A. SYNOPSIS This is a request for information. It is not a solicitation for proposals, proposal abstracts, or quotations. Release of this information should not be construed as a commitment to procure items discussed or to incur costs for which reimbursement would be required or sought. The purpose of this notice is to identify comprehensive cost avoidance and recovery solutions in the following areas: 1. Recoupment of monies from New York State Workers' Compensation Insurers for medical and pharmacy related treatments costs paid by the World Trade Center Health Program and covered by an active claim; 2. Avoidance of potentially fraudulent or wasteful payments by using limited member data (not including Social Security Numbers) to determine deceased members from the Social Security Death Index or other sources; and 3. Identification and verification of other health insurance for Survivor members of the World Trade Center Health Program for coordination of benefit (COB) and for recovery of paid claims. B. BACKGROUND On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Act established with the Department of Health and Human Services a program to be known as the World Trade Center Health Program (WTC Health Program). The WTC Health Program provides medical monitoring, screening and treatment for responders and survivors of the 9/11 terrorist attacks. Responders include a worker or volunteer who provided rescue, recovery, demolition, debris removal, and related support services in the aftermath of the September 11, 2001, attacks on the World Trade Center including members of the Fire Department of New York City whether fire or emergency personnel, active, or retired. Survivors include persons that worked, lived, or attended school, childcare, or adult day care in the New York City disaster area, who were adversely affected by the September 11, 2001, terrorist attacks in New York City. As of December 31, 2018, there are a total of 74,107 responders and 18,921 survivors. The statute authorizes these services and directs the WTC Health Program to recover monies from workers' compensation (WC) insurers for medical treatment (including pharmaceuticals) when the responder or survivor who is treated by WTC Health Program is also eligible for workers' compensation benefits. The New York State (NYS) Workers' Compensation Board (WCB) has established a Health Insurers' Match Program (HIMP) that permits health plans, such as the WTC Health Program, to identify individuals who are eligible for workers' compensation benefits and to seek reimbursement from workers' compensation insurers for treatment-related costs paid by the health plan. The statute also requires that medical treatment and pharmacy claims for Survivors are coordinated with the member's primary insurance. Clinics responsible for seeing Survivor members collect private or public health insurance information and coordinate benefits with these payers with the WTC Health Program as the "last payer." The WTC Health Program seeks to have information on the use of the New York State Workers Compensation Board HIMP to recoup WTC Health Program costs for medical and pharmacy claims covered by workers' compensation claims for WTC related health conditions. The WTC Health Program found through audits that payments were made for certain claims against member numbers where the member was known to be deceased. The WTC Health Program seeks to have regular checks against the Social Security Death Index or other sources to confirm the status of its members using limited sources of data that do not include the member's Social Security Number. The Coordination of Benefit and Recovery (COB&R) function involves the collection, management, and reporting of other insurance coverage for beneficiaries and the recovery of paid claims which were paid incorrectly or should have been paid by other insurances or coverages. The WTC Health Program seeks to have information on health insurance identification, COB&R functions and reporting of other insurance coverage for beneficiaries and the recovery of paid claims which were paid incorrectly or should have been paid by other insurances or coverages. C. REQUESTED INFORMATION To help inform the WTC Health Program with a comprehensive cost avoidance, COB and recovery solutions that can support robust financial and healthcare cost management, please respond to the following questions in order. Please respond to all questions. 1. Please describe how your company would implement comprehensive and proactive cost avoidance solutions that ensure beneficiaries' healthcare claims cost are appropriately covered by their respected primary insurance. Should the solutions include real-time identification and verification of other insurance coverage? 2. How would your company be able to identify, predict and avoid preventable and unnecessary high healthcare cost while ensuring beneficiaries' healthcare services? What member's management solutions are available? 3. Once other health insurance is identified and validated, should your company conduct the COB? How would the COB be implemented? 4. Once a healthcare claim is paid, how would your company recover a wrongly paid claim? 5. Should your company participate in the NYS WCB HIMP to recoup the WTC Health Program its costs for services covered by workers' compensation for WTC related health conditions? If so, how would your company implement this process as part of its comprehensive cost control solutions? 6. Are there any additional considerations for a comprehensive cost control solution or reduction in administrative costs? How and why they should be implemented in the WTC Health Program? 7. Please explain the types of platforms available with your company's capabilities to successfully work with NYS WCB HIMP to recoup funds for services covered by workers' compensation for WTC related health conditions. 8. Provide any additional platform capabilities that may identify all healthcare insurance providers including workers' compensation. 9. Please describe any types of platforms with the capabilities in the identification/verification of other healthcare insurance providers and the ability to recoup. 10. If a platform in question 8 and 9 is identified, explain how the platform will be structured and be implemented. 11. Explain any downside to the platforms described in questions 8-10. 12. What metrics should be tracked to evaluate recoupment success? 13. Provide a description of sources to verify whether members are living or deceased and the types of information necessary to make that determination with those sources. D. INSTRUCTIONS 1. Questions about the RFI are due by April 25, 2019, via email to Lauren Peel at
[email protected]. 2. Interested parties are request to respond to this RFI with a white paper. White papers are due by 10 AM on May 24, 2019, to Lauren Peel at
[email protected]. White papers should list each question identified above and provide the accompanying response below. 3. Interested parties may provide a capabilities statement in addition to your white paper. Please do not submit a capabilities statement without an accompanying white paper. 4. Section 1 of the white paper shall provide administrative information, including: a. Name, mailing address, phone number, and email of designated point of contact; b. Business type (small, large, 8(a), women-owned, etc.); c. Relevant NAICS code; and d. Participation in a GSA Schedule or other government-wide vehicle.