SOURCES SOUGHT
R -- PREDICTIVE MODELING SOLUTIONS FOR FEE-FOR SERVICE (FFS) MEDICARE CLAIMS
- Notice Date
- 8/27/2010
- Notice Type
- Sources Sought
- NAICS
- 541511
— Custom Computer Programming 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, Maryland, 21244-1850
- ZIP Code
- 21244-1850
- Solicitation Number
- RFP-CMS-2010-0054
- Archive Date
- 10/25/2010
- Point of Contact
- Monica N Carter, Phone: 410-786-7432, Donald M Knode, Phone: 410-786-1046
- E-Mail Address
-
monica.carter@cms.hhs.gov, donald.knode@cms.hhs.gov
(monica.carter@cms.hhs.gov, donald.knode@cms.hhs.gov)
- Small Business Set-Aside
- N/A
- Description
- The Centers for Medicare & Medicaid Services (CMS) seeks to identify and solicit feedback from capable sources regarding leading cutting-edge technology capabilities for Predictive Modeling/Management software as well as administrative claim review services and workflow management tools for Medicare Fee for Service (FFS) claims. At this time, CMS is interested in procuring services to establish and manage a real-time or near real-time Predictive Modeling/Management and Reporting System that will be used for identifying high risk claims in either or both a pre/post pay environment and denying after claims review has been completed. The Predictive Modeling System will have the capability to integrate within the existing Medicare FFS healthcare claims flow, analyze Medicare FFS data and provide real-time transaction risk scoring and referral strategy capabilities. Management and reporting will provide workflow management and workstation tools that present systematic data on the Medicare FFS claims selected by the Predictive Modeling System so that analysts are able to review, investigate and approve or decline claims in an automated manner consistent with Medicare program requirements and Medicare FFS payment processing. This announcement is a Request for Information (RFI) for planning purposes only. CMS is hereby conducting market research to identify interested qualified businesses that meet the requirements for this effort. Our market research consists of receiving appropriate capability statements to identify and understand what is available on the market, and organizing an innovative advisory multi-step acquisition process for this procurement. BACKGROUND: Medicare is a multifaceted program. The Medicare Fee-for-Service (FFS) program consists of a number of payment systems, with a network of contractors that process over 1.2 billion claims each year, submitted by more than 1 million health care providers such as hospitals, physicians, skilled nursing facilities, hospice facilities, home health agencies, National Council for Prescription Drug Programs (NCPDP) claims from suppliers and labs, ambulance companies, and durable medical equipment (DME) suppliers. These contractors, called "Medicare Administrative contractors (MAC)," process claims, make payments to health care providers in accordance with Medicare regulations, and are responsible for educating providers about how to submit accurately coded claims that meet Medicare's medical necessity guidelines. HIPAA defined healthcare fraud as any scheme to obtain payment by means of misrepresentation from any healthcare benefit program. Since 1990, GAO has annually declared Medicare at high risk for improper payments and fraud due to its size, score and decentralized administrative structure. A January 2008 report by the Office of Management and Budget (OMB) indicated that Medicare is among the top three Federal programs with improper payments, totaling an estimated $10.8 billion in 2007. The estimated improper payments were $10.2 billion in 2008 and 24.8 billion in 2009 (increase due to strict adherence to policy documentation requirements and the addition of inpatient review policies). CMS currently uses a limited application of pre-payment screening, editing and selective review of claims conducted by Medicare Administrative Contractors (MACs) along with post-payment review activities by Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs). Despite these actions to prevent or recoup improper payments, it is impractical to prevent all improper payments under the current rule-based technology utilized in the Medicare FFS systems. There is growing concern that the Medicare Trust Funds may not be adequately protected against erroneous payment through current administrative procedures. REQUIREMENTS: CMS is looking for a predictive modeling solution to supplement the traditional rule-based screening and editing of Medicare FFS claims by employing advanced predictive modeling techniques that can screen, score and select claims that have a high probability of payment error and refer them for review and verification. Comprehensive pre-payment and/or post-payment review will prevent suspect claims from being reimbursed. Specifically, CMS seeks information about predictive modeling solution(s) that are able to: a. Handle high volume (e.g. approximately 4.5 million claims per business day) b. Integrate into the existing Medicare FFS claims flow with minimal effort, time and cost c. Integrate into multiple points along a health care claim flow (pre or post adjudication) for the identification of high-risk claims d. Provide a rapid, real time or near real time solution with large data storing, data mining and pooling capabilities e. Provide administrative claim review services f. Maintain current processing times and work within the architecture to improve them g. Utilize a statistically sound, empirically derived predictive modeling technology designed to prevent improper payments. h. Provide advanced predictive modeling techniques based on historical transaction data across all markets and regions i. Provide continuous recalibration of scoring models and allow for regular updates through a feed-back loop j. Utilize integrated real-time transaction risk scoring and referral strategy capabilities to identify claims that are statistically unusual k. Permit modification to the software and system edits in a rapid and timely manner. l. Provide a change control process that applies quick changes to react to changing patterns of behavior m. Mark each flagged claim with a Medicare-defined reason code or model rule explaining to the human reviewer the reason the claim is potentially improper and providing a recommended action (research, obtain medical records) n. Allow CMS visibility into data analysis so that patterns of excessive usage, unusual patterns, comparison to peers, etc are identified, scored, and implemented rapidly o. Provide views for all provider and patient activities across all federal health program payers p. Provide workflow management and workstation tools that have the ability to systematically present scores, reason codes, and treatment actions for high-risk scored transactions q. Provide an audit trail on actions taken on claims (denied on a specified date, etc) that is available to authorized users via an interactive web-based application r. Provide a feed-back loop of final claim status indicating the final resolution of the claim (approved, fraud, abuse, waste, education, deny) incorporating Medicare appeals data s. Provide CMS with decision support and data analysis functions along with robust tracking and reporting features via an interactive web-based application so that Return on Investment can be accurately measured and reported An integral part of this Sources Sought is to identify and understand what is available on the market. CMS understands that more than one product may be required to obtain the full functionality required in (a) through (s). CMS's goal is to select one or more product(s) for integration into the Medicare fee-for-service standard claims processing system flow to meet the requirements. Vendors expressing an interest should provide appropriate capability statements that include the following information: 1. Please provide appropriate company contact information as follows: •The name and address of the firm •Dun and Bradstreet identification number •Point of contact: name, title, phone, fax and e-mail •Information Technology Security Official: name, title, phone, fax and e-mail 2. Identification of whether your company is a small or large business and whether you have any Small Business Administration identification of socioeconomic programs such as 8(a), woman owned, veteran owned, etc. 3. A description of your organization's capability, staffing profile and workflow process to provide management and review including claim review (i.e. would you perform the review yourself or would you partner with someone else). 4. A description of your organization's experience and past performance integrating into a pre-existing large processing environment, including any multi-tiered applications, pre-payment and post-payment implementations, and whether your staff provided transaction review. Provide, at a minimum, two (2) descriptions of large scale integration efforts. 5. A description of your organization's contracts, subcontracts or other arrangements, if any, with current Medicare contractors, including but, not limited to, Medicare Administrative Contractors, Recovery Audit Contractors, Zoned Program Integrity Contractors, Medicare Advantage Plans, Medicare shared systems, etc. 6. A list of current customers who use the software applications and administrative review and reporting functions identified in your response to this notice. 7. A description of the ability to provide the capabilities as listed in (a) through (s) above. Each capability requirement must be addressed separately in the order listed. 8. A description of the architecture (software, hardware, communication protocols), the proposed CPU or Server configuration, storage requirements, scalability, and ability to handle more than 1.3 TB of data. Provide processing timeliness versus system configuration trade-offs and statistics as well as a high level architecture diagram illustrating the main system components. 9. A description of your product's capability to integrate within the Medicare FFS environment and deploy at a CMS designated processing site. 10. Documentation that the technology is current, flexible, expandable and able to scale for the growth projected for Medicare FFS claims. 11. A description of whether the organization is compliant with the Federal Information Security Management Act (FISMA) requirements, and if not, how you will comply with CMS data and IT security requirements that will be necessary to implement this system. 12. Please provide your product list, price list and product literature. 13. Please estimate product costs based on 4.5 million claims analyzed per day for product licensing, warehouse development, development of CMS modeling rules, and data analysis. 14. Additionally please estimate the staff costs required for review of 1,000,000 claims per year. 15. Suggestions as to how CMS could best: • Assess the accuracy of the models and claims selected for review • Review and assess the processing capability of the product • Perform a small scale test • Perform a large volume field test • Establish initial processing goals including specific programmatic or geographic factors. (e.g. variation of providers, distribution of services or beneficiaries) that exploit features of your product and bring benefit to CMS and the Medicare program in FY 2011. 16. A description of your product's compliance with Section 508 of the Rehabilitation Act of 1972 (29 U.S.C. § 794 (d)), as amended by the Workforce Investment Act of 1998 (P.L. 105-220), August 7, 1998. 17. A description of your organization's processing maturity level in relation to: • The Carnegie Mellon Software Engineering Institute (SEI) Capability Maturity Model Integration® (CMMI)® • International Organization for Standardization (ISO) registration. CMS anticipates awarding a firm fixed price contract for an enterprise-licenses and maintenance of the software. The contract is for one (1) 12 month base period plus four (4) 12-month Option years. The procurement may result in multiple awards. INSTRUCTIONS: NO FORMAL SOLICITATION IS BEING ISSUED AT THIS TIME. Responses submitted to this notice are for informational purposes only. Responses are due no later than September 24, 2010 at Noon local prevailing time and shall be submitted electronically via e-mail only to the attention of the Monica Carter at Monica.Carter@cms.hhs.gov. Fax, mail, or courier delivery of responses will not be permitted. The page limitation is 20 pages. Product list, price list and product literature used as marketing material are in addition to the 20 page limit and may be submitted as separate files. However, the total file size limitation for e-mail attachments is 3 megabytes. Further, access by CMS to information in any files attached to a response is the responsibility of the submitting party. The CMS is not responsible for any failure to access information. Therefore, please ensure that files are easily accessible by CMS - Word files are preferable, but we will accept pdf files as long as they meet the 3 megabyte size limitation. The subject line of the e-mail message shall read: "2010 Predictive Modeling Solution for FFS Medicare". CMS will not be responsible for any costs for the preparation of responses to this announcement or project. THIS IS NOT A REQUEST FOR PROPOSAL. THIS NOTICE CONSTITUTES THE ENTIRE SOURCES SOUGHT ANNOUNCEMENT AND IS THE ONLY INFORMATION PROVIDED BY CMS. REQUESTS FOR ADDITIONAL INFORMATION WILL NOT BE HONORED.
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-
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- Record
- SN02258238-W 20100829/100827235608-11544b2cabff35928ef807472d8d468f (fbodaily.com)
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