OWCP Medical Physician Network and Medical Bill Processing Services

BACKGROUND The Department of Labor (DOL) is conducting market research on industry's capabilities to provide nationwide medical provider services by means of a provider network or networks, and to serve as a third party biller to receive and process medical bills, according to industry standards and OWCP rules where necessary. DISCLAIMER This Request for Information (RFI) is issued solely for information and does not constitute a solicitation. In accordance with the FAR 15.201 (e), RFIs may be used when the Government wants to obtain price, delivery, other market information, and capabilities for planning purposes. Responses to these notices are not offers and cannot be accepted by the Government to form a binding contract. Respondents are solely responsible for all expenses associated with this RFI response. For the purposes of this RFI, the term "vendor" refers to those members of the industry providing a response to this RFI. Payment will not be provided for information obtained in this RFI, nor will it be returned. Respondents will not be notified of the RFI assessment. INTRODUCTION The U.S. Department of Labor (DOL), Office of Workers Compensation Programs (OWCP) administers four major workers compensation programs: the Federal Employees Compensation Act (FECA), the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), the Black Lung Benefits Act, and the Longshore and Harbor Workers Compensation Act (LHWCA). Each program seeks to mitigate the impact of work-related injuries for specified workers through the provision and management of medical and other benefits. In addition, Division of Federal Employees and Longshore Harbor Workers Compensation (DFELHWC) claims examiners facilitate return-to-work for workers with work-related injuries or illnesses who are able to work. OWCP claims examiners working in offices throughout the United States adjudicate and manage claims. To provide a sense of scope, in a recent 1-year period OWCP processed 3,343,466 medical bills. The total amount paid in medical benefits was $1,446,174,300. These were distributed among the programs as follows: Federal Employees Compensation had 79% of bills and 41% of payments; Energy Employees Occupational Illness had 19% of bills and 58% of payments; and Disabled Coal Miners had 2% of bills and 1% of payments. Currently, the OWCP pays claims through a medical bill-processing vendor at a significant administrative cost due to each of the programs having unique needs. The programs are open to change but one of the custom features that OWCP's bill processing vendor has incorporated historically are the OWCP Treatment Suites. Treatment Suites are in-house, International Classification of Diseases (ICD) code-driven algorithms used to determine authorization requirements and eligibility for payment of Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, diagnosis-related groups (DRG), durable medical equipment (DME), therapeutic drug classes, and other services for accepted condition(s) according to Office of Workers Compensation Programs (OWCP) business rules. Billed diagnoses are validated against the claimant's accepted conditions. Below are the Government's current activities to support this function, which is not an indicator of where future policies will end. Support program-specific business rules, which include prior authorization (PA) levels. There are multiple PA levels available. PA level 1 procedures do not require prior authorization. PA level 2 procedures require review and a payment decision by the bill payment vendor. PA level 3 procedures require review and approval by the OWCP. OWCP also maintains a treatment suite called - Basics, which includes those HCPCS and CPT codes, and DME assigned to and part of all standard suites. In addition, the OWCP maintains custom or special treatment suites which include homegrown codes. Process bills for services according to program-specific business rules, accepted conditions and treatment suites (or Contractor provided alternative). OVERVIEW The Government is seeking information from companies that can provide 1) access to provider networks and 2) bill processing services. The government's goals for its medical provider networks is to provide: Access to multiple medical provider networks (e.g., preferred provider organization - PPO networks of physicians and hospitals). Ideally, this would include the ability to access networks of physical therapy, durable medical equipment, and other services/products, in an effort to expand the availability and ease of scheduling with providers for our claimants. Nationwide coverage and access to treating physicians and medical providers through the vendor's own direct provider contracts or through access to other medical provider networks. Access to a sufficient nationwide network of physicians to accommodate OWCP Directed Medical Services. The Government's goals for bill processing services include: Enrollment capability of non-network providers Pre-authorization services Bill processing services that include digital and physical mailroom bill intake (together with 100% required medical attachments to include medical reports, physician progress notes, etc.). Customer service operations via the web and call centers for claimants and providers. Processing all bills to payment or denial within 15 calendar days for electronic submission and 28 calendar days for hardcopy bills . Using industry standard edits, including but not limited to, National Correct Coding Initiative (NCCI), CMMS publicly-available Medically Unlikely Edits (MUEs), utilization review (UR), etc., wherever possible to ensure correct processing of bills and to reduce the risk of successful fraudulent billing. Using additional government-specified edits where necessary to meet OWCP programs regulatory and policy requirements. Reduce OWCP's medical and bill-processing administrative costs. Recent market research indicates that insurance companies and third party administrators can provide full service operations with access to physician networks and bill processing services, with full-featured customer service capabilities. These entities have access to their own, and other PPO networks. When processing bills, the company runs the provider associated with the bill through internal edits to determine the most cost efficient PPO network agreement the provider appears in, or to determine the best pricing reduction if the provider is associated with more than one PPO network. CONTRACT STRUCTURE The government envisions a contract structure in which the primary revenue generated to the Contractor will be the difference between the Contractor's negotiated rates with its network providers and the negotiated OWCP Fee Schedule discounts included in the contract. All costs and profit for rendering required services must be covered by the - Net Proposed Price/Discount. The Contractor shall pay in-network providers directly, and separately invoice OWCP at the - Net Proposed Price/Discount. Billing for these services would be by individual service, at contracted rates at the case number level. All the medical support services and associated costs are considered to be FECA/BLBA/EEOICPA/LHWCA benefits. The Contractor shall pay out of network providers the OWCP Fee Schedule amount for the payable services, and bill OWCP the Fee Schedule amount plus an additional per-bill administrative processing fee. SCOPE OF WORK See attached MSWord document for known requirements. DESCRIPTION OF INFORMATION REQUESTED The government is requesting information from vendors interested in doing business with OWCP, regarding industry practices and company capabilities. Answers to government questions in the attached MSWord document should be included. VIRTUAL INDUSTRY DAY EVENT: In addition to the RFI, the government will likely host an Industry Day virtual event. During this event, the government will further clarify the objectives and requirements provided in this RFI. All interested parties will be encouraged to attend and ask questions. Further details will be posted as an amendment to this notice. RESPONSES/CAPABILITY STATEMENT All responses shall include a written Capability Statement, and the following: Company name, mailing address, e-mail address, telephone and website address (if available), and the name, telephone number, and e-mail address of a point of contact having the authority and knowledge to clarify responses with Government representatives. Company's GSA Federal Supply Schedules contract number, if applicable, and Special Item Numbers. Customary practices, including warranty, discounts, contract type under which commercial sales of these services are made. Business size and status (i.e. 8(a), Small Disadvantaged Business, Woman-Owned Small Business, HUBZone, and/or Service-Disabled Veteran-Owned Small Business). DUNS number, CAGE Code, Tax Identification Number, and company structure (Corporation, LLC, partnership, joint venture, etc.). Companies also must be registered in the System of Awards Management at www.beta.sam.gov to be considered as potential sources. In addition, all interested parties shall provide answers to the questions asked in the attached requirements document. HOW TO RESPOND: Responses to this RFI must be letter sized (8.5 x 11) in length using the standard margins and font. Responses that send sales material will not be assessed. All responses must clearly and directly address capabilities and answer Government questions, and must also comply with the format identified above. Again, responses consisting of marketing material will not be reviewed. All responses are to be submitted electronically to the DOL contract specialist provided below by 4pm Eastern Standard Time (EST) on Monday, July 26, 2021. Hard copy responses will not be accepted. Send the email responses to: Evans.Tomeka.E@dol.gov and please cc Reynolds.Debra@dol.gov. CONTACTS: For questions regarding this RFI, you are welcome to contact: Tomeka Evans Email: Evans.Tomeks.E@dol.gov Debra Reynolds Email: Reynolds.Debra@dol.gov