Page 1
DRAFT PRE‐ DECISIONAL
1
STATEMENTOFWORK(SOW)
FORMEDICAREADVANTAGE(MA)RISKADJUSTMENTDATAVALIDATION(RADV)RECOVERYAUDITCONTRACTOR(RAC)
I. StatutoryBackgroundandGeneralPurpose
TheMedicareRecoveryAuditProgrambeganasathree‐yeardemonstrationauthorizedbyCongressinsection306oftheMedicarePrescriptionDrug,ImprovementandModernizationActof2003(MMA)(P.L.108‐173).ThedemonstrationwasconductedinsixstatesfromMarch2005toMarch2008,anditspurposewastodetermineifRecoveryAuditorContractors(RACs)couldeffectivelyidentifyimproperclaimspaidunderMedicarePartAandPartB.ThisinitialpilotprogramsucceededinreturningmillionsofdollarsinoverpaymentstotheMedicareTrustFunds.BasedonthesuccessoftheRecoveryAuditdemonstration,section302oftheTaxReliefandHealthCareActof2006(TRHCA)(P.L.109‐432)createdapermanentMedicareRACprogramandaddedanewparagraph(h)tosection1893oftheActthatrequiredCMStoestablishanationwideRACprogramforMedicarePartAandPartBbyJanuary1,2010.Specifically,thestatutestates:
(1)UndertheProgram,theSecretaryshallenterintocontractswithrecoveryauditcontractorsinaccordancewiththissubsectionforthepurposeofidentifyingunderpaymentsandoverpaymentsandrecoupingoverpaymentsunderthistitlewithrespecttoallservicesforwhichpaymentismadeunderthistitle.Underthecontracts—
(A)paymentshallbemadetosuchacontractoronlyfromamountsrecovered;(B)fromsuchamountsrecovered,payment—
(i)shallbemadeonacontingentbasisforcollectingoverpayments;and(ii)maybemadeinsuchamountsastheSecretarymayspecifyforidentifyingunderpayments;and
(C)theSecretaryshallretainaportionoftheamountsrecoveredwhichshallbeavailabletotheprogrammanagementaccountoftheCentersforMedicare&MedicaidServicesforpurposesofactivitiesconductedundertherecoveryauditprogramunderthissubsection.
...(4)Auditandrecoveryperiods.—Eachsuchcontractshallprovidethatauditandrecoveryactivitiesmaybeconductedduringafiscalyearwithrespecttopaymentsmadeunderthistitle—
(A)duringsuchfiscalyear;and(B)retrospectively(foraperiodofnotmorethan4fiscalyearspriortosuchfiscalyear).
Page 2
DRAFT PRE‐ DECISIONAL
2
Section6411(b)ofthePatientProtectionandAffordableCareActof2010(PPACA)(P.L.111‐148),asamendedbytheHealthCareandEducationReconciliationActof2010(HCERA)(P.L111‐152),requiresexpansionoftheRACprogramtoMedicarePartCandPartD.CMSiscurrentlyexploringstrategiesforexpandingtheRACprogramtoMedicarePartC.ThepurposeofthisdraftScopeofWorkistosolicitcommenton,andinterestin,CMSenteringintoacontractwithaRACtoidentifyunderpaymentsandoverpaymentsandrecoupingoverpaymentsassociatedwithdiagnosisdatasubmittedtoCMSbyMedicareAdvantageOrganizations.CMScurrentlyconductsRiskAdjustmentDataValidation(RADV)auditstovalidatetheaccuracyofdiagnosisdatasubmittedtoCMSforpaymentbyMedicareAdvantageOrganizationsandtorecovernetoverpaymentsassociatedwithinaccuratediagnosisdata.ThisdraftSOWdescribesthePartCRAC’sroleintheexistingRADVauditprocess,referredtohereinastheComprehensiveRADVaudits,andtheirroleinadditionalauditsofdiagnosisdatasubmittedtoCMSbyMedicareAdvantage(MA)Organizations,referredtohereinasCondition‐SpecificRADVAudits.ErrorsandomissionsinthediagnosisdatasubmittedtoCMSbyMedicareAdvantageOrganizationsarethedriversofthe9.5%improperpaymentrateinMedicarePartC.Currently,CMSaudits30MedicareAdvantageOrganizationcontracts(approximately5%)perpaymentyear.CMSisconsideringcontractingwithaPartCRACtoincreasethenumberofMedicareAdvantageOrganizationcontractsthataresubjecttosometypeofRADVauditforeachpaymentyear.OurultimategoalistohaveallMAcontractssubjecttoeitheraComprehensiveorCondition‐SpecificRADVauditforeachpaymentyear.
II. RiskAdjustmentandRADVBackgroundA. RiskAdjustmentinMATheBalancedBudgetAct(BBA)of1997mandatedthatpaymentsmadetoMedicaremanagedcareorganizationsbeadjustedtoreflecttherelativehealthstatusoftheirenrollees.RiskadjustmentimprovestheaccuracyofMedicare’spaymentstoMAorganizationsandreducestheincentivesforplanstoriskselectonlythehealthiestbeneficiaries.Underriskadjustment,CMScalculatesariskscoreeachyearforeachMAenrollee.TheriskscorereflectsCMS’predictionofeachbeneficiary’slikelyrelativecostbasedontheirdemographiccharacteristicsandhealthconditions(e.g.,diabetes).CMSdeterminesthehealthconditionsforeachbeneficiaryusingdiagnosisinformationreportedtoCMSbytheirMAorganization.RiskscoresarecalculatedusingtheCMSHierarchicalConditionCategory(CMS‐HCC)riskadjustmentmodel.
Page 3
DRAFT PRE‐ DECISIONAL
3
B. RiskAdjustmentinMA:DiagnosisDatasubmission
MAorganizationsarerequiredtosubmittoCMSdiagnosisinformation(i.e.,“riskadjustmentdata”)fortheirenrollees.AlldiagnosiscodessubmittedtoCMSforMedicareAdvantageriskadjustmentmustmeetanumberofrequirements.Theymust:
Bedocumentedinthemedicalrecord. Bedocumentedasaresultofaface‐to‐facevisit. Comefromacceptabledatasources(inpatient,outpatient,physician,‐seethe
MedicareManagedCareManual,Chapter7–RiskAdjustmentformoreinformation,whichmaybefoundathttps://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/Downloads/mc86c07.pdf).
Besubmittedatleastonceduringtheriskadjustmentdata‐reportingperiod. BecodedaccordingtotheICDClinicalModificationGuidelinesforCodingand
Reporting.Chronicconditionsmustmeetalloftheaboverequirementseachyearinordertobeacceptableforriskadjustment.
C. ComprehensiveRADVAuditsCMSconductsRADVauditsforthepurposeofensuringtheaccuracyandintegrityofriskadjustmentdataandconductingoverpaymentrecoveryfromMAorganizations.UnderComprehensiveRADVAudits,CMSselectsasubsetofMAplancontractstoauditforeachpaymentyearandselectsastatistically‐validsampleofenrolleesforeachauditedcontract.AuditedMAorganizationssubmitmedicalrecorddocumentationtoCMSforeachofthediagnosesthattheyreportedtoCMSforenrolleesintheauditsample.ThefocusofRADVisonreviewingtheplan‐submittedmedicalrecorddocumentationtoverifydiagnosessubmittedbyMAorganizationsforpayment.BeginningwiththeRADVauditsforpaymentyear2011,CMSusesthesampleresultstocalculateanextrapolatedoverpaymentestimateforeachauditedcontractandrecoversoverpaymentsbasedontheextrapolatedestimate.InApril2010,CMSpublishedthePolicyandTechnicalChangestotheMedicareAdvantageandtheMedicarePrescriptionDrugBenefitPrograms[CMS‐4085‐F],whichprovidedanadministrativeappealsprocessunderRADV.TheregulationallowsforanappealofmedicalrecordreviewfindingsandofthepaymenterrorestimatecalculationforRADVaudits.InJanuary2014,CMSpublishedthePolicyandTechnicalChangestotheMedicareAdvantageandtheMedicarePrescriptionDrugBenefitProgramsforContractYear2015[CMS‐4159‐P],whichfinalizedinregulationchangestotheadministrativeappealsprocessunderRADV.OnFebruary24,2012,CMSreleasedthe“NoticeofFinalPaymentErrorCalculationMethodologyforPartCMedicareAdvantageRiskAdjustmentDataValidationContract‐
Page 4
DRAFT PRE‐ DECISIONAL
4
LevelAudits”.Thefinalmethodology,whichcanbefoundat:http://www.cms.gov/Plan‐Payment/02_PaymentValidation.asp,providesthesamplingmethodologyandpaymenterrorcalculationmethodologyfortheComprehensiveRADVAudits. TheCentralizedDataAbstractionTool(CDAT)istheCMSsystemthatsupportsthecollectionandprocessingofallRADVdataandmedicalrecords,medicalrecordreview,andRADVdatamanagement.AllcommunicationsthroughouttheRADVprocessbetweentheMAcontractandCMSareconductedviaCDAT.AlldocumentationrequestsareuploadedelectronicallyintoCDAT,includingcopiesofbothelectronicandpapermedicalrecords.Whenreferencedinthisstatementofwork,thewordCDATmeansthecurrentsystemasitexistsoranothersystemsupportingtheRADVauditsasspecifiedbyCMS.BecausethePartCRACwillbeusingCDAToranothersystemasspecifiedbyCMS,thePartCRACwillnotrequireitsownsystemwithanauthoritytooperate. D. KeyContractorsInvolvedintheRADVAuditProcessThereareseveralkeyCMSRADVcontractorsthatsupporttheRADVprocess:
LeadAnalyticContractorTheleadanalyticcontractorconductsthesamplingandpreparestheenrolleeandHCCleveldatathatiscommunicatedtotheMAcontractsthroughouttheRADVauditprocess.
SecondaryReviewContractorTheSecondaryReviewContractorprovidesacontrolinthemedicalrecordreviewprocess.Thiscontractorre‐reviewsthedocumentation,whereHCCsupportismissing,inordertovalidatetheinitialfindingsandtoconfirmthattheremaybeanoverpaymentproblem.
CentralizedDataAbstractionToolContractor.TheCDATcontractormanagesthesystemwhichfacilitatesallprojectcommunications,supportsthemedicalrecordreviewersinthecodingprocessandtracksreviewfindings.
III. RADVAuditTasks
WorkingindependentlyandnotasanagentoftheGovernment,thePartCRAC shallfurnishallthenecessaryservices,qualifiedpersonnel,material,equipment,andfacilities,nototherwiseprovidedbytheGovernment,neededtoperformtheSOW.Thisincludesallpersonalcomputers,printersandequipmenttoaccomplishtheworkdescribedintheSOWthroughoutthecontractperiodofperformance.CMSwillprovideminimumadministrativesupportwhichmayincludestandardsystemchangeswhenappropriate,helpcommunicatingwithcontractors,policiesinterpretationsasnecessaryandothersupportdeemednecessarybyCMStoallowthePartCRACtoperformitstasksefficiently.CMSwillsupportchangesitdeterminesarenecessarybutcannotguaranteetimeframesor
Page 5
DRAFT PRE‐ DECISIONAL
5
constraints.ThePartCRACwillberequiredtoadapttochangesinRADVauditpolicy,operations,andCDAT(orothersystemasspecifiedbyCMS).ThePartCRACshallidentifybothsufficientpersonnelandappropriatelyskilledprofessionalpersonneltocompletethespecifictaskscontainedhereintobeconductedbythePartCRAC.Underallcircumstances,thePartCRACshallconformtoallrequirementsforconfidentialityofbeneficiaryandMAorganizationleveldata(paperandelectronic).TheCORwillapprovetheprojectplanaswellasallcorrespondenceandwrittendocumentation,includingreports,letters,andtrainingmanuals.AllwrittendocumentationandcommunicationshallbesubmittedtotheCORindraftform,inamannerallowingsufficienttimeforreviews,editsandapprovalsasdeterminedbytheCOR,andshallbeproducedinfinalformatthediscretionandapprovaloftheCOR.TheContractorshallconformtoallrequirementsforconfidentialityofbeneficiaryandMAorganizationleveldata(paperandelectronic).WithinthisSOW,referencesto“medicalrecord(s)”includesalldocumentsrequestedfromandsubmittedbyMAorganizationsforthepurposesoftheseRADVaudits,includingbutnotlimitedtomedicalrecords,CMS‐Generatedattestations,coversheetsandappealsdocumentation.ThePartCRACmayNOTattempttoidentifyanyunderpaymentsandoverpaymentsandrecoupoverpaymentsotherthanasdescribedinTask1orTask2.TASK1.COMPREHENSIVERADVAUDITSComprehensiveRADVauditsarecomprisedofthestepsdescribedbelow.Step1:Selectionforaudit/samplingStep2:IntakedocumentationreviewStep3:MedicalrecordreviewStep4:Paymenterrorcalculation,issuingauditreportsanddemandlettersStep5:Administrativeappealsprocess
Page 6
DRAFT PRE‐ DECISIONAL
6
Thestepsaredescribedbelow,includingspecificPartCRACtasksfortheComprehensiveRADVAudits.ThePartCRACtasksarealsosummarizedinFigure1.PartCRACRolesinComprehensiveAuditProcess.
Step1:Selectionforaudit/sampling.CMSwillselectMAcontractstoauditforeachpaymentyear.Fortheselectedcontracts,theLeadAnalyticContractorwillapplytheComprehensiveRADVAuditsamplingmethodologytoselectastatistically‐validsampleofbeneficiaries.TheLeadAnalyticContractorwillprepareanauditpackageforeachMAcontractthatidentifiesbeneficiariesintheauditsampleandthediagnosessubmittedtoCMSbytheMAorganizationforthesebeneficiaries.ThispackageissenttotheMAcontractsviaCDATandservesasthedetailedmedicalrecordrequest.Step2:Intakedocumentationreview.MAorganizationsselectedforauditwillsubmitmedicalrecorddocumentationtoCDAT(orothersystemasspecifiedbyCMS)forbeneficiariesanddiagnosesintheauditsample.ThePartCRACwillreviewthemedicalrecorddocumentationtodeterminecompliancewithRADVAuditdocumentation
FIGURE 1: PART C RAC ROLES IN COMPREHENSIVE RADV AUDIT PROCESS
Step 2: Intake Documentation Review
Part C RAC reviews medical record documentation for validity. Only valid medical record documentation moves forward for medical record review.
Step 3: Medical Record Review
Part C RAC reviews valid medical record documentation to determine whether the diagnosis(es) submitted by the MA organization are present and whether additional payment diagnoses are supported. The Part C RAC conducts a complete code of the entire medical record.
Step 4: Payment Error Calculation, Issuing Audit Reports and Demand Letters
Part C RAC supports the payment error calculations.
Part C RAC prepares audit reports for each audited MA contract.
Part C RAC issues demand letters for MA organizations that elect not to appeal.
Step 5: Administrative Appeals Process
Part C RAC provides appeals support as necessary.
Part C RAC updates the audit reports and payment error estimates and issues demand letters to MA organizations, as applicable, at the conclusion of the first phase of appeal (Reconsideration).
Page 7
DRAFT PRE‐ DECISIONAL
7
requirements,asspecifiedbyCMS(e.g.,therecordmustbefromtheappropriatetimeperiodandmustbeahospitalinpatient,hospitaloutpatientorphysicianrecord).Asacontrolmeasure,theSecondaryReviewContractorwillreviewandconfirmoroverturneachmedicalrecorddocumentationfindingdeterminedtobeinvalidbythePartCRAC.Onlyvalidmedicalrecorddocumentationmovesforwardformedicalrecordreview.Step3:Medicalrecordreview.IfthemedicalrecorddocumentationwasdeterminedvalidinStep2,thePartCRACwillreviewthemedicalrecorddocumentationtodeterminewhetherthedocumentationsupportsthediagnosessubmittedbytheMAorganizationforpaymentandwhetherthedocumentationsupportsadditionalpaymentdiagnosesnotsubmittedbytheMAorganization.ThePartCRACwillreviewthemedicalrecordsandabstractallICD‐9‐CM(InternationalClassificationofDiseases,NinthRevision,AndClinicalModification)codesorICD‐10‐CM(InternationalClassificationofDiseases,TenthRevision,AndClinicalModification)codes,asapplicable.Inotherwords,thePartCRACwillconductacompletecodeoftheentiremedicalrecord.ThePartCRACwillcodeinaccordancewithInternationalClassificationofDisease,NinthorTenthRevisionClinicalModificationguidelines(ICD‐9‐CMorICD‐10‐CM),asappropriate.CodersmustdemonstrateacceptablecodingaccuracyinordertoparticipateinthecodingprocessasdefinedbyCMSuponcommencementofaCMSaudit(seeSubtask1I.InternalQualityControlandInter‐RaterReliability).CMScontrolsthedevelopmentandupdatingofaCoderGuidancedocumentforComprehensiveRADVAudits.ThePartCRACshallworkwithCMSanditscontractorstoupdate,developand/ormaintainaCoderGuidancedocumentthatcodersmayreferencewhenreviewingmedicalrecordsforthepresenceofdiagnosiscodes.AsrequestedbyCMS,apanelofcodersshallconvenetoidentifyandclarifyambiguousICD‐9/10‐CMcodesandincorporatetheirrecommendationsintotheCoderGuidancedocument.ThePartCRACwillconductallmedicalrecordreviewsinCDAT(orothersystemasspecifiedbyCMS)unlessinstructedotherwisebyCMSinwriting.MedicalrecordswillbereleasedforPartCRACreviewviaCDAT(orothersystemasspecifiedbyCMS)onarollingbasisastheyarereceivedfromtheMAorganizations.ThePartCRACshallprovidesufficient,qualifiedcodingstafftopullamedicalrecordtaskfromCDAT(orothersystemasspecifiedbyCMS)within5businessdaysofthemedicalrecordenteringthePartCRAC’sCDATqueue;andcompletethereviewwithin14calendardaysofthemedicalrecordtaskenteringthePartCRAC’sCDATqueue.ThePartCRACmayrequestawaiverfromCMSifanextendedtimeframeisneededduetoextenuatingcircumstances.ThePartCRACwillinputdiagnosiscodessupportedbymedicalrecorddocumentationintoCDAT(orothersystemasspecifiedbyCMS)inaccordancewithCMS’policiesandprocedures.CDATwillmapthediagnosiscodesinputintoCDAT(orothersystemasspecifiedbyCMS)toCMS‐HCC(s).CMSmayrecallaPartCRACfindingfromeithertheintakedocumentationrevieworthemedicalrecordreviewstepatanytimeandforanyreason.
Page 8
DRAFT PRE‐ DECISIONAL
8
ThenumberofmedicalrecordsreviewedbythePartCRACwillbedeterminedbyCMSbasedonavarietyoffactorsincluding:thenumberofauditedcontracts,thesamplingmethodology,andCMS’rulesregardingthenumberofrecordsthatmaybesubmittedbyanauditedMAorganizationforagivenCMS‐HCC.CMSreservestherighttofurtherlimitthetimeperiodand/ormedicalrecordsavailableforPartCRACreviewifCMSbelievesitisinthebestinterestoftheMedicareprogramtolimitreview.Thisnoticeshallbeinwriting,maybebyemail,andwillbeeffectiveimmediately.AfterthePartCRAChascompletedmedicalrecordreview,theSecondaryReviewContractorwillreviewthemedicalrecorddocumentationtodeterminewhetherthedocumentationsupportsthediagnosessubmittedbytheMAorganizationforpaymentandwhetherthedocumentationsupportsadditionalpaymentdiagnosesnotsubmittedbytheMAorganization.ThedeterminationoftheSecondaryReviewContractorwillstand(e.g.ifthePartCRACdeterminesanauditedCMS‐HCCisdiscrepantandtheSecondaryReviewContractorsubsequentlydeterminestheauditedCMS‐HCCisdiscrepant,theCMS‐HCCwillremaindiscrepant.IfthePartCRACdeterminesanauditedCMS‐HCCisdiscrepantandtheSecondaryReviewContractordeterminestheauditedCMS‐HCCispresentinthesubjectmedicalrecord,theSecondaryReviewContractor’sdeterminationwillstandandthefindingwillbereversedfrom“discrepant”to“confirmed”).MAorganizationsmayappealdiscrepantCMS‐HCCS,whichresultinapaymentrecovery,throughtheRADVadministrativeappealsprocess.Step4:Payment Error Calculation, Issuing Audit Reports and Demand Letters.TheLeadAnalyticContractorwillcalculatetheimpactofdiscrepantCMS‐HCCfindingsonthesampledenrolleeriskscoresandextrapolatethesefindingstotheMAcontractleveltoestimateacontractlevelpaymenterror.TheLeadAnalyticalContractorwillapplytheCMSmethodologytodeterminethesefindings.ThePartCRACwillsupportthepaymenterrorcalculationatCMSdirection.IftherearediscrepanciesbetweenthePartCRACandLeadAnalyticalContractors,theLeadAnalyticContractorwillreviewthePartCRAC’sworkunderthisstepandmakeafinaldeterminationtoCMS.ThePartCRACwillprepareAuditReportsforeachplancontractperCMSinstruction.MAorganizationswillthenhaveanopportunitytoappealthroughtheprocessknownasReconsideration,whichisthefirstphaseoftheRADVadministrativeappealsprocess.ForMAorganizationsthatelectnottoappeal,thePartCRACwillissuedemandlettersapprovedbyCMS.ThePartCRACwillupdatetheAuditReportandpaymenterrorestimatesandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration.Dependingonthenumberoftimesarecordisreviewed,theremaybeseveraltimesapaymenterroriscalculatedandtheresultscommunicatedtoMAorganizationsviaRADV
Page 9
DRAFT PRE‐ DECISIONAL
9
AuditReports(aftertheinitialmedicalrecordreview,andasneeded,aftersubsequentphasesofappeals).Eachtimetheauditreportsareprepared,theLeadAnalyticContractorwillvalidatetheresults,priortothembeingreturnedtotheMAcontracts.Step5:Administrativeappealsprocess.SeeSubtask1L.Thefollowingaresubtasks,whichshouldbeconductedwithinthecontextofthegeneralRADVstepsdescribedabove.
Subtask1A.RADVAuditPlanningandImplementation:SecurityandTrackingPlan(associatedwithsteps1‐5)
ThePartCRACshallprovideandimplementawrittenSecurityandTrackingPlancoveringallaspectsofthiscontract.AdraftofthisdocumentshallbesubmittedtoCMSwithinthree(3)weeksofthecontractdateofaward.ThePartCRACshalledit,revise,and/oramendthedocumentaccordingtoCMSrequirements.TheSecurityandTrackingPlanshalldescribehowthePartCRACshallmaintainoversightofthephysicallocationofthemedicalrecords(ifapplicable)andshallutilizeCDAT(orothersystemasspecifiedbyCMS)totrackthemovementandlocationofthemedicalrecordsfilesandotherdocumentationthroughthevariousstagesoftheRADVprocess.TheproceduressetforthunderthissubtaskshallbeincollaborationwiththesystemrequirementsforCDAT(orothersystemasspecifiedbyCMS)asnecessary.Intheeventthatoff‐sitestorageofanymedicalrecordsorfilesrelatedtothiscontractisnecessary,thenthePartCRACshallobtainpriorapprovalfromCMSandabidebyallsecurityrequirementsfortransferringanyrecordsorfiles.Withinthisplan,thePartCRACshallproposeaplanformitigatingriskassociatedwithpotentialdatabreaches,andalsoforrecognizing,addressing,andreportingdatasecurityissuesastheyarise,accordingtoCMSrequirements.ThePartCRAC’sSecurityandTrackingPlanmaybeincorporatedintoCMS’SOP.
Subtask1B.DocumentationandMedicalRecord,Management,andDestruction(associatedwithsteps1‐5)
ThePartCRACshalldevelopandimplementaCMS‐approvedplanfordocumentationandmedicalrecordmanagementanddestruction.AdraftofthisdocumentshallbesubmittedtoCMSwithinthree(3)weeksofthecontractdateofaward.ThePartCRACshallstoreanddisposeofthemedicalrecordsinaccordancewithCMSguidelines(ifapplicable),andasinstructedbytheCORand/orGTL.ThePartCRACshallfurthersubmitconfirmation/documentationtotheCORensuringthatconfidentialrecordsarestoredasappropriateandinamannerthattheinformationcannotbecompromised.TherequirementsoftheCMS’DataUserAgreementshallbefollowedforalldatausedunderthiscontract.ThePartCRACshallretainandmanageallmedicalrecordsasspecifiedbyCMS.ThePartCRACshallworkwiththeCORand/orGTLtodeterminewhethertoretain,destroyorforwardmedicalrecordcopiestoanotherContractorand/orCMS.Management
Page 10
DRAFT PRE‐ DECISIONAL
10
ofmedicalrecordsshallincludemakingcopiesofthemedicalrecordsasdirectedbytheCORand/orGTL.
Subtask1C.ProcessPlan:IntakeDocumentationandMedicalRecordReview(associatedwithsteps2and3)
ThePartCRACshallprepareandsubmitaProcessPlandocumentdescribingtheprotocolsforitsreviewofphysician,hospitalinpatientandhospitaloutpatientmedicalrecordsforthedatesofservicesprovidedbyCMS,inaformatacceptabletoCMS.ThisdocumentmaybeincorporatedintoCMS’SOP.Thedocumentshall:(1)builduponexistingRADVprocesses;(2)incorporateprotocolsforusingindustrystandardsforaccuratecodingpractices;and,(3)ataminimum,includeimplementationofthefollowingdetailsthatarespecificforRADVprojectprocesses:
1. Theprocessforreviewingthemedicalrecords.2. Allocationofmedicalrecordstocoderstoensuretimelycompletionofcodingbythe
PartCRAC.Includeaprocesstoescalatemedicalrecordswhenacoderhasquestionsaboutaparticularmedicalrecordandrequiresclarification.IncludeaprocesstosendmedicalrecordstotheQApanel.
3. QualitycontrolprotocolforachievingIRRaccordingtoaprotocoltobedeterminedbyCMS.
4. ApplicationofcodingguidelinesbasedonadateofserviceandprovidertypeindicatedbytheMAorganization.
5. Physicianreviewprotocoltobeincorporatedintotheoverallprocesses,utilizingphysiciansasnecessaryforconfirmingcorrectICD‐9/10assignments,overseeingrater‐to‐standardtestingtoimprovecodingdecisionsbasedonclinicalknowledge,addressingambiguityintheclinical,documentation,anddevelopingHCCreviewprotocolguidelines.PhysicianreviewersarenotrequiredtobeICD‐9/10coders;thesecliniciansadvisecodersoftheclinicalcontextsurroundingthediagnosis.
TheIntakeDocumentationandMedicalRecordReviewProcessPlanwillbesubmittedtoCMSforreviewandapproval.ThePartCRACwillmakeeditstothisprocessplanperdirectionfromCMSandwillimplementthefinalplan.Thisprocessplanmaybesubjecttochange,atthedirectionofCMS,overthecourseofconductingtheindicatedtasks.
Subtask1D.ProcessPlan:CollaborationandSupportforAppealsProcesses(associatedwithstep5)
ThePartCRACshallprepareandsubmitaProcessPlandocumentdescribingtheprotocolsforservicesprovidedbythePartCRACundertheCollaborationandSupportforAppealsProcessestaskinaformatacceptabletoCMS.ThisdocumentmaybeincorporatedintoCMS’SOP.
Page 11
DRAFT PRE‐ DECISIONAL
11
TheCollaborationandSupportforAppealsProcessesPlanwillbesubmittedtoCMSforreviewandapproval.ThePartCRACwillmakeeditstothisprocessplanperdirectionfromCMSandwillimplementthefinalplan.Thisprocessplanmaybesubjecttochange,atthedirectionofCMS,overthecourseofconductingtheindicatedtasks.
Subtask1E.CDATTraining(orothersystemasspecifiedbyCMS)(associatedwithsteps2‐5)
ThePartCRACshallattendalltrainingsonCDAT(orothersystemasspecifiedbyCMS)asdirectedbyCMS.ThetrainingsshallbescheduledondatesandatlocationstobedeterminedbyCMS.CDATtrainingsaretypicallyconductedpriortothesubmissionperiodforMAorganizationsandpriortoperiodofcodingbymedicalrecordreviewers.ThePartCRACshallfollowprotocolsforutilizingCDAT(orothersystemasspecifiedbyCMS)forthepurposesofitsreviews.ThePartCRACshallalsoincorporatetheapplicableCDAT(orothersystemasspecifiedbyCMS)trainingsectionsintoitsmedicalrecordreviewstafftraining.
Subtask1F.MedicalRecordReviewStaffTraining(associatedwithsteps2,3,and5)
ThePartCRACshallpreparetrainingmaterialsandconductin‐persontrainingatthePartCRAC’ssiteforthePartCRAC’steamofmedicalrecordreviewersandallappropriatestaffthatwillcontributetotheRADVaudit(s),inaccordancewithCMS’policiesandprocedures.ThePartCRACshallutilizeinformationgainedfromtheProcessPlan:ReviewforCMS‐HCCsunderTask2Casthebasisforthetrainingstrategy,andimplementthefinaltrainingprotocolapprovedbytheCORand/orGTL.ThePartCRACshallprovidetheCORand/orGTLwiththedraftwrittentrainingstrategy.UponapprovalfromtheCORand/orGTL,thePartCRACshallsubmitafinaltrainingCMS‐approvedtrainingplan.ThedraftshallbesubmittedtotheCORand/orGTLatleastone(1)weekinadvanceofeachtraining.OngoingtrainingshallbeprovidedforthePartCRAC’sstaffasneeded,andinitialtrainingshallbeprovidedforallcodersbeforetheybeginworkontheRADVaudit(s).Topromoteconsistencyintrainingmedicalrecordreviewstaff,thePartCRACshallplanaccordinglytoincludeCMSstaffandstafffromtheSecondaryReviewContractor,IndependentCodingConsultant,LACand/orCDATContractoratitstraining(s).ThetrainingstrategyandmaterialsmaybeincorporatedintoCMS’SOP.ItisexpectedthattherewouldbeatleastonetrainingsessionperMAorganizationsubmissionwindow,withthepossibilityof1‐3additionaltrainingspersubmissionwindowifinter‐raterreliabilityamongmedicalrecordreviewersisincorrect,attherequestofmedicalrecordreviewers,and/oratthediscretionofCMS.
Subtask1G.AttendRiskAdjustmentDataValidationContractorTraining(associatedwithsteps2,3,and5)
CMSwillorganizeaninitialtrainingforallcontractorsparticipatingintheRADVaudit.ThistrainingistypicallyconductedpriortothesubmissionperiodforMAorganizationsandpriortotheperiodofcodingbymedicalrecordreviewers.CMSmayorganize
Page 12
DRAFT PRE‐ DECISIONAL
12
additionaltrainingsandmeetingsonanadhocbasistoprovideadditionalinformationandguidancetothePartCRAC.ThePartCRACshallattendtheinitialtrainingandanyadditionaltrainingsandmeetings,nottoexceedtwoperauditandasdirectedbyCMS.
Subtask1H.AttendandContributetoTechnicalDataandOperationsMeetings(associatedwithsteps2,3,and5)
AtCMSrequest,thePartCRACshallattend,assistwithdevelopingagendaanddiscussiondocuments,andcontributetotechnicalanddataoperationsmeetingsthatwillbeconductedbytheCDATContractor.Thesemeetingswillbeconductedprimarilybyteleconference,withnomorethansixin‐persontechnicaldataandoperationsmeetingsperyear.Thesemeetingswillprovideaforumtodiscussandplanfordataandoperationalrequirements,stafftrainingsformedicalrecordreview,useofCDAT(orothersystemasspecifiedbyCMS),andtheoverallprojectmanagement.Themeetingagendasshallincludeproposeddatarequirements,medicalrecordreviewguidance,qualityassuranceplansandprojectplanningfeedbackfromthemedicalrecordreviewcontractors.ThePartCRACshallsubmitwrittenproposeddraftagendaanddiscussiontopicstotheCORand/orGTLinadvanceofthesemeetings.UponapprovalfromtheCORand/orGTL,thePartCRACshallfinalizetheinformationandsubmitfinalapprovedinformationtobeinsertedintothemeetingagendabytheCDATContractor.ThePartCRACshallprovidewrittenfeedbacktotheCORand/orGTLontheproposeddataandoperationalplansandrequirementswithintwo(2)businessdaysfollowingmeetingsand/orreceiptofproposalsfromotherRADVparticipants.Thefeedbackshall,ataminimum,identifyissuesandconcernsfromthePartCRACregardingimplementationplansand,asnecessary,recommendationsforalternativeimplementationplans.
Subtask1I.InternalQualityControlandInter‐RaterReliability(associatedwithsteps2,3,and5)
ThePartCRACwillimplementqualityassurancemonitoringoftheintakeprocessandwillimmediatelyreportaberrantfindingstoCMS.ThePartCRACwillmakechangestotheintakeprocesstocorrectinaccurateintakedeterminationsperdirectionfromCMS.UponCMSdirection,andaccordingtoaprotocolestablishedbyCMS,thePartCRACshallimplementaninitialinter‐raterreliability(IRR)evaluationofeachcoderbeforethecoderbeginscodingoflivemedicalrecordsandshallcheckcodingconsistencyonanongoingbasisthroughoutthereviewprocess.CMSexpectsanIRRof95%orhigher,whichmeansthateachcoder’sresultsareinagreementwithanothercoder’sresults95%ofthetime.IfacoderfailstomeetCMS’IRRstandards,CMSmaylimitthecoder’sroleorremovethecoderfromthereviewprocessentirely.ThePartCRACshallcontinuetomonitorIRRofallcodersandprovideappropriateremediationordismissal.CMSmayrequestthePartCRACtoprepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreportsforcodersandphysicianreview.ThePartCRACshallsubmitthesereportstotheCORand/orGTLuponCMS’request.ThePartCRACmaybedirected
Page 13
DRAFT PRE‐ DECISIONAL
13
bytheCORand/orGTLtoreviseitsinputdataasnecessary,basedonmeetingoutcomes.ThePartCRACshallprovideadetailedjustificationandimplementanyfollow‐upactionasrequiredtoachievetheappropriateoutcomes.ThePartCRACshallbepreparedtodiscusswiththeCORand/orGTLandotherRADVcontractorsalldatafindingspertainingtoreviewandIRRoutcomes.CMSconductsataminimumanannualreviewofContractoractivities.IfCMShasevidencetobelieveaContractorisnotaccuratelyreviewingintakedocumentationormedicalrecords,orisnotreviewingtheminaccordancewithCMSinstructionorestablishedprotocols,CMSwillissueawarninginwritingtothePartCRAC.Italsoshallincludethedocumentationcitationsthatsupporttheconclusions,andaCMSallottedtimeframeforContractorcorrection.Iftheissuecontinues,CMSwillconsiderrecallingsuchreviewsfromthePartCRAC,andmaydirectthereviewofthemedicalrecordstoanotherCMScontractor.
Subtask1J.PaymentErrorCalculation,IssuingAuditReportsandDemandLetters(associatedwithstep4)
TheLACwilldetermineenrolleeandcontractlevelfindings.ThePartCRACwillpreparedraftAuditReportsforeachauditedcontractfollowingtheCMSprotocol.ThePartCRACwillsubmitthedraftAuditReportstoCMSanduponCMSapprovalwillcoordinatethereleaseofthefinalizedreportsviaCDATorothersystemspecifiedbyCMS.ForMAorganizationsthatelectnottoappeal,thePartCRACwillissuedemandlettersperCMSinstruction.ThePartCRACwillpreparedraftlettersforeachauditedMAcontractwithnetoverpayments.UponCMSapproval,thePartCRACwillissuetheletters.ThePartCRACwillupdatetheAuditReportwithrevisedpaymenterrorestimatesandissuedemandletterstoauditedMAorganizations,asapplicablethroughouttheappealprocess.Foreachiteration,thePartCRACwillprepareadraftreportand/ordraftdemandletterforCMSapprovalanduponapprovalwillissuethefinalizedreportsand/ordemandletters.TheamountsidentifiedinthedemandletterswillberecoveredfromMAorganizationsthroughroutineCMSpaymentprocesses. AttheconclusionoftheReconsiderationphaseoftheadministrativeappealsprocess,CMSwillpayPartCRAC’scontingencyfeeaccordingtocontractualterms.ThePartCRACwillprepareaHIPAAcompliantand508compliantversionofeachAuditReport,suitableforpostingtoCDATorothersystemspecifiedbyCMS.ThePartCRACshallnothaveanyauthoritytoreduce,compromise,and/orsettleanyidentifiedorpossibleoverpaymentsorunderpayments.
Subtask1K.Documentation(associatedwithsteps2through5)
Page 14
DRAFT PRE‐ DECISIONAL
14
Inadditiontothedocumentationrequirementsdescribedelsewhere,thePartCRACwillbesubjecttoanumberofdocumentationrequirementsperCMSdirection.Theyinclude:
ThePartCRACshallclearlydocumentinCDAT(orothersystemasspecifiedby
CMS)therationaleforitsunderpaymentandoverpaymentdeterminations.ThisrationaleshalllistthereviewfindingsincludingadetaileddescriptionofanyidentifiedICD‐9/10‐CMcodes.ThePartCRACshallensureitisidentifyingpertinentfactscontainedinthemedicalrecordtosupportitsreviewdeterminations.Eachrationaleshallbespecifictotheindividualmedicalrecordreviewed.ThedeterminationofanoverpaymentoranunderpaymentwillbebasedonthedefinitionsandcriteriaspecifiedbyCMS.
Overpayments&UnderpaymentsReport:ThePartCRAC,onamonthlybasis,shall
providetheCORand/orGTLwithdetailedinformationconcerningoverpaymentsandunderpaymentsthathavebeenidentified.ThePartCRACshallhavesupportingdocumentationforalllineitemsonthereport.Thisreportshallbeduenolaterthanthefifth(5th)businessdayofthefollowingmonth.Task3specifiesadditionalinformationrequiredinthemonthlyprogressreports.
StandardOperatingProcedures(SOP)ContributionandImplementation:RADV
ContractorandStaffTraining.ThePartCRACshallprepareandsubmitadraftwrittenplanfortrainingofPartCRACstaff.ThisdocumentmaybeincorporatedintoCMS’SOP.
ContributiontoOverallComprehensiveRADVStandardOperatingPlan(SOP):The
PartCRACshallcollaboratewithCMStocontributetoanoverallcomprehensiveRADVStandardOperatingPlan(SOP).UponCMSrequest,thePartCRACshallsubmitadraftofSOPcontributionstotheCORand/orGTLforcommentandrevision.Itshallbecomprisedofachronologyanddocumentationofplansforactivitiesdescribedinthiscontract,atCMS’discretion,andshallincludeanyotherrelevantinformationandappendices.ThePartCRACshallmakespecifiedchangesandsubmitfinalSOPcontributionsfortheCOR’sand/orGTL’sapproval.ThePartCRACshallsubmitthefinalizedelementsofitsSOPcontributionstoCMS.
Subtask1L.Appeals(associatedwithsteps5)
MAorganizationsmayappealthemedicalrecordreviewdeterminationsand/orthepaymenterrorcalculation.Per§422.311,theRADVauditappealsprocessbeginsattheMAorganization’selectionforReconsideration,inwhichCMSreviewsthemedicalrecordandpaymenterrorcalculationagain.TheReconsiderationresultscanbeappealedtotheOfficeofHearings,whichcanfinallybeappealedtotheCMSAdministrator,whosedecisionisfinal.
Page 15
DRAFT PRE‐ DECISIONAL
15
IfanMAorganizationchoosestoappealthemedicalrecordreviewdeterminationsand/orthepaymenterrorcalculation,thePartCRACshallassistCMSwithsupportofthedeterminationthroughouttheapplicableadministrativeappealsprocessand,whereapplicable,anappealtotheappropriateFederalcourt.Specifically,thePartCRACshallprovideRADVappealssupporttoCMSanditsdesignatedcontractorsbyprovidingrelevantinformationuponrequestbytheCORand/orGTL.Thisincludesprovidingsupportingdocumentation(includingthemedicalrecord)withappropriatereferencetoMedicarestatutes,regulations,manualsandinstructions,providingassistance,andsupportingCMSatanyhearingsassociatedwiththedetermination,whenrequestedbyCMS.ThePartCRACshallprovidewrittendocumentationtoclarifyandexplainspecificprotocolsandprocessesthatwereimplemented,andjustificationsfordifferentmedicalrecordreviewfindingsanddecisions,whenrequestedbyCMS.Forexample,thismayincludeprovidingmedicalrecorddocumentationforasampledbeneficiary,ortheactualmedicalrecordreviewedbythePartCRACandcodingopinions.UpondirectionbytheCORand/orGTL,thePartCRACshallprovidetherequesteddocumentationandsupportincludingparticipatinginconferences,hearingsandlitigationrelatedtoRADVmedicalrecordrequest,intake,andreview,andproviderelevantinformationuponCMS’request.ThePartCRACshallhaveanappealoverturnrateoflessthan10%atthefirstlevelofappealofReconsideration.CMSexpectsthePartCRACtofullycooperateinprovidingappealssupport,whichshallcomplywith42C.F.R.§422.311andCMS’protocol.Additionally,thePartCRACshallprovidesupport,asneeded,fordisputesoutsideoftheformaladministrativeappealsprocess.
Subtask1M.CollaborationwithCMSRADVContractors(associatedwithsteps2through5)
ThePartCRACshallcollaborateandcoordinatewithotherCMSRADVcontractors.Thesecontractorsinclude,butarenotlimitedto,theSecondaryReviewContractor,theLeadAnalyticContractor(LAC)andtheCDATcontractor.ThePartCRACwillparticipateinmeetingswithotherRADVcontractorsandwillcollaboratewiththemtoensureaccurateandtimelyintakeandmedicalrecordreviewfindings. TASK2.CONDITIONSPECIFICRADVAUDITSConditionSpecificRADVAuditswillbeconductedforasubsetofMAcontractsnotsubjecttoaComprehensiveAuditforanygivenpaymentyear.ThefocusofConditionSpecificAuditswillbeaset(s)ofHCCsdeterminedtohaveahigherprobabilityofbeingerroneous,forexample,itmaybedecidedthatthehierarchyofHCCsrelatingto‘diabetes’shouldbethesubjectofthistargetedreview.Itmayfurtherbedecidedthatcertainplanshavecharacteristicswhichsuggesttheyaremorelikelytohavediabetescodingdiscrepancies.UnderthisConditionSpecificAuditprotocol,thissubsetofidentifiedplanswouldbesubjecttoatargetedmedicalrecordreviewofdiabetes.
Page 16
DRAFT PRE‐ DECISIONAL
16
Thesamplingand,ifapplicable,paymenterrorextrapolationmethodologyforeachConditionSpecificAuditwillbedevelopedbytheLeadAnalyticContractorandmustbeapprovedbyCMS.ThismethodologywillthenbegiventothePartCRACforusetocompletethebelowsubtask.ThePartCRAC’sresponsibilitiesforthistaskarethesameasthoseidentifiedunderTask1,exceptthatStep1underTask1wouldbereplacedbythefollowing:
Step1forCondition‐specificRADVAudit:SelectionofHCCsandMAContractsforAudit.ThePartCRACwillproposecriteriatoidentifydiagnosesand/orconditionsthataremorelikelytobesubjecttoriskadjustedpaymenterrorbecausetheyarenotsupportedbymedicalrecorddocumentation.ThePartCRACwillproposethesecriteria,alongwithsupportanddrawbacks,toCMSforconsideration.ThePartCRACwillalsoprovidetheMAcontractsthatwouldbeselectedifsuchcriteriawereapplied.Underthiscontract,thePartCRACmayseekaccesstoRAPSdataand/orencounterdatatoassistintargetingMAcontractsandspecificHCCs.UponapprovalbyCMS,thePartCRACmayproceedwiththeauditfortheselectedMAcontractsandconditions.ThescopeandnumberofConditionSpecificAuditswillbedeterminedbyCMS.Asaresult,thereisnoguaranteeforthePartCRACofaminimumvolumeofConditionSpecificAudits.
TASK3.MEETINGREQUIREMENTS
Subtask3A.InitialMeetingwithCMSCOR,GTLandCMSStaffProjectPlan‐ThePartCRAC'skeyprojectstaff(includingoverallProjectDirectorandkeysubProjectDirectors)shallmeetinBaltimore,MarylandwiththeCOR,GTL,andappropriateCMSstaffwithintwo(2)weeksofthedateofaward(DOA)todiscusstheprojectplan.Thespecificfocuswillbetodiscussthetimeframesforthetasksoutlinedbelow.ThePartCRACshallprovidetheCORand/orGTLwithminutesfromthemeetingnomorethanforty‐eight(48)hoursafterthecompletionofthemeeting,inaformacceptabletotheCORand/orGTL.Withintwo(2)weeksofthismeeting,thePartCRACshallsubmitaformalprojectplanoutliningtheresourcesandtimeframeforcompletingtheworkoutlined.Theinitialprojectplanwillbeforthebaseperiodofthecontract.ItisthePartCRAC’sresponsibilitytoupdatetheprojectplanasnewissuesariseornewtasksareperformed.TheinitialprojectplanandanysubsequentupdatesshallbeapprovedbyCMSpriortoimplementation.Theprojectplanshallincludethefollowing:ContractorOrganizationalChart–TheorganizationalchartshallidentifythenumberofkeypersonnelandtheorganizationalstructureofthePartCRAC.Adetailedorganizationalchartextendingpastthekeypersonnelshallbesubmittedwithintwo(2)weeksoftheinitialmeeting.ThePartCRACshallinformCMSofanychangestothePartCRAC’s
Page 17
DRAFT PRE‐ DECISIONAL
17
organizationalchartwithinseven(7)businessdaysofthePartCRAC’sknowledgeofthechange.
Subtask3B.ConferenceCalls
1.OnaweeklybasisthePartCRAC’skeyprojectstaffshallparticipateinaconferencecall
withCMStodiscusstheprogressofthework,evaluateanyproblems,anddiscussplansforimmediatenextstepsoftheproject.ThePartCRACshallberesponsibleforsettinguptheconferencecalls,preparinganagenda,documentingtheminutesofthemeetingandpreparinganyothersupportingmaterialsasneeded.DraftagendasshallbefurnishedtotheCORand/orGTLatleasttwenty‐four(24)hoursinadvanceofthemeeting.Draftsofmeetingminutesshallbefurnishedwithinforty‐eight(48)hoursofthemeetingtotheCORand/orGTL.
2.OnamonthlybasisthePartCRAC’skeyprojectstaffshallparticipateinaconference
callwithCMStodiscussfindingsandprocessimprovementsthatwillbenefitCMSinRADVauditsinthefuture.ThePartCRACwillberesponsibleforsettinguptheconferencecalls,preparinganagenda,documentingtheminutesofthemeetingandpreparinganyothersupportingmaterialsasneeded.Iftimeallowsduringtheweeklycalls,thisitemmayalsobefulfilledduringoneofthescheduledweeklycalls.
AtCMS’discretionconferencecallsmayberequiredtobecompletedmorefrequently.Also,otherconferencecallsmayberequiredtodiscussindividualitemsand/orissues.TASK4.ADMINISTRATIVEANDMISCELLANEOUSISSUESThePartCRACshallreportpotentialqualityissuesimmediatelytotheCORand/orGTL.
Subtask4A.MonthlyProgressReports1. ThePartCRACshallsubmitmonthlyadministrativedetailedprogressreportsoutlining
allworkaccomplishedduringthepreviousmonth,exceptinthecaseofTask2forwhichweeklydetailedprogressreportsshallbesubmitted.Thesereportsshallincludethefollowing:
b. Reviewaccomplishmentstodate,remainingactivitiestobecompletedand
thestatusoftheprojectcomparedwithitsschedule;c. Discussproblemsencounteredorthatareanticipatedandtheirimpacton
thescheduleoftheproject,orifsevereenough,ontheoverallabilitytoaccomplishtheprojectgoals;
d. IncludethePartCRAC’splanstodealwithanyidentifiedsignificantproblemandifappropriate,newdeliveryorcompletiondatesshallbeproposed;
e. Includeabriefdiscussionofsubstantivefindingstodate;f. Issuesthathavearisenandanyanomaliesrelatedtoanytask;g. Updateofitemsbeingreviewedinthenextweekormonth;
Page 18
DRAFT PRE‐ DECISIONAL
18
h. Updateofprojectplan;i. Recommendedcorrectiveactionsforvulnerabilities;j. Updateonhowvulnerabilityissueswereidentified;k. UpdateonJOAs;l. ActionItems
ThePartCRACshallincorporateanyfinalrevisionsasdirectedbytheCORand/orGTLanduponapproval,shallsubmittheMonthlyProgressReporttotheCORand/orGTLinelectronicformwithin10daysofmonthend.
2. ThePartCRACshallsubmitmonthlyfinancialreportsoutliningallworkaccomplished
duringthepreviousmonth.Thereportshallbebrokendownintothefollowingcategories:
a. Overpaymentsidentified(insummaryanddetail)–Thisreportincludes
reviewswherethePartCRACbelievesanoverpaymentexists,buttheamounthasnotyetbeendemandedbyCMS.
b. Underpaymentsidentified(insummaryanddetail)–ThisreportincludesreviewswherethePartCRACbelievesanunderpaymentexists,buttheamounthasnotyetbeendemandedbyCMS.
c. OverpaymentsAdjusted‐AmountsshallbeincludedonthisreportifthePartCRAC’soverpaymentdeterminationhasbeenreversed(decidedintheMAorganization’sfavor)(insummaryanddetail).
d. NumberofreviewsperformedbythePartCRAC(insummaryanddetail).e. Numberofreviewscompletedwithinthe5businessdaytimeframe(in
summaryanddetail).f. Numberofreviewsthatfailedtobecompletedwithinthe5businessday
timeframeandtherationaleforfailuretocompletethereviewstimely.Allreportsshallbeinsummaryformatwithallapplicablesupportingdocumentation.AtCMSdiscretion,astandardizedmonthlyreport(s)mayberequired.Ifastandardizedmonthlyreportisrequired,CMSwillprovidetheformat.Unlessalternativearrangementsareapproved,eachmonthlyreportshallbesubmittedbythecloseofbusinessonthefifthbusinessdayfollowingtheendofthemonth.Themonthlyreportshallbesentviae‐mailtotheCORandtheContractingOfficer.
Subtask4B.SeparateReportingThereportinganddatacollection/analysisforeachofthemajortasksunderthiscontractshallbekeptseparateandsubmittedintheappropriateformatperthestatementofwork.
Subtask4C.CentralizedDataAbstractionTool(CDAT)&DataAccessibility
Page 19
DRAFT PRE‐ DECISIONAL
19
ThePartCRACmustfollowCMSinstructiontoobtainandmaintainaccesstotheCentralizedDataAbstractionTool(CDAT)(orothersystemasspecifiedbyCMS).CDATisawebbasedapplicationwhichthePartCRACshallberequiredtousewhenperformingallreviewsforauditedCMS‐HCCsintheMARADVaudits.ForaccessingCDAT,thePartCRACmustbeabletobeflexibleinmanagingstaffschedules,includingconductingmedicalrecordreviewactivitiesduringnon‐businesshours.ThePartCRACshallberesponsibleforhavingtheappropriateequipmentsuchascomputersconfigurabletoaccessCDATwithphoneat‐handtocompletethemulti‐factorauthentication.AllreviewsconductedbythePartCRACshallbeperformedinCDATunlessinstructedotherwisebyCMSinwriting.ThePartCRACshallberesponsibleforallcostsassociatedwiththestorageandprocessing,andprotectionofanydatanecessarytoaccomplishtheworkassociatedwiththiscontract.
Subtask4D.CMSWorkgroupMeetingsThePartCRACshallparticipateinin‐personWorkgroupmeetingswithCMSstaffandotherRADVcontractors.Uptotwelve(12)suchmeetingsmaybescheduledoverthecourseofthecontract.AtthedirectionoftheCORand/orGTL,thePartCRACshalldraft,revise,andproduceagendas,trainingmaterialsandpost‐sessionreportsforallsuchmeetings.ThePartCRACshallalsoparticipateonweeklyscheduleRADVOperationscallswiththeSecondaryReviewContractorand/orotherRADVcontractors.AtthedirectionoftheCORand/orGTL,thePartCRACshalldraft,revise,andproduceagendas,discussionmaterialsandpost‐sessionreportsforallsuchmeetings.
Subtask4E.AdHocMeetingsThePartCRACshallalsobeavailableuptoseven(7)timesperyearfornon‐trivialconsultationwithCMS,itscontractors,and/orselectedMAorganizations.ThismayincludesitevisitstothePartCRAC’slocation.Thesecallsandmeetingsmaybeusedasamechanismfordiscussingandmanagingissuesastheyarise.Non‐trivialconsultationsshallbethosewhichdonotrelatetoongoingoperationsandwhichareexpectedtorequiremorethan20butlessthan60man‐hourstocomplete.
Subtask4F.CorrectiveActionAssociatedwithEvaluationCMSwillperformanevaluationofthePartCRAC.Advancenoticemayormaynotbegiven.TheRACsmustagreetoviewtheevaluationcontractorasarepresentativeofCMSandtoagreenottorequirethattheevaluationcontractorsignanyseparateagreementwiththeRACasaconditionforhavingaccesstothefacilities,dataandemployeesnecessarytoundertakethenecessaryreviews.AnyfindingfromthereviewwillrequirethePartCRACtosubmitacorrectiveactionplantoCMSatthedirectionoftheCORand/orGTL.
Subtask4G.RecalledAuditsCMSmaydeterminethatitisinthebestinterestoftheMARADVRACProgramtoceaseworkincertainareas.CMSmayrecallanauditfromthePartCRACatanytimeandforany
Page 20
DRAFT PRE‐ DECISIONAL
20
reason.ShouldCMSinitiatearecall,thePartCRACshallimmediatelystopallactivitiesincludedintherecall.Recallscouldoccurbecauseofadditionalactivitythatisoccurringbyanothercontractor/entityorlackofadherencebythePartCRACofanyprovisionofthiscontractorforsomeotherreason.Recallsareindefiniteandmayrequireacorrectiveactionplantoresumeactivity.RecallscanbeMAorganization,MAcontract,audit,medicalrecord,CoversheetID,auditedCMS‐HCC,orenrolleespecific.UnlessinstructedbyCMSthroughtechnicaldirection,workpreviouslyissuedwillcontinuewithacontingencyfeemodifiedfortherecall,asappropriate.
Subtask4H.CommunicationwithOtherCMSContractorsJointOperatingAgreement:ThePartCRACshallberequiredtocompleteaJointOperatingAgreement(JOA)withallapplicableCMScontractors(asinstructedbyCMS).TheJOAshallencompassallcommunicationbetweenthecontractors.TheJOAshallbeamutuallyagreedtodocumentthatisreviewedquarterlyandupdatedasneeded.TheJOAshallprescribe:1)agreeduponservicelevelsand2)notificationandescalationmechanismswithCMSinvolvement.CMShasthefollowingexpectationswithregardtotheCDATContractor,LeadAnalyticContractor,SecondaryReviewContractor,andPartCRAC:contractorrelationships:
TheCDATContractor,LeadAnalyticContractor,SecondaryReviewContractorsarecontractorsofCMSanddonottakedirectionfromthePartCRAC.
TheCORandGTLforthePartCRACshallbeapartytoanyandallcommunicationissuesbetweenthePartCRACandotherRADVcontractors.
Subtask4I.SupportOIGorOtherAudits
ShouldtheOIG,CMSoraCMSauthorizedcontractorchoosetoconductanauditofthePartCRAC,thePartCRACshallprovideworkspaceandproduceallneededreportsandinformationwithinone(1)businessdayoftherequest,unlessotherwisedetermined.
Subtask4J.AnnualReportsandFinalReportTheannualreportshallincludeasynopsisofactivitiesforagivenaudityearcoveringallprojectsunderthiscontract.Thisincludesadraftannualreportidentifyingalloverpaymentsandunderpaymentsidentified.Itshallincludeabrieflistingoftheidentificationmethodsandtheirsuccessorfailure.ThePartCRACshallincludeanyfeedbackandrecommendationsfortheRACprogram,aswellasanyadvantagesordisadvantagesencountered.Fromacontractorpointofview,thedraftfinalreportshalldetermineifthecontractwasasuccessorafailureandprovidesupportforeitheropinion.
Page 21
DRAFT PRE‐ DECISIONAL
21
ThedraftannualreportshallbedeliveredtotheCORandGTLinelectronicformatasonefileinPortableDocumentFormat(PDF),withoneclearly‐markedsectioncontaininga200‐wordabstract/summaryofthefinalreportsuitableforsubmissiontotheNationalTechnicalInformationService.ThedraftannualreportshallbeprovidedtoCMSapproximatelyfour(4)weekspriortofinaldeliverableduedatesunlessotherwiseagreedto.CMSstaffwillreviewthematerialsandprovidecommentsbacktothePartCRAC.ThePartCRACwillmakeallCMSrevisionsandresubmittoCMSforreview.ThedocumentwillbefinalizedatCMSdirection.
Subtask4K.ReturnofMaterialsPartCRACshallreturntoCMSallinformationrelatedtothisSOWinaccordancewithCMSinstructions.Alldatafiles,software,programs,computertapes,interimandfinalfiles,andfiledocumentationcreatedunderthiscontractshallbethesolepropertyofCMS.ThePartCRACshallprovidealloriginalsandcopiestoCMSuponrequestintheappropriateformat.TheyshallnotbeusedforanyotherpurposeotherthanfulfillingthetermsofthiscontractwithouttheexpresspermissionoftheCMSContractingOfficer.AllcasefilesshallmeettherequirementsassetbyOMBCircularA‐130,whichcanbefoundathttp://www.whitehouse.gov/omb/circulars/a130/a130trans4.html.
Subtask4L.Transitions:OutgoingContractorstoIncomingContractorsFromtimetotimeintheMARADVRACprogram,transitionsfromonecontractor/stoanothercontractor/swillneedtooccur(e.g.,whentheoutgoingcontractor/sceasesworkandanewincomingcontractor/sbeginswork).Itisinthebestinterestofallpartiesthatthesetransitionsoccursmoothly.Thetransitionplanshallincludespecificdateswithregardtoeachtaskofthecontract.ThetransitionplanshallbecommunicatedtoallaffectedpartiesbyCMSwithinsixty(60)daysofitsenactment.TheimpacttotheMARADVRACprogramwillbedeterminedwithinsixty(60)daysoftheannouncementoftheupcomingtransition.EachimpactedcontractorwillberequiredtosubmitatransitionplantoCMSforapproval.
IV. ScheduleofDeliverablesThePartCRACshallprovidethenecessarypersonnel,materials,equipment,support,andsuppliestoaccomplishthetasksshownbelowinthespecifiedtime.ThePartCRACshallcompletetheevaluationandreporttoCMSitsfindings.AllworkdoneunderthiscontractshallbeperformedunderthegeneralguidanceoftheSOWsubjecttotheCOR’sapproval.Writtendocumentsforthisprojectshallbedeliveredelectronicallyviasecuree‐mailunlessotherwisespecified.Atpresent,theCMSstandardisMicrosoftWord2010andMicrosoftExcel2010.Thisissubjecttochange,andthePartCRACshallbepreparedtosubmit
Page 22
DRAFT PRE‐ DECISIONAL
22
deliverablesinanynewCMSstandard.AlldeliverablesshallmeetallRehabilitationAct,Section508AccessibilityStandards.
BasePeriod:TBD
TaskNumber
DeliverableNumber Deliverable
DueDate(DOA=DateofContractAward)
11
Update,developand/ormaintainCoderGuidancedocument TBD
12
PrepareAuditReportsforeachplancontract TBD
13
IssueDemandLettersforMAorganizationsthatelectnottoappeal TBD
1
4
UpdateAuditReportsandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration
TBD
1A 5 SecurityandTrackingPlan TBD
1B6
Planfordocumentationandmedicalrecordmanagementanddestruction TBD
1C7
IntakeDocumentationandMedicalRecordReviewProcessPlan TBD
1D8
CollaborationandSupportforAppealsProcessesPlan TBD
1F9
MedicalRecordReviewStaffTrainingPlan&Materials
TBD
1H10
AgendaanddiscussiontopicsforTechnicalDataandOperationsMeetings TBD
1H11
Writtenfeedbackonproposeddataandoperationalplansandrequirements TBD
1I12
Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports TBD
1J13 PrepareAuditReports TBD
1J 14 DraftDemandLetters TBD
1J
15
UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess
TBD
1K16
Documentrationaleforunderpaymentandoverpaymentdeterminations
TBD
1K17 Overpayments&UnderpaymentsReport TBD
1K 18 WrittenplanforContractorstafftraining TBD1K ContributionstoRADVStandardOperating TBD
Page 23
DRAFT PRE‐ DECISIONAL
23
19 Plan(SOP)
1L20
Providesupportingdocumentationandwrittendocumentationforappealssupport
TBD
221
ProposecriteriaforConditionSpecificRADVAudits TBD
222
Update,developand/ormaintainCoderGuidancedocument TBD
223
PrepareAuditReportsforeachplancontract TBD
224
IssueDemandLettersforMAorganizationsthatelectnottoappeal
TBD
2
25
UpdateAuditReportsandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration
TBD
2 26 SecurityandTrackingPlan TBD
227
Planfordocumentationandmedicalrecordmanagementanddestruction TBD
228
IntakeDocumentationandMedicalRecordReviewProcessPlan TBD
229
CollaborationandSupportforAppealsProcessesPlan
TBD
230
MedicalRecordReviewStaffTrainingPlan&Materials TBD
231
AgendaanddiscussiontopicsforTechnicalDataandOperationsMeetings TBD
232
Writtenfeedbackonproposeddataandoperationalplansandrequirements TBD
233
Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports
TBD
2 34 PrepareAuditReports TBD2 35 DraftDemandLetters TBD
2
36
UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess
TBD
237
Documentrationaleforunderpaymentandoverpaymentdeterminations TBD
2 38 Overpayments&UnderpaymentsReport TBD2 39 WrittenplanforContractorstafftraining TBD
240
ContributionstoRADVStandardOperatingPlan(SOP) TBD
241
Providesupportingdocumentationandwrittendocumentationforappealssupport
TBD
3A 42 InitialMeetingMinutes TBD3A ProjectPlanincludingContractor TBD
Page 24
DRAFT PRE‐ DECISIONAL
24
43 OrganizationalChart
3B44
Weeklyconferencecallagendas,minutesandsupportingmaterials
TBD
3B45
Monthlyconferencecallagendas,minutesandsupportingmaterials TBD
4A 46 Monthly/WeeklyProgressReports TBD4A 47 MonthlyFinancialReports TBD4C 48 Returnallfiles TBD
4D
49
Prepareagendas,trainingmaterialsandpost‐sessionreportsforCMSWorkgroupMeetings
TBD
4D
50
Prepareagendas,trainingmaterialsandpost‐sessionreportsforRADVOperationcalls
TBD
4F51
CompleteStatementofAuditingStandardsNo.70 TBD
4F52
Correctiveactionplanforcontractorperformanceevaluationfindings TBD
4H 53 CompleteJointOperationAgreement TBD
4I54
Producereportsandinformationforotheraudits TBD
4J 55 AnnualReport TBD4J 56 FinalReport TBD4K 57 ReturnofMaterials TBD4L 58 TransitionPlan TBD
OptionYear:TBD
TaskNumber
DeliverableNumber
Deliverable
DueDate(DOYA=DateofOptionYearAward)
11
Update,developand/ormaintainCoderGuidancedocument TBD
12
PrepareAuditReportsforeachplancontract
TBD
13
IssueDemandLettersforMAorganizationsthatelectnottoappeal TBD
1
4
UpdateAuditReportsandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration
TBD
1A 5 SecurityandTrackingPlan TBD1B Planfordocumentationandmedicalrecord TBD
Page 25
DRAFT PRE‐ DECISIONAL
25
6 managementanddestruction
1C7
IntakeDocumentationandMedicalRecordReviewProcessPlan
TBD
1D8
CollaborationandSupportforAppealsProcessesPlan TBD
1F9
MedicalRecordReviewStaffTrainingPlan&Materials TBD
1H10
AgendaanddiscussiontopicsforTechnicalDataandOperationsMeetings TBD
1H11
Writtenfeedbackonproposeddataandoperationalplansandrequirements
TBD
1I12
Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports TBD
1J 13 PrepareAuditReports TBD1J 14 DraftDemandLetters TBD
1J
15 UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess
TBD
1K16
Documentrationaleforunderpaymentandoverpaymentdeterminations
TBD
1K 17 Overpayments&UnderpaymentsReport TBD1K 18 WrittenplanforContractorstafftraining TBD
1K19
ContributionstoRADVStandardOperatingPlan(SOP)
TBD
1L20
Providesupportingdocumentationandwrittendocumentationforappealssupport TBD
221
ProposecriteriaforConditionSpecificRADVAudits TBD
222
Update,developand/ormaintainCoderGuidancedocument TBD
223
PrepareAuditReportsforeachplancontract
TBD
224
IssueDemandLettersforMAorganizationsthatelectnottoappeal TBD
2
25
UpdateAuditReportsandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration
TBD
2 26 SecurityandTrackingPlan TBD
227
Planfordocumentationandmedicalrecordmanagementanddestruction TBD
228
IntakeDocumentationandMedicalRecordReviewProcessPlan
TBD
229
CollaborationandSupportforAppealsProcessesPlan TBD
Page 26
DRAFT PRE‐ DECISIONAL
26
230
MedicalRecordReviewStaffTrainingPlan&Materials TBD
2
31
AgendaanddiscussiontopicsforTechnicalDataandOperationsMeetings TBD
232
Writtenfeedbackonproposeddataandoperationalplansandrequirements TBD
233
Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports
TBD
2 34 PrepareAuditReports TBD2 35 DraftDemandLetters TBD
2
36
UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess
TBD
237
Documentrationaleforunderpaymentandoverpaymentdeterminations TBD
2 38 Overpayments&UnderpaymentsReport TBD2 39 WrittenplanforContractorstafftraining TBD
240
ContributionstoRADVStandardOperatingPlan(SOP) TBD
241
Providesupportingdocumentationandwrittendocumentationforappealssupport TBD
3A 42 InitialMeetingMinutes TBD
3A43
ProjectPlanincludingContractorOrganizationalChart
TBD
3B44
Weeklyconferencecallagendas,minutesandsupportingmaterials TBD
3B45
Monthlyconferencecallagendas,minutesandsupportingmaterials TBD
4A 46 Monthly/WeeklyProgressReports TBD4A 47 MonthlyFinancialReports TBD4C 48 Returnallfiles TBD
4D
49
Prepareagendas,trainingmaterialsandpost‐sessionreportsforCMSWorkgroupMeetings
TBD
4D
50
Prepareagendas,trainingmaterialsandpost‐sessionreportsforRADVOperationcalls
TBD
4F51
CompleteStatementofAuditingStandardsNo.70 TBD
4F52
Correctiveactionplanforcontractorperformanceevaluationfindings
TBD
4H 53 CompleteJointOperationAgreement TBD
4I54
Producereportsandinformationforotheraudits
TBD
4J 55 AnnualReport TBD
Page 27
DRAFT PRE‐ DECISIONAL
27
4J 56 FinalReport TBD4K 57 ReturnofMaterials TBD4L 58 TransitionPlan TBD