Health Care Claims Preferred Pricing Market Research Request For Information (RFI) PURPOSE: The purpose of this RFI is to assist the Department of Veteran Affairs (VA) in meeting its economic objective of providing high quality, accessible health care services to the nation's military veteran's at the most reasonable prices obtainable. When eligible veterans receive health care services from private sector providers, this contract allows the VA, through VA Medical Centers (VAMC) to share in the savings available through the contractor's discount agreements with institutional and individual providers. The preferred pricing services provided are applicable to health care claims generated under the VA's Non-VA Care (Fee Basis) program. This scope is identified below. BACKGROUND: VA intends to utilize the services of a preferred pricing contractor to identify cost savings on all types of health care claims by using the discounted rates of the contractor's network providers. The contractor must be URAC (Utilization Review Accreditation Commission) certified and/or NCQA (National Committee for Quality Assurance) certified. Also, the contractor operation must be in compliance with the Privacy Act and HIPAA Privacy Rule. OBJECTIVES: The purpose of market research is to allow Government the opportunity for dialogue and interaction with industry in order to: " Seek new ideas and approaches; " Get a more complete understanding of what the market has to offer; " Initiate dialogue with subject matter experts; and " Improve understanding of best practices and lessons learned. The primary goal for this information gathering effort is to better understand the offerings for claims preferred pricing through the contractor's network providers. The preferred pricing savings should exceed rates normally paid using Medicare's (CMS) Prospective Payments Schedules (PPS). RESPONSE 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 requirements described. Respondents are requested to provide information via email to the contracting officer
[email protected] no later than 4:30 PM January 23, 2013, local Denver, Colorado time (MDT). 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. NOTE: We cannot discuss the prospect of any future VA requirements, and providing responses to this questionnaire in no way provides your firm with any advantage or disadvantage toward a potential VA solicitation. The information collected by VA for the purpose of this effort will not be distributed or utilized for any other use or intent. PREFERRED PRICING SCOPE: The preferred pricing services scope, provided under this request, entails health care claims generated under the VA's Non-VA Care (Fee Basis) program. VA intends to work with the preferred pricing contractor to develop a process whereby outpatient, non-contracted health care claims will be electronically referred to the contractor. The types of health care claims will be determined upon contract award as the contractor will work with the VA to determine that the claims sent to them are appropriate for preferred pricing. The contractor shall review each claim to determine whether the provider is part of the contractor's network of providers and shall return to VA the lower contracted allowable amount for the services rendered. If the provider is not part of the contractor's network of providers, the contractor shall return the claim to VA with no cost savings indicated. VAMCs will submit Non-VA health care claims meeting specific criteria to the contractor for preferred pricing at the contractor's expense. The contractor identifies savings for Non-VA health care claims by applying its discounted network provider prices. Claims will be sent to the contractor for preferred pricing with the exception of: " Claims where the VA allowable is less than $10.00. This is the national standard threshold. VAMCs are allowed to send claims for less than $10.00 for 30 days after the first claim is sent to the contractor, and review the savings to determine if a lower threshold would be appropriate. The new threshold would be valid for a period of 1 year and would be re-evaluated at that time. " Claims paid under the Millennium Bill authority (Title 38 USC 1725) " Claims paid under a contractual agreement (to include Memorandums of Understanding and Sharing Agreements) " Claims for providers not included in the contractor's network. " Claims from stations without a current fiscal year purchase order. " Claims with an approved waiver. Questions 1. Please tell us about your company and how you are positioned in the health care marketplace. a. Company type [e.g. Public, for-profit or non-profit] b. Are you classified as a small business or SDVOSB? c. Organizational chart for the overall system d. Number of covered lives or enrolled beneficiaries as of Jan 1, 2012 (or other specified date) for Health Care Services e. Current year Health Care premium revenues from claim preferred pricing f. Current year Health Care claims paid g. States/locations served " Please provide the zip codes of your service areas or another geographic description such as counties. h. Describe your Health Care Services product and service offerings i. Have you previously contracted with the federal government to offer claim preferred pricing " If so please describe the contract period; typical contract renewal timeframe? 2. If registered in the federal government's Central Contractor Registration (CCR), what are your NAICS codes? 3. Please describe your Health Care Services provided through your network. 4. Describe your Health Care Services process(es) to include claim processing, timeliness of pricing claims, and preferred pricing for your network providers. 5. Please describe your credentialing and acceptance of Health Care Services for your network provider processes and best practices. a. Access (do you have providers where you have beneficiaries?) b. What tools are in place to describe where the providers are; what kind of providers are available etc. c. Processes, best practices in place and requirements for certification? d. What steps do you take to ensure current valid licenses are in place as required by law and provider has not been excluded from participation in the Medicare and Medicaid programs? e. How often do you update your provider network listings? 6. How do you measure and report quality of Health Care Services care in your network? a. Should VA pursue a partnership with your network, what considerations about measuring and reporting clinical care quality should be taken into account? b. Please describe the structures that are used to communicate quality issues to providers 7. How do you ensure privacy and security of patient information, clinical information, etc.? a. Describe your policies and procedures for protecting health information. b. What are your medical documentation sharing expectations of your network providers and any entity that you have existing contracts or partnerships with? c. How is medical documentation shared? d. What are the timeline expectations for response of submitting medical documentation? e. How is quality of documentation ensured, inspected and what are the expectations that current partners have in this regard? f. Describe the information systems that are in place to support the integrated system. g. Summarize your electronic records approach. h. Indicate how physician data, hospital data and health plan data are integrated. 8. What are the most appropriate pricing strategies, methodologies, systems (etc.) (or combination of these pricing schemes) that correspond to Health Care Services support for both contract and non-contract with your providers? 9. Describe your claims processing infrastructure to capture and process Health Care Services provided in a timely and compliant manner. a. Do you capture referral data as part of your claims process? b. Are you aware of the 5010 and ICD-10 regulations timelines and have evidence that you are on track to meet these requirements? c. Indicate what level of claims detail you could provide and how frequently (e.g., monthly?). At the line item level? " Including procedure and diagnostic detail (CPT codes, ICD-9/10, etc.) specific savings by provider for the DRGs and CPT codes utilizing the 2013 Medicare pricing schedule, and inpatient prospective payment system. " In what electronic format? " What types of cost data could be provided on these claim records? d. Upon contract termination, ability to provide preferred priced claims data in a ASCII text format, claim delimited, electronically transferred or on stored media 10. In terms of care coordination and management contracts, how have you used financial and other incentives with providers and with contracting entities (to maintain quality of services, share risks e.g. with medical groups, maintain access standards, manage costs)? a. Describe any positive or negative incentives used. b. Objective and/or subjective measurements used to determine incentives. c. Who is responsible for clinical quality; how it is measured? d. Incentives and/or measurement programs that were least useful, did not work as intended, or had unintended consequences? e. What positive or negative financial incentives should be tied to meeting or falling short of these achievement standards? f. What portion of total revenue should explicitly be linked to achieving quality standards compared to the health care cost capitation? 11. Do you think this effort will require one firm or do you think subcontractors would be required in order to accomplish the objectives? 12. If you have experience working under performance measures external to your organization, please describe those measures and how they affected your solutions and ability to perform a service. 13. What are the most important contract administration strategies to ensure successful, mutually beneficial care management contracts? 14. Describe how you would use and implement an Electronic Data Interchange (EDI) environment for this effort and return the priced or un-priced claims to the VAMC within three (3) calendar days. 15. What would be your approach for innovative and cost saving proposed methods of conducting business (e.g.: providing a secure web site for instant preferred pricing)? 16. How would you maintain a sufficient provider network? 17. Describe your approach to audit all incoming claims for preferred pricing suitability. 18. Describe the metrics and reporting that will be used to maintain the quality, consistency, and accuracy of the preferred pricing process. 19. Describe your approach for the following scenario: a. If discounted pricing is available, the contractor shall apply preferred pricing and annotate the claim accordingly. The contractor shall apply its best price, which shall be as low as or lower than the price charged to its most favored customer for comparable services and quantities under similar term and conditions. 20. Describe your implementation and operational approach to include mandatory deliverables, plan strategy, and performance management plan.