Medical Claims Adjudication System Services

The Federal Bureau of Prisons (Bureau) currently provides healthcare to approximately 160,000 inmates in 120 prisons (institutions) geographically dispersed throughout the contiguous United States, Hawaii, and Puerto Rico. For the contract award, all federal inmates are considered to have a single benefit plan and are members of this plan. Inmate access to healthcare benefits is applied universally throughout the Bureau’s system. There are no accumulators or capitation in the Bureau’s healthcare system. Inmates do not pay premiums, copayments (for the purpose of contract award), or deductibles.

Medical services rendered to all inmates in Bureau custody are governed by federal law and Bureau policies/procedures.  Primary care is provided by Bureau employees as part of a medical team (e.g., physicians, advanced practice providers, nurses, pharmacists, dentists, social workers, therapists, etc.).

In addition, each institution within the Bureau solicits comprehensive medical contracts, including but not limited to the facilities referenced under Place of Service Codes in the List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (see Attachment A for the relevant excerpt) for facility and physician services, based on the prevailing:

1) Federal Operating Rate Medicare rates for the applicable area for inpatient facility services;

2) Medicare fee schedule amounts for the area for outpatient facility services;

3) Skilled nursing facilities, and

4) Medicare fee schedule amounts for the area for physician services.

Healthcare providers, when negotiating rates for the Bureau are expected to propose a discount from or a premium to Medicare benchmarks. The Bureau has successfully awarded most comprehensive medical contracts based on structured Medicare rates. However, there are locations where the Bureau has been unsuccessful in awarding contracts based on Medicare rates. In those cases, contracts are typically awarded at a percentage of billed charges or the fee schedule. Only Bureau institutions with contracts that are structured using Medicare rates shall participate in claims adjudication process under this contract.

The Bureau is the sole payer for all healthcare services rendered to inmates in Bureau custody. The number of claims processed each year may vary based on healthcare services provided. Most healthcare providers are using electronic billing via ANSI 837 format consistent with the industry standard. For the purpose of contract award, a claim for contracted healthcare services reimbursed using the Medicare model is defined as electronic claims that conform to Medicare and Health Insurance Portability and Accountability Act (HIPAA) electronic billing standards (see http://www.cms.hhs.gov/ElectronicbillingEDITrans/01 overview.asp) from a contracted facility, physician’s office, or other healthcare provider.

In summary, each institution has separate and unique contract(s) with healthcare providers in their area. Therefore, the “network of healthcare providers” shall be those healthcare providers with current Bureau contracts and agreements. These contracts and agreements shall each have formally negotiated and contract payment rates.

The vendor shall met DOJ/FBOP IT information security requirements and is able to continue reviewing and adjudicating community medical billing for accuracy and fraud detection without lapses in service and has developed the necessary information network with community providers to allow for receipt of digital claims and processing against the negotiated rate structures at each FBOP facility. Any system that shall connect to or be hosted in a non-FBOP cloud service shall use cloud service providers (CSP) that have been independently evaluated by an authorized FedRAMP 3PAO and are FedRAMP-certified. The vendor shall provide a MCA system environment hosted within a vendor instance of Amazon Web Services (AWS) GovCloud. This MCA system shall inherit various Federal Risk and Authorization Management Program (FedRAMP) certified functions and services, such as CloudWatch, CrowdStrike, and CloudTrail.

The Federal Bureau of Prisons has awarded a sole-source firm-fixed-price task order for Medical Claims Adjudication (MCA) System Services, acquired against General Services Administration’s (GSA) MAS contract GS-00F-392GA, NAICS 541519, Other Computer Related Services, and Product Service Code, Q601, Medical Coding and Auditing.

The approved Justification is attached.