: * The actual procedure performed was coded with an incorrect code. * The presence of a severe or concomitant medical condition made treatment especially difficult. * The provider possesses an "unusual qualification" (however, Board Certification in a specialty is not sufficient to justify "unusual qualification"). Adjustment Processing (PWS section 23) The Contractor shall implement the ability to perform Program-specific adjustment, void and credit transactions for previously paid and/or denied bills. The Contractor shall provide the capability to perform Program-specific history-only adjustments, void and credit transactions in response to billing errors. The Contractor shall make available methods and tables necessary to edit and process bills including, but not limited to: approve, adjust, re-price, suspend, or deny bills based on any criteria in the bill, provider files, claimant files, or reference files; allow any rule to be applied to the bill header area or bill detail line level; and, transmit the adjustment/recoupment file to the Government. Location Independent Electronic Access Portal (PWS section 27.4) The Location Independent Electronic Access Portal (User Portal) provides secure means for authorized users (providers, claimants, government) to access bill processing-related information. The Contractor shall provide electronic access to CBP information in compliance with Section 508 of the Rehabilitation Act, as amended. The Contractor shall provide electronic enrollment functionality for providers and shall make recommendations to the Government on the use of electronic signatures in the implementation of this functionality. The Contractor shall implement, host and manage a system capable of meeting requirements contained in the Location Independent Electronic Access section of the PWS. Group 3 - Support Management Reporting (PWS section 25) The Contractor shall develop standard and ad-hoc operational and performance reports (Section 25) to be available as scheduled and on-demand as requested by the Government. The Contractor shall provide the capability to report information covering system monitoring, program analysis, service utilization analysis, management queries, and bill processing performance. The Contractor shall ensure that federal and contract staff are able to access only that report information for which they are approved (e.g., a user from one program or District Office should not be able to access report data from another program or District Office).The Contractor shall develop the means of customizing, producing and distributing reports as specified in the Management Reporting section of the PWS. The Contractor shall implement all workflows and requirements listed in the draft PWS section. Change Management (PWS section 26) The Contractor develops and implements Change Management processes that track the status of all changes to the WCMBP from their initiation, through approval process to eventual implementation or disposition. During the Operations phase, the Contractor shall enhance WCMBP, using an allocation of 10,000 labor hours per operations year, based on approved Government requests. Enhancements are defined as changes to add new functionality or to change existing requirement functionality. In years where operational processing is not performed for the full year, the Contractor shall pro-rate the 10,000 hours by month. Corrections to defects will not use labor hours from this pool. The Contractor shall provide an audit trail capability that records every CR implementation with date, time, and operator performing the implementation. In addition, the Contractor shall implement a test and release system and methodology that will be used to ensure that requested changes do not negatively impact the operational system and that they produce expected results. The Contractor shall provide isolated environments that exactly replicate the Production processing environment and functionality, to be used to develop, test, and train for the changes made to the CBP. Call Center (PWS section 27.3) The Contractor shall provide a call center facility, process, and staff to receive and handle claimant and provider calls. The Contractor shall maintain Call Center operating hours of 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, unless otherwise specified by the Government. The Contractor shall ensure that the current phone numbers, transitioned from the current Contractor or provided by the Government, are properly integrated into the Contractor's CBP solution. The Contractor shall hire and maintain staff that are acquainted with medical terminology and the intricacies of OWCP Programs' requirements. This facility has to be able to support call volumes as described in this RFI. The call center facility must be located in the lower 48 contiguous States (CONUS) to allow DOL to perform site visits on as-needed basis. IVR (PWS section 27.5) Contractor shall implement and operate an interactive voice response (IVR)-based system to meet requirements contained in section 27.5 of the PWS. The Contractor shall establish and maintain a tollfree number for the IVR with sufficient capacity to satisfy Government-specified IVR performance metrics. The Contractor shall make the IVR available 24 hours a day, 7 days a week, except during normally-scheduled system maintenance during non-peak hours, as approved by the Government. Fraud and Abuse Detection (PWS section 24) The Fraud and Abuse Detection (FAD) function is responsible for monitoring bill processing with the intent of detecting suspected cases of fraud and abuse. This function also is used to report and track these suspected cases and to provide the Government with the capabilities required to prevent fraud and abuse cases. The Contractor shall maintain and operate a FAD function that includes, but is not limited to, the following capabilities: * Produce reports and charts as approved by the Government. * Run fraud studies when requested by the Government. * Provide the functionality for unrestricted aggregations of data elements. * Provide the functionality for fraud studies to be initiated by the Government or the Contractor staff including the ability to save the results. Information Requested Responses to this RFI should demonstrate the firm's capability to perform the work described in the attached PWS. To ensure uniformity among responses, DOL requests that the Contractor organize their responses in the following manner: 1. Provide company name, address, point of contact, email address and telephone number. Respondents should also indicate business size and Socioeconomic Category (HUBZone, 8(a) small business, Service Disable Veteran-Owned small business, Small Business, Large Business, or womenowned small business). SMALL BUSINESSES ARE ENCOURAGED TO RESPOND. 2. Technical Approach a. Group 1 - Inputs and Outputs i. Describe the technologies and systems you would use to implement the functions in. ii. Identify how much customization versus configuration would be needed for each system/application to meet Government requirements. iii. Address methodology you would employ to ensure accurate accounting of all incoming and outgoing mail. iv. Discuss which functions would be candidates for outsourcing or teaming arrangements b. Group 2 - Core i. Describe the technologies and systems you would use to implement and host the functions in Group 2 - Core. ii. Identify how much customization versus configuration would be needed for each system/application to meet Government requirements. iii. Describe your approach to allow the Government to make configuration changes to the business rules as needed. iv. Discuss licensing and ownership of the platform(s). c. Group 3 - Support i. Describe the technologies and systems you would use to implement the functions in Group 3 - Support. ii. Identify how much customization versus configuration would be needed for each system/application to meet Government requirements. d. Please describe data flow and architecture of the complete solution. Please discuss use of any proprietary or non-standard components, e.g., operating system, programming languages, network protocols, interfaces, and databases. Please recommend how to modularize the development/implementation of the capability by functional groups. e. Please make a recommendation on the use of FedRAMP-certified cloud services given security constraints associated with medical records, e.g., PII/PHI. f. Please discuss any experience your firm has in implementing Cloud- based solutions 3. Procurement Options The Government is investigating two approaches to meeting its business needs: Option 1 - contractor develops and operates the complete BPS solution. Contractor will own the solution and provide bill processing as a service to DOL. Option 2 - contractor develops and operates the complete solution; however DOL "owns" (including all source code) the business logic associated with Group 2 - Core functionality. Group 2 - Core functionality will include all interfaces to external elements such as mail room, call center, reporting, IVR, and user portal. Questions: a. For option 2 only - Can your firm build Core Functionality (option 2) such that the Government retains exclusive data rights for all source code and executables? Please indicate your prior experience with such an approach. What are the implications for licensing, intellectual rights, maintenance, support, and enhancements? b. For each option, please address the approximate length of time required to implement your solution for an effort of this size. c. For each option, please provide recommended costing methodology and cost structures for development/implementation and operations and overall ROM price. 4. Group 2 - Core lists the Governments best estimate regarding what functionality should reside in the core. Please identify alternate groupings of functions for all Groups and explain why and impacts to schedule and cost. 5. Describe your company's expertise and experience in developing and implementing large scale workers compensation medical bill processing solutions of similar scope and complexity to the OWCP requirements. For each client, describe the bill volume and services (a. Mailroom processing, b. Document scanning and indexing, c. Bill coding / data entry, d. Bill review and processing, e. Pricing, f. Pharmacy, g. Payments, h. Call center / IVR, i. User access portal, j. Management reporting, k. Provider enrollment and management, l. Fraud and error detection, l. Other - please specify) performed by your company. 6. Describe your company's expertise and experience in operating large scale workers compensation medical bill processing solutions of similar scope and complexity to the OWCP requirements. For each client, describe the bill volume and services performed by your company. 7. Identify the Government contracting vehicles and schedules on which the required efforts may be obtained. 8. What recommendations does your company have for locating your development, implementation, and operations facilities and staff to ensure both a sufficient pool of qualified staff and to minimize costs? What approach would you employ to maintain close collaboration with the DOL staff? Identify any impact to your ability to pursue this opportunity if DOL requires that the Contractor's facilities be located in close proximity to DOL headquarters in Washington, DC. 9. How would you ensure an adequately experienced and trained labor pool that is knowledgeable and able to support a large scale workers compensation medical bill processing solutions of similar scope and complexity to the OWCP requirements? What approaches do you use to minimize employee turn-over? How do you propose to incorporate institutional knowledge of the DOL's staff to better service OWCP's clients? 10. Identify how your solution would maximize use of electronic bill submission, e.g., how would you motivate providers and claimants to submit information electronically. 11. Describe your experience with implementing proactive and systematic identification and resolution of bill processing errors, such as keying errors and duplicate bills. 12. Describe your experience implementing fraud and abuse detection in medical bill processing systems. 13. Is your solution already ICD-10 compliant? If not, describe your plan for the shift from ICD-9 CM to ICD-10 CM 14. Describe your experience implementing program management processes to support your solution, to include strategic planning, project scheduling/tracking/reporting, cost control, performance measurement and metrics, corrective action planning, quality control, system security, configuration management, risk management and responding effectively and efficiently to customer requests. 15. DOL anticipates holding an Industry Day prior to the release of the RFP. Please list topics you would like to see addressed during the Industry Day. General Instructions All responses shall be in English and submitted electronically in Microsoft Word 2007 format to the email address(s) listed. Hard copy responses will not be accepted. Responses to this RFI must be no more than twenty-five (25) letter sized (8.5 X 11) pages in length using one inch page margins and 11 point Times New Roman font. Marketing brochures or corporate advertising material will not be considered an acceptable response. Interested parties should forward capability statements by March 25, 2013 at 3:00 pm, est. All questions/responses will be communicated via email and should be directed to Patricia Hammons, Contract Specialist at hammons.patricia.e@dol.gov. DOL will only accept questions to clarify the information requested in this RFI-DOL will not respond to technical questions.
 

Web Link

FBO.gov Permalink
(https://www.fbo.gov/spg/DOL/OASAM/WashingtonDC/DOL131RI21641/listing.html)
 

Place of Performance

Address: WASHINGTON, District of Columbia, 20210, United States

Zip Code: 20210
 

Record

SN02981446-W 20130209/130207234249-6bac54bf6fcd127321753f481d5aa74c (fbodaily.com)
 

Source

FedBizOpps Link to This Notice
(may not be valid after Archive Date)

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