SOLICITATION NOTICE
99 -- UEPs Review of MAOs/PDPs and AUPs Review of Cost - Based MCOs Cost Reports
- Notice Date
- 12/4/2009
- Notice Type
- Combined Synopsis/Solicitation
- NAICS
- 541219
— Other Accounting Services
- Contracting Office
- Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Acquisition and Grants Management, 7500 Security Blvd., C2-21-15, Baltimore, Maryland, 21244-1850
- ZIP Code
- 21244-1850
- Solicitation Number
- RFP-CMS-2010-0011
- Archive Date
- 12/22/2009
- Point of Contact
- Liz Hammond, Phone: 410-786-7440, Robin Denise Evans, Phone: 410-786-7909
- E-Mail Address
-
elizabeth.hammond@cms.hhs.gov, robin.evans@cms.hhs.gov
(elizabeth.hammond@cms.hhs.gov, robin.evans@cms.hhs.gov)
- Small Business Set-Aside
- Partial Small Business
- Description
- From the beginning of the Medicare program in 1965, Medicare has recognized the unique nature of Health Maintenance Organizations (HMOs) and HMO-like entities and has provided for alternative payment methodologies appropriate for such organizations. The original Medicare amendments to the Social Security Act included the authority for prepaid plans to receive payments for physician services on a basis other than individual charges. Even before the enactment of the federal HMO Act in 1973, the 1972 amendments to the Social Security Act provided authority to contract with HMOs on a risk-sharing basis and on a cost basis. In 1996, Section 202 of the Health Insurance Portability and Accountability Act (HIPAA) added section 1893, to the Social Security Act. Section 1893 established the Medicare Integrity Program (MIP). MIP was established to strengthen CMS's ability to deter waste, fraud and abuse in the Medicare program. It provides for separate and stable long term funding for MIP activities. MIP expands CMS's contracting authority so the agency can more aggressively carry out program safeguard functions. The Balanced Budget Act of 1997 (BBA) established the Medicare+Choice (M+C) program, allowing additional types of managed care organizations to secure Medicare contracts. A major intent of the BBA was to replace the Tax Equity and Fiscal Responsibility Act (TEFRA) with new managed care options (i.e. M+C plans, etc.) for beneficiaries. It allowed for new beneficiary options in addition to the well established types of HMO options operating under TEFRA contracts. A major intent of the BBA was to replace TEFRA with a new managed care options (i.e. M+C plans, etc.) for beneficiaries. It allowed for new beneficiary options in addition to the well established types of HMO options operating under TEFRA contracts. The recently-enacted Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) has expanded the role of private entities in providing benefits to Medicare beneficiaries. First, the law adds a new section to the Social Security Act, 1860D ("Part D") that offers prescription benefits beginning in 2006 through Prescription Drug Plans (PDPs). Secondly, the statute allows for payments to Medicare Advantage Organizations (MAOs) "local plans" formerly M+C plans, and creates a new type of private plan, "Regional" MA plans or Regional Preferred Provider Organizations (RPPOs). Synopsis: CMS anticipates releasing one (1) solicitation for the award of multiple IDIQs for firm fixed price (FFP) task orders (contracts) for the examination engagement to review the Medicare Advantage Organizations (MAOs) and/or Prescription Drug Plans (PDPs) and/or the Agreed-Upon Procedure (AUPs) review of Cost-Based Medicare Managed Care Organizations (MCOs) on and/or about Tuesday, December 22, 2009. Examination Engagement for Review of Medicare Advantage Organizations and Prescription Drug Plans' Financial Information CMS's Office of Financial Management (OFM) has overall responsibility for the fiscal integrity of all Agency programs which includes the mandated one-third financial audit requirement. OFM will conduct annual audits of the financial records of at least one third of the MAOs and PDPs as required by Sections 1857(d)(1) and 1860D-12 of the Social Security Act. The main objectives of the examinations are to provide assurance that Medicare Advantage and Prescription Drug payments were proper and organizations' self reported information used to determine payment amounts were valid and correct. The audit contractor shall document the results of the examination, extrapolate the value of appropriate exceptions to the entire population and propose payment adjustments. The examination engagements shall be made in accordance with the Uniform Examination Program (UEP) for the Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) which, includes: • Governmental Accounting Standards Board (GASB) • Generally Accepted Accounting Procedures (GAAP) • Generally Accepted Auditing Standards (GAAS) • Generally Accepted Government Auditing Standards (GAGAS). • American Institute of Certified Public Accountants (AICPA) • General Accounting Office Government Auditing Standards (2007 revision, Yellow Book) • Social Security Act (the Act) Titles XVIII and XIX and; the Code of Federal Regulation (CFR) governing the MAO program including, standards and processes for imposing the enforcement provisions. Agreed-Upon Procedure Review of Cost-Based Medicare Managed Care Organizations (MCO) Cost Reports CMS's Office of Financial Management (OFM) has overall responsibility for the fiscal integrity of all Agency programs which include the oversight of cost-based managed care organizations as well as the mandated one-third financial audit requirement. OFM will conduct periodic audits of cost-based managed care organizations in accordance with Section 1876 of the Social Security Act and based on criteria established by CMS. The objective of the Agreed-Upon Procedure (AUPs) review is to determine whether reimbursable costs claimed by the Managed Care Organization are reasonable, allowable, and allocable in accordance with applicable Medicare laws and regulations. In addition, the contractor shall evaluate the MCO's Medical Review programs and make recommendations for improvement. The review includes, but is not limited to, the review of the MCO procedures and internal controls over duplicate payments and situations when Medicare is a Secondary Payer (MSP). In addition, the Offeror shall evaluate the accuracy and allowability of Medical Coding (CPT codes) and related Relative Value Units (RVUs) (if applicable) to ensure fair apportionment and the accuracy of the claimed medical services costs. The examination engagements shall be made in accordance with the Agreed Upon Procedures (AUPs) for the Managed Care Organizations (MAOs) which, includes: • Thorough understanding of Medicare managed care cost reimbursement principles and the required cost reporting formats. • Thorough understanding of Medicare cost apportionment methodologies and the ability to distinguish administrative and general cost from plan administration costs and their respective allocation and apportionment methodologies. • Thorough understanding of the review of medical claims costs and the review of financial information relating to Managed Care Organizations. (End of text)
- Web Link
-
FBO.gov Permalink
(https://www.fbo.gov/spg/HHS/HCFA/AGG/RFP-CMS-2010-0011 /listing.html)
- Record
- SN02016906-W 20091206/091204235045-29da7c9e25fc80966572050a18a7545f (fbodaily.com)
- Source
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