SPECIAL NOTICE
D -- Code Editing Software
- Notice Date
- 10/4/2010
- Notice Type
- Special Notice
- NAICS
- 541512
— Computer Systems Design Services
- Contracting Office
- Department of Veterans Affairs;Health Administration Center;3773 Cherry Creek Drive North, Suite 450;Denver CO 80209
- ZIP Code
- 80209
- Solicitation Number
- VA74111RI0003
- Archive Date
- 10/19/2010
- Point of Contact
- Jan Bertapelle-Anderson
- E-Mail Address
-
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- Small Business Set-Aside
- N/A
- Description
- DEPARTMENT OF VETERANS AFFAIRS HEALTH ADMINISTRATION CENTER REQUEST FOR INFORMATION 1.0SUBJECT The VA Health Administration Center (HAC) is issuing this Request for Information (RFI), in accordance with the Department of Veterans Affairs (VA) Health Administration Center (HAC) laws, regulations, and requirements to ensure that appropriate and accurate payments for outpatient claims are consistent with HAC's coding and coverage policies. The appropriate measure is for the implementation of automated cost containment claims editing/auditing software product. 2.0DESCRIPTION The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The program is administered by the Health Administration Center and our offices are located in Denver, Colorado. Specifically, this RFI will be used to identify software products for the use of: The automated cost containment claims editing/auditing product should provide: 1)Automated code editing/auditing review on medical claims, and 2)Automated utilization review of medical claims. This product's payment and coding edits must be based on guidelines developed by the American Medical Association's Physician's Current Procedural Terminology (CPT ®), a review of the Centers for Medicare & Medicaid Services (CMS) guidelines, and specialty society guidelines; incorporating agreed upon industry practices, reviews and analysis by an extensive clinical consultant network. The following specific characteristics required of this software are: 1)Product must have the capability to identify the discrepancies in claims, to include: a)Verifying the validity of codes submitted for each date of service on a claim, b)Identify appropriate procedures for reimbursement, c)Apply multiple procedure/surgery payment percentages, and d)Rebundle claims to appropriate procedure codes. 2)Product must identify which procedures on a claim should not be paid and why. 3)Product must audit CPT ® codes for a)Surgery, b)Medicine, c)OB/GYN, d)Radiology, nuclear medicine, and diagnostic ultrasound, e)Pathology/laboratory, f)Anesthesia, and g)Psychiatry and mental health. 4)Code editing/auditing software must be able to identify all form of code manipulation on all types of medical claims to include the following multiple code conflicts: a)Procedure unbundling b)Mutually exclusive procedures c)Incidental procedures d)Medical visits, same date of service e)Bilateral and duplicate procedures f)Pre- and postoperative care unbundling 5) Code editing/auditing software must be able to identify all form of code manipulation on all types of medical claims to include the following single code conflicts: a)Age conflicts, b)Sex conflicts c)Cosmetic procedures d)Investigational procedures e)Obsolete procedures 6)The product must correct the claim and provide feedback to the users both in a report format and to the CHAMPVA payment system of any action taken on a claim to include approve the claim as is, reject, flag for manual review, or apply reimbursement decisions based on the above listed discrepancies. 7)The product must provide qualified clinical staff responsibility for developing, documenting and supporting the decision to: a)Ensure that the clinical logic is a credible and legally supportable source for editing/auditing decisions, b)Provide detailed documentation describing the medical rationale for each editing/auditing decision, which can be shared with providers/beneficiaries when necessary (documentation should be both hard copy and automated, c)Provide access to medical professional/providers representing all medical and surgical specialty areas to support and defend the software's editing/auditing decisions through any appeals or legal processes, d)Verifies the validity of codes submitted for billing on a single date of service, plus verifying pre-operative and post-operative procedures or visits billed in conjunction with a related surgical procedure across dates of service, and e)Identifies the appropriate procedure(s) for reimbursement. 8)The product must allow for CHAMPVA policy customization to include: a)Ability to implement CHAMPVA specific policy coverage benefits and limitations, b)Ability to enter CHAMPVA specific codes (local codes), c)Flexibility to quickly implement medical policy changes as dictation by CHAMPVA regulations, d)Tracking and changes made through ongoing reports. 9)The product must have the capability to be implemented in: a)Online web-based mode - an independent application that is accessed using online screens, b)Batch-inquiry mode - an independent application that is fed claims data using a batch file, and c)Integrated mode - a component part of your claims processing system (CPS). 10) The vendor must supply automatic updates in order to keep pace with current coding methodologies. Updates include software version revisions, CPT ®, HCPCS, ICD-9 CM and ICD-10 codes. Also, ANSI X-12 specifically for the development and maintenance of Electronic Data Interchange (EDI) standards. In addition, all changes in medical rationale or new processing steps as they become available. 11) The product must also be able to flag claims and create summary reports either on a prepayment or post-payment basis. 12) The product must produce automated hard copy reports to include, but not limited to: a)A report listing by provider all claims with coding errors divided into categories as defined above along with the dollar savings identified; b)A report listing by claim with the date of service, the procedure code(s), description of codes, payment percentages applied based on assistant surgeon or multiple surgery, action taken if codes are rebundled or a procedure is mutually exclusive to another, and the dollar savings identified; c)A report summarizing the total number of claims with conflicts as identified above divided into categories of problems with dollar savings identified, d)A report detailing software performance and efficiency statistics. The user must have the option to run reports from any date or date range or by batch. User must also have the ability to print information from all claims by a date or date range, not just claims with conflicts. This would include ability to print all claims for a specific procedure code or range of codes. The user must also have the ability to review claims on either a prepayment or post payment basis to any given time in the event of a workload backlog. The user must have access to a staff of medical experts, including physicians of all specialties who assist in the development of medical criteria programmed within the software, and who are available on occasions when this criterion is challenged by outside physicians on an appeal. 3.0 SYSTEM INTEGRATION REQUIREMENTS The Product must have the capability for full integration with the HAC's CHAMPVA automated payment system to provide the functionality outlined in section 2.0, 6, and to provide a throughput of nnnnn claims per day. The CHAMPVA payment system software and database are developed on Intersystems Corporation Caché (version 5.2.3) running on the OpenVMS Alpha operating system (version 8.3). 4.0RESPONSE All interested parties are requested to provide the following information: Company name, address, point of contact information, size and business status (small, large, veteran owned etc.), location, DUNS number, GSA Schedule information, if applicable; and a description of the firm's capabilities with respect to the requirement described. Respondents are requested to provide information via email to the contracting officer Janice.Bertapelle-Anderson@va.gov no later than 4:30 PM October 18, 2010 local Denver, Colorado time. DISCLAIMER This RFI is issued solely for information and planning purposes only and does not constitute a solicitation. All information received in response to this RFI that is marked as proprietary will be handled accordingly. In accordance with FAR 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. Responders are solely responsible for all expenses associated with responding to this RFI.
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