SOURCES SOUGHT
R -- Medicaid Integrity Program
- Notice Date
- 11/22/2006
- 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-19561944
- Response Due
- 12/19/2006
- Archive Date
- 1/3/2007
- Small Business Set-Aside
- Total Small Business
- Description
- The Centers for Medicare & Medicaid Services (CMS) is seeking to identify businesses (in particular Small Business sources) with capabilities or prior experience for potential award of a contract to conduct activities required by the Medicaid Integrity Program provisions in the Deficit Reduction Act. The activities include the review of the actions of individuals or entities furnishing items or services under a Medicaid state plan; the audit of claims for payment of these services; identifying overpayments to individuals or entities receiving Federal funds; and educating providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care. CMS anticipates providing selected contractors with related protocols for each activity. CMS encourages teaming/partnering arrangements. In order to assist industry with developing these arrangements, the following assumptions are provided: 1. The contractor(s) shall be familiar with and use the Government Auditing Standards, commonly known as the Yellow Book, and audit work paper documentation. 2. CMS anticipates the following labor categories to be key positions and most likely will be identified in the solicitation as a requirement of the contract: A. Program Director The Program Director shall possess: Work Experience Ten or more years of professional experience with at least 3 years as a manager responsible for managing complex systems and work flow. Educational Requirements A bachelor?s degree from an accredited institution, plus a master?s degree from an accredited institution or substitution of 4 additional years of related work experience in lieu of the master?s degree. B. Medical Director The Medical Director shall possess: Work Experience Prior work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines. Extensive knowledge of the Medicaid program, particularly the coverage and payment rules. Public relations experience such as working with physician groups, health maintenance organizations, hospitals, beneficiary organizations, and/or congressional offices is preferred. Educational Requirements Experience practicing medicine for at least 3 years as a board-certified doctor of medicine or doctor who is currently licensed. C. Cost Report Audit/Reimbursement Manager The Cost Report Audit/Reimbursement Manager shall possess: Work Experience Three to 5 years management experience in Medicaid cost report auditing, settlement, and reimbursement. Educational Requirements Bachelor?s degree in accounting or equivalent with a master?s and/or Certified Public Accountant (CPA) certification (or 4 additional years of related work experience in lieu of CPA certification). Knowledge of Medicaid law, regulations, manuals, and instructions, and Government Auditing Standards (GAS). D. Medical Review Manager The Medical Review Manager shall possess: Work Experience A minimum of 3 years supervisory experience in the general area of medical/ utilization review. Educational Requirements Bachelor?s degree in nursing with an active Registered Nurse license. E. Chief Legal Counsel The Chief Legal Counsel shall possess: Work Experience A minimum 3 years experience applying Federal and/or State Medicaid regulations. Educational Requirements Must be a licensed attorney. F. Chief Statistician The Chief Statistician shall possess: Work Experience A minimum of 3 years experience using statistics to support corporate/business information needs. Experience in statistical detection of fraud, fuzzy logic, development of mathematical models, neural networks, and data mining or other analytical methods. Demonstrated experience and knowledge of health care information (health claims data, ICD-9-CM codes, physician specialty codes, survey and certification data, provider identifiers, etc.). Educational Requirements A minimum of a master?s degree in statistics or related discipline. 3. CMS may have a need for additional labor requirements to perform individual task orders that is not identified as key personnel above. The following knowledge and skills may be required: ?X Staff to perform utilization/quality assurance reviews. ?X Knowledge of ICD-9-CM and CPT-4 coding, Medicaid coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, Ambulatory Surgical Center). ?X Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs) Medicaid, Prospective Payment Systems, and coverage guidelines. CMS envisions a Registered Nurse (RN) or Licensed Practical Nurse (LPN) with an active license and personnel with education in the areas of disease process and human anatomy and physiology. Background: Medicaid was enacted in 1965 as Title XIX of the Social Security Act (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 established by Federal statutes, regulations, and policies, each State establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. State participation in Medicaid is voluntary; however, all States have chosen to participate. The federal government supports state administration by providing matching funds and establishing general programmatic guidelines. The Deficit Reduction Act (DRA) of 2005, Section 6034, signed February 8, 2006, established the Medicaid Integrity Program (MIP). The MIP offers a unique opportunity to identify, recover, and prevent inappropriate Medicaid payments. It will also support the efforts of State Medicaid agencies through a combination of oversight and technical assistance. Objectives of the Medicaid Integrity Program (MIP) include: ? Review of the actions of individuals or entities furnishing items or services for fraud, waste or abuse; ? Audit of paid claims for items or services furnished, or administrative services rendered; ? Identification of overpayments to individuals or entities receiving Federal funds under this title; and, ? Education of providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care. Type of Procurement: This is NOT a Request for Proposal (RFP). CMS anticipates issuance of multiple Indefinite Delivery Indefinite Quantity (IDIQ) contracts under a forthcoming solicitation in the beginning of January 2007. However, CMS reserves the right to use any other procurement instrument as deemed appropriate at the time of the official solicitation. It is anticipated the IDIQ contract(s) will be awarded as a base plus four (4) one-year options for a total not-to-exceed effort of 5 years. Instructions and Requirements for Submitting responses to this RFI to CMS: CMS requests capability responses to this Sources Sought/RFI from particularly Small Businesses. At a minimum, your capability response should 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://wwwccr.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. 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. 3. CMS is looking to obtain industry?s comments on how to divide the Medicaid Integrity Contractor (MIC) program amongst the country, e.g., Three regions with two contract holders per region. 4. Please provide a statement on what activities you believe should be included in the IDIQ contract(s) that are not addressed above. 5. Please provide a statement that describes your thoughts on how to procure the education component of the regulation activities, e.g., Should the same contractor conduct this activity who also conducts other mandated activities. 6. Please provide a statement on what qualifications, other than the ones provided for in the DRA, an entity must have to qualify. 7. Per the statutory requirement, CMS envisions having a contractor perform review of the providers. Please provide a statement as to whether CMS should separate out the review task from the audit of claims and overpayment activities. Additionally, please identify any potential conflicts of interest in having the contractor perform all three functions. 8. Please provide any information you would like the Government to consider while developing the Statement of Work for this requirement. Please submit responses in the following manner: 1. E-mail your responses addressing the specific requests detailed above to thomas.snyder@cms.hhs.gov on or before 12:00 PM (noon) local time Baltimore, MD Wednesday, December 19, 2006. Please be advised that e-mail transmitted files over 5 megabytes are not delivered during standard working hours and are only released from the CMS server after 5:00 PM EST, and may affect the timeliness of your response. 2. Responses should be submitted in MicroSoft Word document with page size 8.5 by 11 inches. Document Font shall be Time New Roman Size 10-12 with no less than single spacing between lines. The number of pages shall be limited to 15 total pages. Other considerations: CMS will use the information submitted in response to this RFI at its discretion and will not provide comments to any submission; however, the content of any responses to this RFI may be reflected in subsequent RFP(s). CMS reserves the right to contact any respondent to this RFI for the sole purpose of enhancing CMS? understanding of a RFI submission. This notice is for informational purposes only and does not constitute a solicitation or Request for Proposal. This RFI is not to be construed as a commitment by the Government. The Government will not pay for any information provided as a result of this RFI and will not recognize or reimburse any costs associated with any RFI submissions.
- Place of Performance
- Address: Baltimore, MD
- Zip Code: 21244-1850
- Country: UNITED STATES
- Zip Code: 21244-1850
- Record
- SN01185503-W 20061124/061122220217 (fbodaily.com)
- Source
-
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