Medicare Secondary Payer Business Process & Operations

THIS IS NOT AN INVITATION FOR BID, REQUEST FOR PROPOSAL (RFP), OR OTHER SOLICITATION, AND IN NO WAY OBLIGATES CMS TO AWARD A CONTRACT. THE SOLE INTENT OF THIS SSN IS TO OBTAIN CAPABILITY STATEMENTS NECESSARY TO DETERMINE IF SMALL and/or SMALL DISADVANTAGED BUSINESSES HAVE THE CAPABILITY TO PERFORM MEDICARE SECONDARY PAYER BUSINESS PROCESS & PROGRAM OPERATIONS. THIS WILL FACILITATE DETERMINATION OF THE APPROPRIATE ACQUISITION STRATEGY FOR PROCURING THESE SERVICES. Background The Centers for Medicare & Medicaid Services' (CMS) Medicare Secondary Payer (MSP) program is designed to promote the sustainability of the Medicare program by shifting Medicare beneficiaries' health care costs to private sources of payment, when available. The MSP law states that Medicare is prohibited from making payment where payment has been made or can reasonably be expected to be made by another insurer. In order to adhere to its statutory requirements, CMS' MSP program performs two primary functions: (1) coordinating benefits in order to ensure that Medicare pays properly, and (2) pursuing recoveries, where Medicare has paid conditionally and is entitled to reimbursement. The intent of this Sources Sought is to identify potential small or small disadvantaged businesses sources that are capable of performing both functions and all associated activities known as the Business Process & Program Operations. CMS is seeking to establish a centralized Coordination of Benefits (COB) and Medicare Secondary Payer Recovery (MSPR) operation by consolidating under a single program, the performance of all activities that support the collection, management, and reporting of other insurance coverage of Medicare beneficiaries, and the collection of mistaken primary payments. These activities are currently being performed under two separate contracts. CMS intends to establish a centralized COB and MSPR operation that provides quality customer service and a single source to Medicare providers, suppliers, beneficiaries, insurers and other stakeholders by streamlining the MSP data and debt collection processes while ensuring the integrity of the Medicare Trust Funds. CMS will establish a matrix organization of independent contracts to manage the major functions of this program (see attachment A). Under the matrix organization, the combined program (COB&R - Coordination of Benefits and Recovery) would be composed of at least five primary contracts: • Business Process & Program Operations • Information Technology Systems • Program Integration • Group Health Plan Recovery Audit • Non-Group Health Plan Ongoing Responsibility for Medicals Recovery Audit These components would work in concert to encompass all of those activities necessary to ensure that the primary payer -- whether it is Medicare, employer insurance or other insurance -- pays first, then identify claims that were mistakenly paid as Medicare primary, as well as claims where Medicare paid conditionally, and pursue recovery in the most cost effective and efficient manner. Purpose and Objectives: Overall goals in this consolidation initiative are to: • Administer the MSP process more efficiently and effectively by providing a single contractor entity to operate, coordinate and maintain the MSP process and thus generate cost savings through a reduction in mistaken primary Medicare payments and identification of conditional Medicare payments. • Provide beneficiaries and their representatives with a more efficient, user friendly and less intrusive MSP identification and debt recovery operation by streamlining the process from the collection of MSP information through to the collection of debt. • Achieve other cost reductions and management efficiencies by consolidating performance of similar activities (e.g., mail-room activities, Customer Service / Help Desk activities, etc.) that are necessary to carry out daily operations. • Provide greater flexibility in contracting to ensure the best earned value for the government. • Enhance program integrity consistent with the objectives of the Medicare Integrity Program (MIP). Requirements of Sources Sought for Business Process & Program Operations: The intent of this Sources Sought is to identify potential small and/or small disadvantaged business sources that are capable of performing the functions and activities associated with Business Process & Program Operations portion of the COB&R program only. The role of the Business Process and Program Operations Contractor (BPOC) is to maintain all business operations associated with the overall COB&R contract functions. As a supporting matrix contractor to the COB&R, the BPOC will work in concert with supporting matrix contractors to coordinate benefits and pursue MSP recoveries. CMS request responses from and encourages small businesses having experience performing the same or similar work identified in the Statement of Work to provide a capability response to this Sources Sought. Your capability responses should include documentation demonstrating the following: 1. Knowledge or experience relating to the MSP statute and/or related statutes, regulations, policy, and manual instructions, including, but not limited to, 42 U.S.C. 1395y(b), 42 C.F.R. part 411, et. seq., Medicare Secondary Payer Manual Section 100-05; (Also, refer to Attachment B, Section C.1.3) 2. Call center maintenance, oversight of a large scale customer service operation, an Interactive Voice Response Unit, and call recording, monitoring and distribution functionality; a. The average monthly coordination of benefits call volume for the timeframe June 2010 through May 2011 was 369,930 calls received per month. b. The average recovery call volume for time frame June 2010 through May 2011 was 55, 740 calls handled per month. This does not include abandoned calls or calls handled through an Interactive Voice Response unit alone. 3. Experience and/or knowledge related to internal workflow management tools, document management systems, case inventory management processes, correspondence management tools, and case management systems consistent with CMS security requirements, acceptable risk safeguards, Health Insurance Portability & Accountability Act, and Federal Information System Controls Audits Manual; Experience implementing and managing a high volume mailroom with Imaging functionality to archive all correspondence and associated documentation. For purposes of determining and demonstrating capabilities, see Attachment A, Section 3. 4. Experience and/or knowledge of inventory management processes and case management systems, consistent with CMS information security requirements, acceptable risk safeguards, HIPAA, and Federal Information System Controls Audits Manual (FISCAM). 5. Debt development and collection, including debt referral, where appropriate; 6. Knowledge of government accounting and funds control procedures, FISCAM, and ability to demonstrate Section 508 compliance; 7. Experience interacting with the health insurance, health care, and legal communities, including, but not limited to, insurers, attorneys, employers, third-party administrators, and claims administrators; 8. Understanding of EDI (Electronic Data Interchange) process, including ANSI X12 standards; 9. Ability to manage a complex computer-based system Recovery Management and Accounting System (REMAS) involving telephone customer service, beneficiary medical case investigation and management, financial recovery applications, workflow management tools (RSC-Recovery Service Ctr), and Medicare beneficiary accounting (SMART, MARTI, and/or HIGLAS). 10. Experience with referring and recalling debt(s) to/from the Department of Treasury 11. Documentation of an approved government approved accounting system which has been reviewed by the government and found adequate to identify, segregate, accumulate, and invoice costs. Attachments A and B represents an idea of the work to be performed under the Medicare Secondary Payer Business Process & Program Operations. Where noted please refer to the applicable sections . Attachment A: DRAFT Coordination of Benefits Statement of Work Sections 3.5.2 et. seq. 3.5.2.1.9, 3.5.2.1.11 - 13, 3.5.2.1.13.1, 3.5.2.1.15, 3.5.2.1.16 Sections 3.5.3, 3.5.3.1.2, 3.5.3.2.1, 3.5.3.3-3.5.3.14, 3.5.3.16-3.5.3.18, 3.5.3.20-3.5.3.20.1.2, Sections 3.5.5-3.5.5.2, 3.6 et seq., and 3.7.2-3.7.3 Sections 3.5.4-3.5.4.3, 3.5.4.7-3.5.4.8, 3.5.4.12, 3.5.4.15, 3.5.4.16-3.5.4.16.1, 3.5.4.17-3.5.4.17.8 Section 3.5.3.20.1.2 Sections 3.7, 3.7.1-3.7.1.4, 3.7.1.6-3.7.1.7, 3.7.3-3.7.7, 3.8.6. ) Sections 3.5.3.2.1 and 3.5.4.1. Section 3.9 et seq. Attachment B: DRAFT Medicare Secondary Payer Recovery Statement of Work Section C.3.3.3, Section C.3.3.4.3, Section C.3.3.4.4 (minus ORM) through and including C.3.3.4.11, Section C.3.3.4.13 (minus GHP demand issuance) through and including C.3.3.4.16, Section C.3.3.4.18 through and including C.3.3.4.22, Section C.3.3.4.24 through and including C.3.3.4.25. Attachment J-1.1 Interest on MSP Recovery Claims Attachment J1.2 MSP Debt Write Off Procedures Attachment J1.3 Federal Bankruptcy/State Insurer Liquidation Actions and MSP Debt Attachment J1.4 Handling Freedom of Information Attachment J1.5 Reopenings and Appeals Attachment J1.6 Miscellaneous MSP Policy Attachment J-2: Government Furnished Property (GFP) Attachment J-3: Contractor Furnished Property (CFP) Anticipated Period of Performance: CMS anticipates issuance of a Cost Reimbursement-type contract under the forthcoming solicitation. However, CMS does reserve the option to use any other procurement instrument as deemed appropriate at the time of the official solicitation. It is also anticipated that this award will be issued as one (1) base period and four (4) option periods, with a total effort of five (5) years. Capability Statement: Please provide a brief capability statement for our organization, tailored to demonstrate your relevant experience and/or ability to provide requirements of this magnitude . Please note that if individual capability information does not provide sufficient information for CMS to determine: (1) the potential to successfully perform the work described or (2) the ability to handle the volume indicated, the evaluation of the information will reflect that the offeror did not provide sufficient information to make a determination and CMS will not include the contractor for further consideration. All offerors will submit written documentation that their accounting system is adequate for determining costs applicable to the anticipate contract type. The written documentation shall be a letter signed by the appropriate Government official attesting to the adequacy of the accounting system. It is not the responsibility of CMS to obtain this written documentation. Interested parties having the capabilities necessary to perform the stated requirements may submit capability statements via email to [email protected] . CAPABILITY STATEMENTS MUST DEMONSTRATE THE CAPABILITY REQUIREMENTS OUTLINED ABOVE. Please address each in order listed above. Capability Statements shall be limited to 15 pages and shall include any/all teaming arrangements . Capability statements shall also include the following 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 Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp. e. Current General Service Administration (GSA) Schedules (include schedule description/number. f. Company Point of Contact, Phone and Email address g. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. Responses must be submitted no later than 3:00 PM EST, September 1, 2011. They should clearly reflect the respondent's ability to meet the requirements included in this notice. Capability statements will not be returned and will not be accepted after the due date. Respondents will not be notified of the results of the review of their submissions. Information received will be considered solely to make informed decisions regarding a potential small business set-aside. Disclaimer and Important Notes: This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization's qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. After a review of the responses received, a pre-solicitation synopsis and solicitation may be published in Federal Business Opportunities. However, responses to this notice will not be considered adequate responses to a solicitation. Confidentiality: No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s).