Intent: This Request For Information (RFI) is to understand industry leading practices around detection, recovery and prevention of pharmacy fraud, waste, and abuse. In addition, it seeks to assess industry capability to develop and implement fraud, waste, and ab use programs for the Military Health Systems (MHS) pharmacy program. All potential vendors must have expertise in pharmacy auditing and be able to deploy of a full set of proven tools to identify and recover savings. Expected outcomes of a pharmacy fraud, waste and abuse program for the Military Health System should include the ability to: " Analyze pharmacy claims data to identify errors, fraud, and/or abuse in mail and retail channels " Generate reports that assist MHS Pharmacy Leadership in monitoring and oversight efforts " Enlist support of beneficiaries to identify potential fraud, waste or abuse situations " Utilize statistical methods to select targeted pharmacies, providers, and claims for desk audits " Perform random and targeted field audits to assess compliance with MHS processes and procedures and to identify control weaknesses and opportunities for improvement " Conduct a detailed improper payments review to identify and collect overpayments " Demonstrate a strong return on investment Background: The Military Health System mission is to enhance the Department of Defense (DoD) and the Nations security by providing health support for the full range of military operations and sustaining the health of all those entrusted to its care. One of the compo nents of the Military Health System is the operation of a health care plan for military personnel and their dependants TRICARE. The TRICARE program is managed by TRICARE Management Activity (TMA) under the authority of the Office of the Assistant Secret ary of Defense for Health Affairs (OSD/HA). The DoD administers an integrated TRICARE Pharmacy Benefits Program which offers pharmacy services to eligible beneficiaries through direct care pharmacies located at Military Treatment Facilities (MTFs), the TRICARE Mail Order Pharmacy (TMOP) contract, or the TRICARE Retail Pharmacy (TRRx) contract. The TRRx contract allows eligible beneficiaries to obtain pharmacy services through either TRICARE retail network pharmacies or otherwise authorized retail non-network pharmacies. TMA contracts with several large corporations to provide claims processing, customer service and other administrative functions to the TRICARE program. More specific to pharmacy, one contractor serves as the national TRICARE Pharmacy Benefit Manager Exp ress Scripts, Inc. (ESI). ESI provides the TMOP (including specialty pharmacy) services, provides a TRICARE retail pharmacy network, and performs as a fiscal intermediary on behalf of DoD to pay for all authorized pharmaceuticals and supplies for eligible beneficiaries. In Fiscal Year 2006, TRICAREs retail pharmacy network filled 58.8 million prescriptions and TMOP filled 7.8 million prescriptions. Information Requested from Industry: In responding to this RFI, potentially interested parties are asked to submit information on the following: 1. Please provide the name of your organization and contact information for your main point of contact for this RFI. 2. Briefly describe the scope of pharmacy fraud, waste and abuse detection and prevention services available in the marketplace and how these services could apply to the Military Health System. Please include a description of typical savings achieved by c lients who implement pharmacy fraud, waste and abuse programs (i.e., percentage savings recovered). 3. If you have experience with pharmacy audits or pharmacy claims payment review for Medicare or Medicaid, please provide details related to scope, approach and process. 4. Please describe approaches used for auditing various types of pharmacy fraud, waste, and abuse scenarios (see examples below). Describe any differences that exist when aud iting large versus small organizations. a. Inappropriate billing practices by pharmacies b. Prescription forging or altering by pharmacists or beneficiaries c. Prescription refill errors d. Illegal remuneration schemes involving pharmacies and providers e. Script mills (non-medically necessary prescriptions usually written for controlled drugs and sale on the black market) f. Prescriber DEA number or prescription pad theft g. Provision of false information by prescribers or beneficiaries h. Prescription stockpiling by beneficiaries i. Doctor shopping by beneficiaries j. Other examples 5. What types of performance metrics are reported to clients related to the detection and recovery of pharmacy fraud, waste, and abuse? 6. Please provide descriptions and examples of reports provided to clients. 7. Please describe the Pharmacy Benefit Manager (PBM) functions and processes that are typically audited (e.g., pharmacy and pharmacist credentialing, PBM internal controls, claims processing). 8. Please provide a description of pharmacy claims sampling techniques, confidence, and precision levels, error rate calculation formulas, and timing/schedule of pharmacy claims payment reviews that have proven efficacy and positive return on investment. 9. Please describe the approach of a pharmacy claims payment review to include: a. Documentation and process used/required to conduct review (manual vs. automated) b. Beneficiary eligibility verification c. Duplicate claim information d. Consideration of other health insurance benefits/coordination of benefits e. Prior authorization or medical necessity determinations f. Application of program policies (timely claims filing, claims signature, provider requirements) g. Pharmacy claim types reviewed (electronic, paper, mail order) h. Accurate claims pricing i. Application of tiered pharmacy program co-payments j. Application of program deductibles and catastrophic cap thresholds k. Consideration of discounted fee schedules between the PBM and their network pharmacies 10. Please describe approaches available for the post pharmacy claims payment review process to review findings based on appeals or feedback from the reviewed entity, as well as for the recovery of pharmacy claim overpayments. 11. Please describe the type of data required to perform pharmacy audits. 12. Please list the various methods used to receive claim data/account information from clients. 13. Please describe the technology available for pharmacy fraud, waste and abuse auditing processes. Describe any differences in the approach for auditing paper versus electronic claims. 14. Please describe the capabilities required to configure networks to support access to Government systems, ensure records security and confidentiality, and comply with Information Assurance Requirements. 15. What other technical requirements may be necessary for implementation (e.g., server purchase, flat file downloads)? 16. What is an appropriate historical timeframe to consider for pharmacy audits? 17. What types of compensation arrangements would you recommend in order to achieve the highest return on investment for both the Military Health System and the contractor? To request additional information or to provide your comments and responses to this request, please visit http://iiprfi.fedworx.org. DoD requests that potentially interested parties in industry use this website to respond to the RFI by 5 pm EST on Wednesd ay, April 18, 2007. If you have additional questions regarding the RFI, please transmit them through the Submit your Questions page. All questions and answers will be made available on this website within 10 business days after posting of the RFI. (See Ans wers to Your Questions). Questions must be submitted no later than 4:00 pm EST on April 6, 2007 for answers to be posted on the website. Questions submitted after this date may not be answered, but will be retained by DoD for consideration in further developing this program. Disclaimer: The purpose of this RFI is to gather information from industry. This RFI is not to be considered a request for proposals or a formal solicitation from which a contract will be awarded. The Government does not currently have a contract requir ement associated with the TRICARE Pharmacy Fraud Waste & Abuse. Participants are reminded that any information provided will be considered proprietary only if it is marked as such and generally not releasable under the Freedom of Information Act unless an exception applies. The Government reserves the right to use information gathered from this RFI and any information subsequently received, regardless of the source, for any purpose deemed necessary and legally appropriate by the Department of Defense, inc luding preparation of a contract requirement. Any contract action resulting from the analysis of information gathered will be announced to the public in accordance with the Federal Acquisition Regulation.
