RFP# OMIG 26-23- Home Health Care Medicare Maximization Services (HHC MMX)

The Home Health Care Medicare Maximization Services (HHC MMX) program is housed within OMIG’s Division of Medicaid Audit, Bureau of Provider Audit. The program is designed to maximize Medicare coverage for dual eligible recipients who receive home health care services paid by Medicaid. Under the program, OMIG and its Contractor pursue Medicare coverage for home health services through the Medicare Administrative Appeals Process when Medicaid has paid for fee-for-service claims that may have been covered by Medicare. If Medicare coverage is obtained, Medicare reimburses the home health provider for the approved services, and the provider is required to return the amounts paid by Medicare to New York State. The HHC MMX program also includes audit and recovery activities involving providers that fail to comply with Medicare demand billing requirements, fail to return amounts paid by Medicare, or otherwise fail to comply with program directives. The program supports OMIG’s broader responsibility to ensure that Medicaid remains the payer of last resort and that all legally liable third-party coverage is pursued in accordance with Federal and State law. OMIG is seeking a qualified Contractor to perform HHC MMX under the direction of OMIG’s Bureau of Provider Audit. The Contractor will support OMIG’s efforts to maximize Medicare coverage for dual eligible Medicare and Medicaid recipients who receive home health services paid by Medicaid. Responsibilities include data analysis/case selection, Medicare appeals processing, provider coordination, audit and recovery support, reporting, provider education, and related operational activities necessary to support the HHC MMX program. OMIG intends for the resultant contract to support efficient Medicare appeal and recovery operations, improve provider compliance, reduce unnecessary administrative burden where possible, and maintain positive working relationships with the provider community and other stakeholders. Because Federal and State healthcare regulations, Medicare policies, and Medicaid Managed Care requirements may change during the term of the contract, the Contractor must maintain operational flexibility and be capable of adapting program processes and methodologies as directed by OMIG. Business enterprises awarded an identical or substantially similar procurement contract within the past five years: None Service-Disabled Veteran-Owned Business (SDVOB) SDVOB Goal: 0.00% Minority / Women Business Enterprise contracting goals (MWBE) MBE Goal: 0.00% WBE Goal: 0.00% Disadvantaged Business Enterprise contracting goals (DBE) DBE Goal: 0.00%