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FBO DAILY - FEDBIZOPPS ISSUE OF DECEMBER 08, 2017 FBO #5859
DOCUMENT

R -- Recovery Audit (PC3-Choice) - Attachment

Notice Date

12/6/2017
 

Notice Type

Attachment
 

NAICS

541211 — Offices of Certified Public Accountants
 

Contracting Office

Department of Veterans Affairs;Commodities & Services Acquisition Svc;(003B6E);555 Corporate Circle;Golden CO 80401-5621
 

ZIP Code

80401-5621
 

Solicitation Number

9189
 

Response Due

12/20/2017
 

Archive Date

12/25/2017
 

Point of Contact

Sheila Kiker
 

E-Mail Address

.kiker@va.gov<br
 

Small Business Set-Aside

N/A
 

Description

THIS IS A REQUEST FOR INFORMATION (RFI) ONLY. This RFI is issued solely for information and planning purposes it does not constitute a Request for Proposal (RFP) or a promise to issue an RFP in the future. This request for information does not commit the Government to contract for Recovery Audit services. Further, the VA is not seeking proposals and will not accept unsolicited proposals for these services. Responders are advised that the U.S. Government will not pay for any information or administrative costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested party s expense. Not responding to this RFI does not preclude participation in any future RFP, if any is issued. If a solicitation is released, it will be synopsized on the www.fbo.gov. It is the responsibility of the potential offerors to monitor these sites for additional information pertaining to this requirement. DUE DATE: Submittal of requested information is due not later than 3:00pm Mountain Standard Time, on Dec 20, 2017. Responses and Questions regarding this announcement shall be submitted in writing to the Contracting Specialist at Sheila.kiker@va.gov. Email responses are preferred. If brochures are available then attach them to the email, or identify a website where the brochures can be downloaded, or mail to: Department of Veterans Affairs Commodities and Services Acquisition Service (CSAS) Attn: Sheila Kiker 555 Corporate Circle Golden, CO 80401-5621 Interested providers are invited to review the attached PWS and provide comments along with capabilities and capacity to provide the desired services. Specifically, comments are encouraged in the following areas: Contractor capabilities in being issued an Authority to Operate (ATO) under a security category of Moderate. Does your company now hold or have has ever held an ATO with a Government agency. If yes, when and with what agency? Contractor understanding of CMS payment methodologies. Ability to safely exchange date under secure electronic means. Ability to store date Protected Health Information and Personally Identifiable Information (PHI/PII) in accordance with FISMA standards at the Moderate control level. Contractors socioeconomic status and DUNS number. Pricing (proposed percentage of recovered funds) DESCRIPTION QTY UNIT PRICE % * 0001 Recovery Audit 1 Each PURPOSE The Department of Veterans Affairs (VA), Office of Community Care (OCC) requires a highly skilled contractor to conduct Recovery Audit (RA) activities on claims paid under national health care contracts for the VA Community Care program. The audit activities will include auditing, recovery and reporting services of VA payments made for applicable paid claims related to healthcare programs under the Patient-Centered Community Care (PC3) and Veterans Choice Program, as well as for dialysis services. OCC intends to award a Recovery Audit, no cost (contractor is paid out of recovered funds only) contract to provide payment recapture/recovery auditing services. The Government s obligation to make payments to the contractor under this contract is contingent upon both the contractor s correct identification of valid overpayments and the Government s subsequent recovery of overpayments, or portion of overpayments. The Contractor shall bear the burden of costs of performing the auditing services and will be compensated only on a percentage of the actual funds recovered. Although OCC wants to obtain payment recapture/recovery auditing services that leverage effectively proven tools, methodologies, and/or best practices to improve the VA s activities in meeting these requirements, the VA also has options under Public Law 111 204, Improper Payments Elimination and Recovery Act of 2010 (IPERA) for conducting recovery auditing besides using the private sector. OCC and VA reserve the right to conduct recovery auditing using any of the options under IPERA, when it is in the best interest of VA. Recovery audits under this contract must always be provided in accordance with the procedures outlined in this Performance Work Statement (PWS) and only those claims identified for auditing by VA shall be subject to the terms and conditions of this contract. 1.1 Program Description and Governance The claims to be audited under this contract are only those paid under the PC3 and Veterans Choice Program and claims for dialysis services. Choice Program: Definition and Resources The Choice program allows eligible Veterans the opportunity to elect to use non-VA health care for a period of one year based either on the distance a Veteran lives from a VA facility, or if he or she is experiencing wait-times beyond the 30-day standard. Veterans who meet certain eligibility requirements will be able to elect to receive care from eligible non-VA entities and providers through the program. PC3: Definitions and Resources PC3 is a VHA nationwide program that utilizes  health care contracts to provide eligible Veterans access to primary care, inpatient/outpatient specialty care,  mental health care, limited emergency care, and limited newborn care for enrolled female Veterans following birth of a child. 1.2 Claims Paid Under the PC3 and Veterans Choice Program The table below represents individual claims paid under the PC3 and Choice programs, as well as dialysis claims; it does not include data on bulk payments. All data presented in this document is essentially unaudited and is provided only as an estimate of the number and costs of claims covered by the scope of this recovery audit contract. This information may contain claims which are not within the scope of this contract and are provided for informational purposes only. OCC Programs and Fiscal Year Total Expended Amount Claim Volume by Fiscal Year PC3 2014 $4,870,070.74 35,279 2015 $136,554,569.03 485,107 2016 $164,099,440.59 323,432 2017* $48,474,126.11 84,135 Choice           2015 $16,316,142.52 72,628 2016 $831,078,665.03 2,452,755 2017* $1,549,649,905.59 4,135,867 Contract Dialysis   2014 $365,338,219.86 102,355 2015 $441,206,868.41 122,313 2016 $476,896,632.17 130,680 2017* $250,018,230.44 69,405 Non-Contract Dialysis 2014 $85,399,826.73 24,881 2015 $46,290,966.77 13,578 2016 $36,498,683.34 12,251 2017* $17,432,438.52 5,831 PERFORMANCE WORK STATEMENT The Contractor shall develop and conduct recovery audit activities on 100% of claims paid under the PC3 and Veterans Choice Program exclusive of those claims listed under Section 4.4 Specific Exclusions to the PWS. The recovery audit must cover all claims throughout the lifespan of these programs, with the exception of the specific exclusions. The PC3/Choice lifespan currently covers the timeframe from October 1, 2013 through September 30, 2018. If the PC3/Choice contracts are extended beyond September 30, 2018, this recovery audit contract may be modified to include the additional timeframe. The legal authorities for PC3 and Choice include 38 U.S.C. 8153, Sharing of Health Care Resources; and Public Law 113-146, The Veterans Access, Choice, and Accountability Act. This recovery audit contract will also include all dialysis claims paid between Oct. 1, 2013 and Sept. 30, 2018. These claims were paid through national contracts with select dialysis providers as well as through direct agreements between VA Medical Centers and individual dialysis providers. As an optional task, VA may elect to include claims paid under the Project HERO program. This program paid claims to a contractor for medical services in four VISNs (8, 16, 20, and 23) from Fiscal Year 2009 through March 31, 2013. If exercised, this optional task will add approximately 800,000 claims to the audit universe. Exchange of information, establishing debts, and collection activities will be accomplished and shared electronically as much as is practical. The contractor shall furnish the necessary services and qualified personnel, facilities, equipment, materials, and supplies needed to perform the requirements set forth in this Performance Work Statement (PWS). The contractor recognizes and agrees that all materials, information and data provided to the contractor by VA are solely for use by the contractor in the performance of the contract and no other purpose. The contractor shall not release or share any VA information, data, and reports drawn from the VA information and data, or audit results with any entities within or outside of the contractor s corporation structure. All information obtained by the contractor while conducting the audit remains the property of the VA. The contractor also recognizes that while the activities conducted under this contract are essential, the contractor must conduct the audit with minimal disruption to and impact on both the providers or contractors and the VA Medical Center (VAMC) personnel. 2.1 Data for this contract will consist of claims paid under the PC3 and Choice programs and claims for dialysis services, excluding those noted in Section 4.4 Specific Exclusions to the PWS. OCC will make the data available to the contractor. The data will contain Personal Health Information (PHI) and Personally Identifiable Information (PII). The data provided for this contract will be limited to the data necessary regarding the claims to be audited under this contract. Noting the VA has minimized the potential of including unnecessary data by using filters and algorithms when pulling the data, filters and algorithms may not prevent unnecessary data from being included in the data provided to the contractor. Any unnecessary data co-mingled with necessary data will be protected in the same manner, ensuring no unauthorized disclosure will occur. The contractor shall not initiate collection activities on unnecessary data. The contractor shall notify the COR in writing when the contractor has an automated data system in place. This system will be required to go through the Risk Management Framework Process for a VA Authority to Operate. The data provided by OCC will consist of multiple files, will be provided at one time and the data will be sent in a comma separated (.csv) file format. However, this system must be ready to receive, manipulate, convert, compile, and transmit demographic and payment information and data needed to conduct the review and account for collection and reporting actions to and from VA within 30 calendar days following the kick-Off meeting. VA will send the initial paid claims data to the contractor via encrypted CD within 30 calendar days following notification their data system is in place and has a VA ATO. When necessary, VA will provide any updates for this data to the contractor, but updates should be minor and should not change greatly. Quarterly updates to the data, if required will be provided to the contractor within 90 calendar days following the end of the quarter. The initial data will be provided to the contractor on encrypted CD using VA approved FIPS 140-2 (or its successor) validated encryption. Access required to VA systems will be coordinated through the COR. 2.2 The Recovery Audit Process The Recovery Audit (RA) process includes but is not limited to recovery audit activities such as; collecting and analyzing the data and supporting documentation for VA payments on claims, identifying overpayments and under payments, establishing cases for recovering overpayment debts, identifying and reporting any suspected Fraud, Waste or Abuse (FWA), reporting results and completing follow-up collection actions throughout the period of performance. When the contractor has achieved compliance with all mandatory VA Information Security protocols and the contractor has received the data (described above in Section 2.1 Data) the contractor will assess that data. The contractor may request additional required documentation for making specific case determinations from the VA. OCC will designate points of contact that the contractor will route all documentation requests through. VA will make the final determination on what documentation will be required to audit a specific claim. When the contractor has assessed the data, they will determine their approach to addressing the overpayments and will request ONLY the documentation required to make a final assessment of specific claims. All documentation from the audit will be provided by OCC or the VAMCs and there is no reason to request documentation from the community providers or contractors. The contractor shall review the data and claims to verify the provider or contractor coding of services invoiced was rendered and appropriately coded, that VA correctly entered data and used the correct and proper payment methodology to pay for the services. Contractor shall determine proper identity of debtor and establish cases for overpayments accordingly. The contractor shall incorporate robust FWA detection analytics to identify FWA activities. By convention, all FWA claims will only include overpayments. If the audit reveals a situation of FWA, the contractor shall discuss the findings with the COR prior to notifying the dialysis contractor or PC3/Choice contractor of an overpayment. VA will provide training for the contractor on VA reimbursement methodologies to include review of applicable contracts governing Choice, PC3 and contracted dialysis used by the VA as required at a date mutually agreeable to both parties to allow the contractor to understand the current VA processes. For those claims the contractor has determined to have been overpaid, the contractor will establish a case for that overpayment. The date a case is considered established for debt collection is the date the contractor has completed their review of a claim and is prepared to move forward with collection activities. This date will be included in reports submitted to VA. Once a case is established, the recovery audit contractor will notify the dialysis provider or PC3/Choice contractor of the overpayment. The recovery audit contractor shall send up to three (3) letters to providers or PC3/Choice contractor requesting repayment to the VA of the overpayment. While the VA can review, any case developed by the contractor in which the provider or PC3/Choice contractor objects to the contractor s overpayment determination or their process, the contractor shall exhaust all efforts to explain the discrepancy prior to forwarding that case to the COR. VA s determination will be final. VA reserves the right to limit the time available for contractor review, by claim type, by provider type, or by any other reason where VA believes it is in the best interest of VA to limit claim review. This notice will be in writing, may be by email, and will be effective immediately. VA may conduct an annual or quarterly review, of contractor activities and the contractor shall provide all data, and documentation requested by VA auditors to fulfill this review. If VA has evidence to believe a contractor is not reviewing all claim/provider types, and/or is incorrectly applying payment methodology, or policy, VA will issue an official warning to the contractor. This notification shall include identification of specific claim/provider types the contractor failed to audit, the documentation citations that support the conclusions, and a time frame for correction. The contractor shall report all details regarding their identification of potential underpayments to VA with no other follow-up actions required. 2.3 Financial Management of Collected Funds 2.3.1 General Collections from dialysis contractor or PC3/Choice contractor will be sent directly to the VA. The VA will record collections into its database and make payments to the contractor based upon the collections received without the need for contractor invoicing. Contractor will maintain a similar database, compatible with the VA, for establishment of debts and reconciliation purposes. VA does not maintain a central database of previous refunds by non-VA providers or PC3/Choice contractor to the VA. Contractor will need to work with the OCC points of contact to determine if bills of collection have previously been executed. Cases that are reviewed and found to have been previously refunded to the VA prior to the audit shall be cancelled without payment to the contractor. Debts established for entities in bankruptcy status will be canceled without collection action. There is no payment to the contractor for these uncollected debts. The contractor shall not use the threat of litigation under this contract to illicit payment from dialysis contractors or PC3/Choice contractor. 2.3.2 Payment to the Contractor Contractor will be paid monthly and only from collected (recovered) funds VA receives from either the provider, TPA or the Department of Treasury. Contractor shall not be paid for uncollected amounts. Upon notification of identified overpayments, the VA will load the overpayments into the VA Recovery Audit Contractor Database. Upon receipt of the payment, the VA will enter the payments into the VA Recovery Audit Contractor Database. The VA will deposit these payments in accordance with VA policy and procedures and furnish the appropriate payment to the contractor. Invoicing by the contractor is not necessary. Payment to the contractor will cease 6 months after contract expiration for all cases submitted to Department of Treasury for offset regardless of the cumulative dollar amount. 2.3.3 Referral to the Department of Treasury The Digital Accountability and Transparency Act of 2014 (DATA Act) requires federal agencies to refer delinquent debt to the Department of Treasury for collection after 120 calendar days. The contractor is required to cease all recovery efforts once the debt is referred to the Department of Treasury. Once the debt is referred it is no longer the responsibility of the contractor. Debts ineligible for referral include: Debts in appeal status Debts where the debtor is in bankruptcy status Debts under a fraud and abuse investigation if the contractor has received specific instructions not to attempt collections. Debts in litigation (litigation means litigation which involves the federal government as a party; it does not include litigation between the debtor and some party other than the federal government); Debts where the debtor is deceased; Debts where VA has identified a specific debt, or group of debtors as excluded from referral; Debts less than $25 (In accordance with VA financial policy and Department of Treasury Offset policy, VA is unable to refer to the Department of Treasury Offset Program any debt established for amounts less than $25, or for any balance due less than twenty-five dollars. Debts for less than twenty-five dollars or with balances less than twenty-five dollars will be closed out after a year of no activity without payment to the contractor.); Debts of $100 or less where no TIN is available. If a debt is delinquent (past 120 calendar days), and ineligible for referral, the debt shall be closed out after one year of no activity without payment to the contractor. 2.4 Specific Exclusions to the PWS The following items are specifically excluded from the scope of this contract: Claims currently under investigation by VA for potential FWA Claims included in equitable relief Claims already reviewed and determined to be improper payments by VA auditors Any claim for which VA has already initiated collection activities 2.5 Innovation The Contractor may use creative approaches in the execution of Tasks as well as conveying results in reports or presentations, thoroughness and appropriateness of communicating issues to the COR or other designated OCC entity. These approaches can include but are not limited to: A robust electronic and/or automated system for the execution of the Tasks, Data query tools for accessing and performing multiple analyses for trending data and finding indications of potential FWA. Effective and efficient forms of data analysis. Current state-of-the-art effective technologies and methodologies that will assist the VA in preventing, detecting and recovering improper payments.
 

Web Link

FBO.gov Permalink
(https://www.fbo.gov/spg/VA/VADDC791/VADDC791/9189/listing.html)
 

Document(s)

Attachment
 

File Name: 9189 9189_1.docx (https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=3949768&FileName=9189-002.docx)

Link: https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=3949768&FileName=9189-002.docx

 

Note: If links are broken, refer to Point of Contact above or contact the FBO Help Desk at 877-472-3779.
 

Record

SN04758528-W 20171208/171206231051-af248bd812a45cc1dc43e8ddc701d232 (fbodaily.com)
 

Source

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

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