R499--Copy of Consolidated Payment RFI

Purpose This is a Request for Information (RFI) to identify services that more efficiently integrate and better serve Veterans who receive community provided care. VA is not, at this time, seeking proposals and will not accept unsolicited proposals. All responses shall be solely in the form of information and materials. 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. The Government is under no obligation to issue a solicitation or to award any contract on the basis of this RFI. All costs associated with responding to this RFI will be the sole responsibility of the respondent. All submissions will be treated as business confidential materials, become Government property, and will not be returned. Program Information Point of Contact Contracting Officer: Glenn Burton, VA Office of Acquisition Operations (OAO), Email: contact@example.gov Contract Specialist: Justin Sink, VA Office of Acquisitions and Logistics (OAL), Email: contact@example.gov Initiative This VHA Office of Community Care (OCC) initiative aims to align its current non-network claims adjudication and payment process with its in-network claims process. It proposes a realignment of government activities by shifting the processing and payment of non-network claims to a contracted claims processor, in order to reduce fragmentation, overlap, and duplicative work. Under this initiative, both the providers and Veterans will experience an improvement on the timeliness, quality, and streamline of the claim s payment process. Community Care Background The Department of Veterans Affairs (VA) is committed to providing Veterans with access to the highest quality of care, whether it be in a local VA facility or among community providers within close proximity to Veterans. As partnerships between the VA and other provider groups strengthen and develop to meet the needs of the Veteran population, there is value in identifying how to maximize the efficiency of the business relationship and contractual obligation across entities. Under the Mission Act of 2018, improvements were made to the Veterans Community Care Program with the aim of improving care for Veterans through the implementation of following initiatives: Development of a Consolidated Veterans Community Care Program that combined existing programs into one consolidated program Better customer service through a streamlined internal processes and improved education and communication resources Veterans access to non-emergency care within the VA network of providers Established a Community Care Network of community providers that are administered by Third Part Administrators (TPA) Modernization of IT system that improves the process of care coordination, authorizations, appointments, claims and payments while also improving communication between Veterans, VA staff and community providers The Office of Community Care (OCC) also takes an active role in providing oversight and implementation in the following areas: Program benefits Member eligibility requirements Referrals and authorizations Oversight and audits of Third-Party Administrator (TPA) performance Establishing reimbursement rates Provider sanctions and funding Community Care Goals As the demand for care increases, the community care goals become more centered on identifying opportunities to maximize operational efficiencies that improve patient health and access by working with both internal and external stakeholders in the industry. Currently there is an opportunity to achieve industry standardization across the board to streamline VHA OCC non-networks claims work. The end goals for Community Care is to realign the claims payment process to achieve the following target end goals: Reducing operational fragmentation by removing the gaps between provider and non-network providers Centralizing the claims processing and payment system in a unified and timely process Identifying regional implications for establishing a centralized location to send and bill claims Working with third-party entities to assist in the processing of claims to yield effective and timely claims processing metrics, as TRICARE has utilized contractors in the past Improving the timeliness, accuracy, and consistency of services to reduce costs Statement of Needs The intent is to ensure accurate and timely receipt, adjudication, and payment of all claims from Community Care providers, to include non-CCN provider claims. VA intends to utilize one claims processor per existing CCN region to manage all of these claims in order to achieve a consolidated claims processing and payment system, while reducing discrepancies in how processes operate between network and non-network providers Component needs are as follows: All non-network claims submitted on industry standard EDI or paper claims will be processed by the claims processor Capability to ensure that duplicate billing does not occur Claims processor must be able to access all VA referrals and approvals to validate and approve claims Claims processor must be able to receive the fee schedule from VA and locally contracted referral or negotiated Veteran Care Agreement (VCA) rates to accurately process claims reimbursements correctly per the CMS fee schedule reimbursement hierarchy depending on program authority that care occurred under Ability to adjudicate approval for claims based on the standardized episode of care (SEOC) that was approved on the referral Ability to deny claims if the timeframe of the care falls outside of the window of the referral of if the care provided falls outside of the scope of the SEOC A centralized billing and provider reimbursement system that effectively and accurately auto-adjudicates claims and pays providers in accordance with industry standards and provides VA with full industry standard EDI HIPAA compliant claims that include with the full HIPAA required data elements for all populated fields from the original 835/837/NCPDP/Dental claim types for each transaction. Ability to process recoupments for inappropriate provider claims payment; this is to include instances where the fee schedule changes Full 837 COB claims data and invoice submission to the VA through VA s approved submission system, including those in pre-payment status, on a daily basis Claims processing status reports on a weekly basis, quarterly claims audit reports, and ad hoc reporting capability Coordination of Benefits - Identification Veteran s OHI when applicable. Fraud, waste and abuse protection and mitigation processes Meet operational, availability and recovery time objectives Capability to pilot claims process and proceed with national rollout in a phased manner More in-depth component needs are contained in the attachment titled, RFI Contractor Capabilities. Program Requirements The scope of this RFI is to obtain information on the service offerings, operations, and data collection mechanisms of existing commercial service claims processors. Specifically, VA requests information about the following components of this potential solution: Integrated Operations Systems (Data Collection, Fee Schedule and Local Rate Capture, Automated Claims Processing and Reporting) Integrated Customer Service (Service Delivery and Quality Monitoring) Integrated Administrative Systems (Eligibility/Enrollment capture, Patient Referral and Approval capture, Provider Reimbursement) Interfacing with VA Systems (Claims and Invoice Data Exchange Including Data Needs for VA Revenue Operations) Specific RFI questions are contained in the attachment titled, RFI Respondent Questionnaire. In Response to this RFI VA is seeking qualified respondents that offer solutions and systems that meet the RFI Statement of Needs in Section 5.0, Statement of Needs and the requirements noted in Section 6, Program Requirements. Respondents are requested to provide the minimum capability listed below this paragraph and answers to questions in the attachment, RFI Respondent Questionnaire. Please simply indicate N/A for any question that is not applicable. Interested parties shall furnish the following minimum information: Company name and address. Company point of contact name, telephone number and email address. Company business size and status (i.e., Large Business, Small Business, Service-Disabled Veteran Owned Small Business, Women-Owned Small Business, etc.), the number of years in business, affiliate information: parent company, joint venture partners, potential teaming partners. If the company holds a Government Wide Acquisition Contract (GWAC), list the Contract Number and relevant Special Item Numbers (SIN). Capabilities/Qualifications: A written response providing clear and unambiguous evidence to substantiate the capacity to fulfill this potential requirement. Description of the capabilities/qualifications/skills the company possesses to perform services described in any potential scope of work or performance work statement. 8. Responses It is requested that the above information be provided no later than October 23, 2020, 2:00 P.M. Eastern Standard Time. Responses must be emailed to contact@example.gov and contact@example.gov. All email correspondence for this project must reference the RFI Number, Project Identifier and Project Title in the subject line of the email. Example: RFI VA-16-N-0006, CITC Sources Sought. 9. Disclaimer This RFI is for the purpose of market research only and is issued for information and planning purposes only. This does not constitute a solicitation, nor does it bind the government to produce a solicitation or restrict as to the ultimate acquisition approach should a solicitation result from this RFI. 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. Any contract that might be awarded based on information received or derived from this market research will be the outcome of a