FOR MEDICARE ADVANTAGE (MA) RISK ... - Modern Healthcare

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STATEMENTOFWORK(SOW)

FORMEDICAREADVANTAGE(MA)RISKADJUSTMENTDATAVALIDATION(RADV)RECOVERYAUDITCONTRACTOR(RAC)

I. StatutoryBackgroundandGeneralPurpose

TheMedicareRecoveryAuditProgrambeganasathree‐yeardemonstrationauthorizedbyCongressinsection306oftheMedicarePrescriptionDrug,ImprovementandModernizationActof2003(MMA)(P.L.108‐173).ThedemonstrationwasconductedinsixstatesfromMarch2005toMarch2008,anditspurposewastodetermineifRecoveryAuditorContractors(RACs)couldeffectivelyidentifyimproperclaimspaidunderMedicarePartAandPartB.ThisinitialpilotprogramsucceededinreturningmillionsofdollarsinoverpaymentstotheMedicareTrustFunds.BasedonthesuccessoftheRecoveryAuditdemonstration,section302oftheTaxReliefandHealthCareActof2006(TRHCA)(P.L.109‐432)createdapermanentMedicareRACprogramandaddedanewparagraph(h)tosection1893oftheActthatrequiredCMStoestablishanationwideRACprogramforMedicarePartAandPartBbyJanuary1,2010.Specifically,thestatutestates:

(1)UndertheProgram,theSecretaryshallenterintocontractswithrecoveryauditcontractorsinaccordancewiththissubsectionforthepurposeofidentifyingunderpaymentsandoverpaymentsandrecoupingoverpaymentsunderthistitlewithrespecttoallservicesforwhichpaymentismadeunderthistitle.Underthecontracts—

(A)paymentshallbemadetosuchacontractoronlyfromamountsrecovered;(B)fromsuchamountsrecovered,payment—

(i)shallbemadeonacontingentbasisforcollectingoverpayments;and(ii)maybemadeinsuchamountsastheSecretarymayspecifyforidentifyingunderpayments;and

(C)theSecretaryshallretainaportionoftheamountsrecoveredwhichshallbeavailabletotheprogrammanagementaccountoftheCentersforMedicare&MedicaidServicesforpurposesofactivitiesconductedundertherecoveryauditprogramunderthissubsection.

...(4)Auditandrecoveryperiods.—Eachsuchcontractshallprovidethatauditandrecoveryactivitiesmaybeconductedduringafiscalyearwithrespecttopaymentsmadeunderthistitle—

(A)duringsuchfiscalyear;and(B)retrospectively(foraperiodofnotmorethan4fiscalyearspriortosuchfiscalyear).


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Section6411(b)ofthePatientProtectionandAffordableCareActof2010(PPACA)(P.L.111‐148),asamendedbytheHealthCareandEducationReconciliationActof2010(HCERA)(P.L111‐152),requiresexpansionoftheRACprogramtoMedicarePartCandPartD.CMSiscurrentlyexploringstrategiesforexpandingtheRACprogramtoMedicarePartC.ThepurposeofthisdraftScopeofWorkistosolicitcommenton,andinterestin,CMSenteringintoacontractwithaRACtoidentifyunderpaymentsandoverpaymentsandrecoupingoverpaymentsassociatedwithdiagnosisdatasubmittedtoCMSbyMedicareAdvantageOrganizations.CMScurrentlyconductsRiskAdjustmentDataValidation(RADV)auditstovalidatetheaccuracyofdiagnosisdatasubmittedtoCMSforpaymentbyMedicareAdvantageOrganizationsandtorecovernetoverpaymentsassociatedwithinaccuratediagnosisdata.ThisdraftSOWdescribesthePartCRAC’sroleintheexistingRADVauditprocess,referredtohereinastheComprehensiveRADVaudits,andtheirroleinadditionalauditsofdiagnosisdatasubmittedtoCMSbyMedicareAdvantage(MA)Organizations,referredtohereinasCondition‐SpecificRADVAudits.ErrorsandomissionsinthediagnosisdatasubmittedtoCMSbyMedicareAdvantageOrganizationsarethedriversofthe9.5%improperpaymentrateinMedicarePartC.Currently,CMSaudits30MedicareAdvantageOrganizationcontracts(approximately5%)perpaymentyear.CMSisconsideringcontractingwithaPartCRACtoincreasethenumberofMedicareAdvantageOrganizationcontractsthataresubjecttosometypeofRADVauditforeachpaymentyear.OurultimategoalistohaveallMAcontractssubjecttoeitheraComprehensiveorCondition‐SpecificRADVauditforeachpaymentyear.

II. RiskAdjustmentandRADVBackgroundA. RiskAdjustmentinMATheBalancedBudgetAct(BBA)of1997mandatedthatpaymentsmadetoMedicaremanagedcareorganizationsbeadjustedtoreflecttherelativehealthstatusoftheirenrollees.RiskadjustmentimprovestheaccuracyofMedicare’spaymentstoMAorganizationsandreducestheincentivesforplanstoriskselectonlythehealthiestbeneficiaries.Underriskadjustment,CMScalculatesariskscoreeachyearforeachMAenrollee.TheriskscorereflectsCMS’predictionofeachbeneficiary’slikelyrelativecostbasedontheirdemographiccharacteristicsandhealthconditions(e.g.,diabetes).CMSdeterminesthehealthconditionsforeachbeneficiaryusingdiagnosisinformationreportedtoCMSbytheirMAorganization.RiskscoresarecalculatedusingtheCMSHierarchicalConditionCategory(CMS‐HCC)riskadjustmentmodel.


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B. RiskAdjustmentinMA:DiagnosisDatasubmission

MAorganizationsarerequiredtosubmittoCMSdiagnosisinformation(i.e.,“riskadjustmentdata”)fortheirenrollees.AlldiagnosiscodessubmittedtoCMSforMedicareAdvantageriskadjustmentmustmeetanumberofrequirements.Theymust:

Bedocumentedinthemedicalrecord. Bedocumentedasaresultofaface‐to‐facevisit. Comefromacceptabledatasources(inpatient,outpatient,physician,‐seethe

MedicareManagedCareManual,Chapter7–RiskAdjustmentformoreinformation,whichmaybefoundathttps://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/Downloads/mc86c07.pdf).

Besubmittedatleastonceduringtheriskadjustmentdata‐reportingperiod. BecodedaccordingtotheICDClinicalModificationGuidelinesforCodingand

Reporting.Chronicconditionsmustmeetalloftheaboverequirementseachyearinordertobeacceptableforriskadjustment.

C. ComprehensiveRADVAuditsCMSconductsRADVauditsforthepurposeofensuringtheaccuracyandintegrityofriskadjustmentdataandconductingoverpaymentrecoveryfromMAorganizations.UnderComprehensiveRADVAudits,CMSselectsasubsetofMAplancontractstoauditforeachpaymentyearandselectsastatistically‐validsampleofenrolleesforeachauditedcontract.AuditedMAorganizationssubmitmedicalrecorddocumentationtoCMSforeachofthediagnosesthattheyreportedtoCMSforenrolleesintheauditsample.ThefocusofRADVisonreviewingtheplan‐submittedmedicalrecorddocumentationtoverifydiagnosessubmittedbyMAorganizationsforpayment.BeginningwiththeRADVauditsforpaymentyear2011,CMSusesthesampleresultstocalculateanextrapolatedoverpaymentestimateforeachauditedcontractandrecoversoverpaymentsbasedontheextrapolatedestimate.InApril2010,CMSpublishedthePolicyandTechnicalChangestotheMedicareAdvantageandtheMedicarePrescriptionDrugBenefitPrograms[CMS‐4085‐F],whichprovidedanadministrativeappealsprocessunderRADV.TheregulationallowsforanappealofmedicalrecordreviewfindingsandofthepaymenterrorestimatecalculationforRADVaudits.InJanuary2014,CMSpublishedthePolicyandTechnicalChangestotheMedicareAdvantageandtheMedicarePrescriptionDrugBenefitProgramsforContractYear2015[CMS‐4159‐P],whichfinalizedinregulationchangestotheadministrativeappealsprocessunderRADV.OnFebruary24,2012,CMSreleasedthe“NoticeofFinalPaymentErrorCalculationMethodologyforPartCMedicareAdvantageRiskAdjustmentDataValidationContract‐


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LevelAudits”.Thefinalmethodology,whichcanbefoundat:http://www.cms.gov/Plan‐Payment/02_PaymentValidation.asp,providesthesamplingmethodologyandpaymenterrorcalculationmethodologyfortheComprehensiveRADVAudits. TheCentralizedDataAbstractionTool(CDAT)istheCMSsystemthatsupportsthecollectionandprocessingofallRADVdataandmedicalrecords,medicalrecordreview,andRADVdatamanagement.AllcommunicationsthroughouttheRADVprocessbetweentheMAcontractandCMSareconductedviaCDAT.AlldocumentationrequestsareuploadedelectronicallyintoCDAT,includingcopiesofbothelectronicandpapermedicalrecords.Whenreferencedinthisstatementofwork,thewordCDATmeansthecurrentsystemasitexistsoranothersystemsupportingtheRADVauditsasspecifiedbyCMS.BecausethePartCRACwillbeusingCDAToranothersystemasspecifiedbyCMS,thePartCRACwillnotrequireitsownsystemwithanauthoritytooperate. D. KeyContractorsInvolvedintheRADVAuditProcessThereareseveralkeyCMSRADVcontractorsthatsupporttheRADVprocess:

LeadAnalyticContractorTheleadanalyticcontractorconductsthesamplingandpreparestheenrolleeandHCCleveldatathatiscommunicatedtotheMAcontractsthroughouttheRADVauditprocess.

SecondaryReviewContractorTheSecondaryReviewContractorprovidesacontrolinthemedicalrecordreviewprocess.Thiscontractorre‐reviewsthedocumentation,whereHCCsupportismissing,inordertovalidatetheinitialfindingsandtoconfirmthattheremaybeanoverpaymentproblem.

CentralizedDataAbstractionToolContractor.TheCDATcontractormanagesthesystemwhichfacilitatesallprojectcommunications,supportsthemedicalrecordreviewersinthecodingprocessandtracksreviewfindings.

III. RADVAuditTasks

WorkingindependentlyandnotasanagentoftheGovernment,thePartCRAC shallfurnishallthenecessaryservices,qualifiedpersonnel,material,equipment,andfacilities,nototherwiseprovidedbytheGovernment,neededtoperformtheSOW.Thisincludesallpersonalcomputers,printersandequipmenttoaccomplishtheworkdescribedintheSOWthroughoutthecontractperiodofperformance.CMSwillprovideminimumadministrativesupportwhichmayincludestandardsystemchangeswhenappropriate,helpcommunicatingwithcontractors,policiesinterpretationsasnecessaryandothersupportdeemednecessarybyCMStoallowthePartCRACtoperformitstasksefficiently.CMSwillsupportchangesitdeterminesarenecessarybutcannotguaranteetimeframesor


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constraints.ThePartCRACwillberequiredtoadapttochangesinRADVauditpolicy,operations,andCDAT(orothersystemasspecifiedbyCMS).ThePartCRACshallidentifybothsufficientpersonnelandappropriatelyskilledprofessionalpersonneltocompletethespecifictaskscontainedhereintobeconductedbythePartCRAC.Underallcircumstances,thePartCRACshallconformtoallrequirementsforconfidentialityofbeneficiaryandMAorganizationleveldata(paperandelectronic).TheCORwillapprovetheprojectplanaswellasallcorrespondenceandwrittendocumentation,includingreports,letters,andtrainingmanuals.AllwrittendocumentationandcommunicationshallbesubmittedtotheCORindraftform,inamannerallowingsufficienttimeforreviews,editsandapprovalsasdeterminedbytheCOR,andshallbeproducedinfinalformatthediscretionandapprovaloftheCOR.TheContractorshallconformtoallrequirementsforconfidentialityofbeneficiaryandMAorganizationleveldata(paperandelectronic).WithinthisSOW,referencesto“medicalrecord(s)”includesalldocumentsrequestedfromandsubmittedbyMAorganizationsforthepurposesoftheseRADVaudits,includingbutnotlimitedtomedicalrecords,CMS‐Generatedattestations,coversheetsandappealsdocumentation.ThePartCRACmayNOTattempttoidentifyanyunderpaymentsandoverpaymentsandrecoupoverpaymentsotherthanasdescribedinTask1orTask2.TASK1.COMPREHENSIVERADVAUDITSComprehensiveRADVauditsarecomprisedofthestepsdescribedbelow.Step1:Selectionforaudit/samplingStep2:IntakedocumentationreviewStep3:MedicalrecordreviewStep4:Paymenterrorcalculation,issuingauditreportsanddemandlettersStep5:Administrativeappealsprocess


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Thestepsaredescribedbelow,includingspecificPartCRACtasksfortheComprehensiveRADVAudits.ThePartCRACtasksarealsosummarizedinFigure1.PartCRACRolesinComprehensiveAuditProcess.

Step1:Selectionforaudit/sampling.CMSwillselectMAcontractstoauditforeachpaymentyear.Fortheselectedcontracts,theLeadAnalyticContractorwillapplytheComprehensiveRADVAuditsamplingmethodologytoselectastatistically‐validsampleofbeneficiaries.TheLeadAnalyticContractorwillprepareanauditpackageforeachMAcontractthatidentifiesbeneficiariesintheauditsampleandthediagnosessubmittedtoCMSbytheMAorganizationforthesebeneficiaries.ThispackageissenttotheMAcontractsviaCDATandservesasthedetailedmedicalrecordrequest.Step2:Intakedocumentationreview.MAorganizationsselectedforauditwillsubmitmedicalrecorddocumentationtoCDAT(orothersystemasspecifiedbyCMS)forbeneficiariesanddiagnosesintheauditsample.ThePartCRACwillreviewthemedicalrecorddocumentationtodeterminecompliancewithRADVAuditdocumentation

FIGURE 1: PART C RAC ROLES IN COMPREHENSIVE RADV AUDIT PROCESS

Step 2: Intake Documentation Review

Part C RAC reviews medical record documentation for validity. Only valid medical record documentation moves forward for medical record review.

Step 3: Medical Record Review

Part C RAC reviews valid medical record documentation to determine whether the diagnosis(es) submitted by the MA organization are present and whether additional payment diagnoses are supported. The Part C RAC conducts a complete code of the entire medical record.

Step 4: Payment Error Calculation, Issuing Audit Reports and Demand Letters

Part C RAC supports the payment error calculations.

Part C RAC prepares audit reports for each audited MA contract.

Part C RAC issues demand letters for MA organizations that elect not to appeal.

Step 5: Administrative Appeals Process

Part C RAC provides appeals support as necessary.

Part C RAC updates the audit reports and payment error estimates and issues demand letters to MA organizations, as applicable, at the conclusion of the first phase of appeal (Reconsideration).


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requirements,asspecifiedbyCMS(e.g.,therecordmustbefromtheappropriatetimeperiodandmustbeahospitalinpatient,hospitaloutpatientorphysicianrecord).Asacontrolmeasure,theSecondaryReviewContractorwillreviewandconfirmoroverturneachmedicalrecorddocumentationfindingdeterminedtobeinvalidbythePartCRAC.Onlyvalidmedicalrecorddocumentationmovesforwardformedicalrecordreview.Step3:Medicalrecordreview.IfthemedicalrecorddocumentationwasdeterminedvalidinStep2,thePartCRACwillreviewthemedicalrecorddocumentationtodeterminewhetherthedocumentationsupportsthediagnosessubmittedbytheMAorganizationforpaymentandwhetherthedocumentationsupportsadditionalpaymentdiagnosesnotsubmittedbytheMAorganization.ThePartCRACwillreviewthemedicalrecordsandabstractallICD‐9‐CM(InternationalClassificationofDiseases,NinthRevision,AndClinicalModification)codesorICD‐10‐CM(InternationalClassificationofDiseases,TenthRevision,AndClinicalModification)codes,asapplicable.Inotherwords,thePartCRACwillconductacompletecodeoftheentiremedicalrecord.ThePartCRACwillcodeinaccordancewithInternationalClassificationofDisease,NinthorTenthRevisionClinicalModificationguidelines(ICD‐9‐CMorICD‐10‐CM),asappropriate.CodersmustdemonstrateacceptablecodingaccuracyinordertoparticipateinthecodingprocessasdefinedbyCMSuponcommencementofaCMSaudit(seeSubtask1I.InternalQualityControlandInter‐RaterReliability).CMScontrolsthedevelopmentandupdatingofaCoderGuidancedocumentforComprehensiveRADVAudits.ThePartCRACshallworkwithCMSanditscontractorstoupdate,developand/ormaintainaCoderGuidancedocumentthatcodersmayreferencewhenreviewingmedicalrecordsforthepresenceofdiagnosiscodes.AsrequestedbyCMS,apanelofcodersshallconvenetoidentifyandclarifyambiguousICD‐9/10‐CMcodesandincorporatetheirrecommendationsintotheCoderGuidancedocument.ThePartCRACwillconductallmedicalrecordreviewsinCDAT(orothersystemasspecifiedbyCMS)unlessinstructedotherwisebyCMSinwriting.MedicalrecordswillbereleasedforPartCRACreviewviaCDAT(orothersystemasspecifiedbyCMS)onarollingbasisastheyarereceivedfromtheMAorganizations.ThePartCRACshallprovidesufficient,qualifiedcodingstafftopullamedicalrecordtaskfromCDAT(orothersystemasspecifiedbyCMS)within5businessdaysofthemedicalrecordenteringthePartCRAC’sCDATqueue;andcompletethereviewwithin14calendardaysofthemedicalrecordtaskenteringthePartCRAC’sCDATqueue.ThePartCRACmayrequestawaiverfromCMSifanextendedtimeframeisneededduetoextenuatingcircumstances.ThePartCRACwillinputdiagnosiscodessupportedbymedicalrecorddocumentationintoCDAT(orothersystemasspecifiedbyCMS)inaccordancewithCMS’policiesandprocedures.CDATwillmapthediagnosiscodesinputintoCDAT(orothersystemasspecifiedbyCMS)toCMS‐HCC(s).CMSmayrecallaPartCRACfindingfromeithertheintakedocumentationrevieworthemedicalrecordreviewstepatanytimeandforanyreason.


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ThenumberofmedicalrecordsreviewedbythePartCRACwillbedeterminedbyCMSbasedonavarietyoffactorsincluding:thenumberofauditedcontracts,thesamplingmethodology,andCMS’rulesregardingthenumberofrecordsthatmaybesubmittedbyanauditedMAorganizationforagivenCMS‐HCC.CMSreservestherighttofurtherlimitthetimeperiodand/ormedicalrecordsavailableforPartCRACreviewifCMSbelievesitisinthebestinterestoftheMedicareprogramtolimitreview.Thisnoticeshallbeinwriting,maybebyemail,andwillbeeffectiveimmediately.AfterthePartCRAChascompletedmedicalrecordreview,theSecondaryReviewContractorwillreviewthemedicalrecorddocumentationtodeterminewhetherthedocumentationsupportsthediagnosessubmittedbytheMAorganizationforpaymentandwhetherthedocumentationsupportsadditionalpaymentdiagnosesnotsubmittedbytheMAorganization.ThedeterminationoftheSecondaryReviewContractorwillstand(e.g.ifthePartCRACdeterminesanauditedCMS‐HCCisdiscrepantandtheSecondaryReviewContractorsubsequentlydeterminestheauditedCMS‐HCCisdiscrepant,theCMS‐HCCwillremaindiscrepant.IfthePartCRACdeterminesanauditedCMS‐HCCisdiscrepantandtheSecondaryReviewContractordeterminestheauditedCMS‐HCCispresentinthesubjectmedicalrecord,theSecondaryReviewContractor’sdeterminationwillstandandthefindingwillbereversedfrom“discrepant”to“confirmed”).MAorganizationsmayappealdiscrepantCMS‐HCCS,whichresultinapaymentrecovery,throughtheRADVadministrativeappealsprocess.Step4:Payment Error Calculation, Issuing Audit Reports and Demand Letters.TheLeadAnalyticContractorwillcalculatetheimpactofdiscrepantCMS‐HCCfindingsonthesampledenrolleeriskscoresandextrapolatethesefindingstotheMAcontractleveltoestimateacontractlevelpaymenterror.TheLeadAnalyticalContractorwillapplytheCMSmethodologytodeterminethesefindings.ThePartCRACwillsupportthepaymenterrorcalculationatCMSdirection.IftherearediscrepanciesbetweenthePartCRACandLeadAnalyticalContractors,theLeadAnalyticContractorwillreviewthePartCRAC’sworkunderthisstepandmakeafinaldeterminationtoCMS.ThePartCRACwillprepareAuditReportsforeachplancontractperCMSinstruction.MAorganizationswillthenhaveanopportunitytoappealthroughtheprocessknownasReconsideration,whichisthefirstphaseoftheRADVadministrativeappealsprocess.ForMAorganizationsthatelectnottoappeal,thePartCRACwillissuedemandlettersapprovedbyCMS.ThePartCRACwillupdatetheAuditReportandpaymenterrorestimatesandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration.Dependingonthenumberoftimesarecordisreviewed,theremaybeseveraltimesapaymenterroriscalculatedandtheresultscommunicatedtoMAorganizationsviaRADV


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AuditReports(aftertheinitialmedicalrecordreview,andasneeded,aftersubsequentphasesofappeals).Eachtimetheauditreportsareprepared,theLeadAnalyticContractorwillvalidatetheresults,priortothembeingreturnedtotheMAcontracts.Step5:Administrativeappealsprocess.SeeSubtask1L.Thefollowingaresubtasks,whichshouldbeconductedwithinthecontextofthegeneralRADVstepsdescribedabove.

Subtask1A.RADVAuditPlanningandImplementation:SecurityandTrackingPlan(associatedwithsteps1‐5)

ThePartCRACshallprovideandimplementawrittenSecurityandTrackingPlancoveringallaspectsofthiscontract.AdraftofthisdocumentshallbesubmittedtoCMSwithinthree(3)weeksofthecontractdateofaward.ThePartCRACshalledit,revise,and/oramendthedocumentaccordingtoCMSrequirements.TheSecurityandTrackingPlanshalldescribehowthePartCRACshallmaintainoversightofthephysicallocationofthemedicalrecords(ifapplicable)andshallutilizeCDAT(orothersystemasspecifiedbyCMS)totrackthemovementandlocationofthemedicalrecordsfilesandotherdocumentationthroughthevariousstagesoftheRADVprocess.TheproceduressetforthunderthissubtaskshallbeincollaborationwiththesystemrequirementsforCDAT(orothersystemasspecifiedbyCMS)asnecessary.Intheeventthatoff‐sitestorageofanymedicalrecordsorfilesrelatedtothiscontractisnecessary,thenthePartCRACshallobtainpriorapprovalfromCMSandabidebyallsecurityrequirementsfortransferringanyrecordsorfiles.Withinthisplan,thePartCRACshallproposeaplanformitigatingriskassociatedwithpotentialdatabreaches,andalsoforrecognizing,addressing,andreportingdatasecurityissuesastheyarise,accordingtoCMSrequirements.ThePartCRAC’sSecurityandTrackingPlanmaybeincorporatedintoCMS’SOP.

Subtask1B.DocumentationandMedicalRecord,Management,andDestruction(associatedwithsteps1‐5)

ThePartCRACshalldevelopandimplementaCMS‐approvedplanfordocumentationandmedicalrecordmanagementanddestruction.AdraftofthisdocumentshallbesubmittedtoCMSwithinthree(3)weeksofthecontractdateofaward.ThePartCRACshallstoreanddisposeofthemedicalrecordsinaccordancewithCMSguidelines(ifapplicable),andasinstructedbytheCORand/orGTL.ThePartCRACshallfurthersubmitconfirmation/documentationtotheCORensuringthatconfidentialrecordsarestoredasappropriateandinamannerthattheinformationcannotbecompromised.TherequirementsoftheCMS’DataUserAgreementshallbefollowedforalldatausedunderthiscontract.ThePartCRACshallretainandmanageallmedicalrecordsasspecifiedbyCMS.ThePartCRACshallworkwiththeCORand/orGTLtodeterminewhethertoretain,destroyorforwardmedicalrecordcopiestoanotherContractorand/orCMS.Management


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ofmedicalrecordsshallincludemakingcopiesofthemedicalrecordsasdirectedbytheCORand/orGTL.

Subtask1C.ProcessPlan:IntakeDocumentationandMedicalRecordReview(associatedwithsteps2and3)

ThePartCRACshallprepareandsubmitaProcessPlandocumentdescribingtheprotocolsforitsreviewofphysician,hospitalinpatientandhospitaloutpatientmedicalrecordsforthedatesofservicesprovidedbyCMS,inaformatacceptabletoCMS.ThisdocumentmaybeincorporatedintoCMS’SOP.Thedocumentshall:(1)builduponexistingRADVprocesses;(2)incorporateprotocolsforusingindustrystandardsforaccuratecodingpractices;and,(3)ataminimum,includeimplementationofthefollowingdetailsthatarespecificforRADVprojectprocesses:

1. Theprocessforreviewingthemedicalrecords.2. Allocationofmedicalrecordstocoderstoensuretimelycompletionofcodingbythe

PartCRAC.Includeaprocesstoescalatemedicalrecordswhenacoderhasquestionsaboutaparticularmedicalrecordandrequiresclarification.IncludeaprocesstosendmedicalrecordstotheQApanel.

3. QualitycontrolprotocolforachievingIRRaccordingtoaprotocoltobedeterminedbyCMS.

4. ApplicationofcodingguidelinesbasedonadateofserviceandprovidertypeindicatedbytheMAorganization.

5. Physicianreviewprotocoltobeincorporatedintotheoverallprocesses,utilizingphysiciansasnecessaryforconfirmingcorrectICD‐9/10assignments,overseeingrater‐to‐standardtestingtoimprovecodingdecisionsbasedonclinicalknowledge,addressingambiguityintheclinical,documentation,anddevelopingHCCreviewprotocolguidelines.PhysicianreviewersarenotrequiredtobeICD‐9/10coders;thesecliniciansadvisecodersoftheclinicalcontextsurroundingthediagnosis.

TheIntakeDocumentationandMedicalRecordReviewProcessPlanwillbesubmittedtoCMSforreviewandapproval.ThePartCRACwillmakeeditstothisprocessplanperdirectionfromCMSandwillimplementthefinalplan.Thisprocessplanmaybesubjecttochange,atthedirectionofCMS,overthecourseofconductingtheindicatedtasks.

Subtask1D.ProcessPlan:CollaborationandSupportforAppealsProcesses(associatedwithstep5)

ThePartCRACshallprepareandsubmitaProcessPlandocumentdescribingtheprotocolsforservicesprovidedbythePartCRACundertheCollaborationandSupportforAppealsProcessestaskinaformatacceptabletoCMS.ThisdocumentmaybeincorporatedintoCMS’SOP.


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TheCollaborationandSupportforAppealsProcessesPlanwillbesubmittedtoCMSforreviewandapproval.ThePartCRACwillmakeeditstothisprocessplanperdirectionfromCMSandwillimplementthefinalplan.Thisprocessplanmaybesubjecttochange,atthedirectionofCMS,overthecourseofconductingtheindicatedtasks.

Subtask1E.CDATTraining(orothersystemasspecifiedbyCMS)(associatedwithsteps2‐5)

ThePartCRACshallattendalltrainingsonCDAT(orothersystemasspecifiedbyCMS)asdirectedbyCMS.ThetrainingsshallbescheduledondatesandatlocationstobedeterminedbyCMS.CDATtrainingsaretypicallyconductedpriortothesubmissionperiodforMAorganizationsandpriortoperiodofcodingbymedicalrecordreviewers.ThePartCRACshallfollowprotocolsforutilizingCDAT(orothersystemasspecifiedbyCMS)forthepurposesofitsreviews.ThePartCRACshallalsoincorporatetheapplicableCDAT(orothersystemasspecifiedbyCMS)trainingsectionsintoitsmedicalrecordreviewstafftraining.

Subtask1F.MedicalRecordReviewStaffTraining(associatedwithsteps2,3,and5)

ThePartCRACshallpreparetrainingmaterialsandconductin‐persontrainingatthePartCRAC’ssiteforthePartCRAC’steamofmedicalrecordreviewersandallappropriatestaffthatwillcontributetotheRADVaudit(s),inaccordancewithCMS’policiesandprocedures.ThePartCRACshallutilizeinformationgainedfromtheProcessPlan:ReviewforCMS‐HCCsunderTask2Casthebasisforthetrainingstrategy,andimplementthefinaltrainingprotocolapprovedbytheCORand/orGTL.ThePartCRACshallprovidetheCORand/orGTLwiththedraftwrittentrainingstrategy.UponapprovalfromtheCORand/orGTL,thePartCRACshallsubmitafinaltrainingCMS‐approvedtrainingplan.ThedraftshallbesubmittedtotheCORand/orGTLatleastone(1)weekinadvanceofeachtraining.OngoingtrainingshallbeprovidedforthePartCRAC’sstaffasneeded,andinitialtrainingshallbeprovidedforallcodersbeforetheybeginworkontheRADVaudit(s).Topromoteconsistencyintrainingmedicalrecordreviewstaff,thePartCRACshallplanaccordinglytoincludeCMSstaffandstafffromtheSecondaryReviewContractor,IndependentCodingConsultant,LACand/orCDATContractoratitstraining(s).ThetrainingstrategyandmaterialsmaybeincorporatedintoCMS’SOP.ItisexpectedthattherewouldbeatleastonetrainingsessionperMAorganizationsubmissionwindow,withthepossibilityof1‐3additionaltrainingspersubmissionwindowifinter‐raterreliabilityamongmedicalrecordreviewersisincorrect,attherequestofmedicalrecordreviewers,and/oratthediscretionofCMS.

Subtask1G.AttendRiskAdjustmentDataValidationContractorTraining(associatedwithsteps2,3,and5)

CMSwillorganizeaninitialtrainingforallcontractorsparticipatingintheRADVaudit.ThistrainingistypicallyconductedpriortothesubmissionperiodforMAorganizationsandpriortotheperiodofcodingbymedicalrecordreviewers.CMSmayorganize


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additionaltrainingsandmeetingsonanadhocbasistoprovideadditionalinformationandguidancetothePartCRAC.ThePartCRACshallattendtheinitialtrainingandanyadditionaltrainingsandmeetings,nottoexceedtwoperauditandasdirectedbyCMS.

Subtask1H.AttendandContributetoTechnicalDataandOperationsMeetings(associatedwithsteps2,3,and5)

AtCMSrequest,thePartCRACshallattend,assistwithdevelopingagendaanddiscussiondocuments,andcontributetotechnicalanddataoperationsmeetingsthatwillbeconductedbytheCDATContractor.Thesemeetingswillbeconductedprimarilybyteleconference,withnomorethansixin‐persontechnicaldataandoperationsmeetingsperyear.Thesemeetingswillprovideaforumtodiscussandplanfordataandoperationalrequirements,stafftrainingsformedicalrecordreview,useofCDAT(orothersystemasspecifiedbyCMS),andtheoverallprojectmanagement.Themeetingagendasshallincludeproposeddatarequirements,medicalrecordreviewguidance,qualityassuranceplansandprojectplanningfeedbackfromthemedicalrecordreviewcontractors.ThePartCRACshallsubmitwrittenproposeddraftagendaanddiscussiontopicstotheCORand/orGTLinadvanceofthesemeetings.UponapprovalfromtheCORand/orGTL,thePartCRACshallfinalizetheinformationandsubmitfinalapprovedinformationtobeinsertedintothemeetingagendabytheCDATContractor.ThePartCRACshallprovidewrittenfeedbacktotheCORand/orGTLontheproposeddataandoperationalplansandrequirementswithintwo(2)businessdaysfollowingmeetingsand/orreceiptofproposalsfromotherRADVparticipants.Thefeedbackshall,ataminimum,identifyissuesandconcernsfromthePartCRACregardingimplementationplansand,asnecessary,recommendationsforalternativeimplementationplans.

Subtask1I.InternalQualityControlandInter‐RaterReliability(associatedwithsteps2,3,and5)

ThePartCRACwillimplementqualityassurancemonitoringoftheintakeprocessandwillimmediatelyreportaberrantfindingstoCMS.ThePartCRACwillmakechangestotheintakeprocesstocorrectinaccurateintakedeterminationsperdirectionfromCMS.UponCMSdirection,andaccordingtoaprotocolestablishedbyCMS,thePartCRACshallimplementaninitialinter‐raterreliability(IRR)evaluationofeachcoderbeforethecoderbeginscodingoflivemedicalrecordsandshallcheckcodingconsistencyonanongoingbasisthroughoutthereviewprocess.CMSexpectsanIRRof95%orhigher,whichmeansthateachcoder’sresultsareinagreementwithanothercoder’sresults95%ofthetime.IfacoderfailstomeetCMS’IRRstandards,CMSmaylimitthecoder’sroleorremovethecoderfromthereviewprocessentirely.ThePartCRACshallcontinuetomonitorIRRofallcodersandprovideappropriateremediationordismissal.CMSmayrequestthePartCRACtoprepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreportsforcodersandphysicianreview.ThePartCRACshallsubmitthesereportstotheCORand/orGTLuponCMS’request.ThePartCRACmaybedirected


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bytheCORand/orGTLtoreviseitsinputdataasnecessary,basedonmeetingoutcomes.ThePartCRACshallprovideadetailedjustificationandimplementanyfollow‐upactionasrequiredtoachievetheappropriateoutcomes.ThePartCRACshallbepreparedtodiscusswiththeCORand/orGTLandotherRADVcontractorsalldatafindingspertainingtoreviewandIRRoutcomes.CMSconductsataminimumanannualreviewofContractoractivities.IfCMShasevidencetobelieveaContractorisnotaccuratelyreviewingintakedocumentationormedicalrecords,orisnotreviewingtheminaccordancewithCMSinstructionorestablishedprotocols,CMSwillissueawarninginwritingtothePartCRAC.Italsoshallincludethedocumentationcitationsthatsupporttheconclusions,andaCMSallottedtimeframeforContractorcorrection.Iftheissuecontinues,CMSwillconsiderrecallingsuchreviewsfromthePartCRAC,andmaydirectthereviewofthemedicalrecordstoanotherCMScontractor.

Subtask1J.PaymentErrorCalculation,IssuingAuditReportsandDemandLetters(associatedwithstep4)

TheLACwilldetermineenrolleeandcontractlevelfindings.ThePartCRACwillpreparedraftAuditReportsforeachauditedcontractfollowingtheCMSprotocol.ThePartCRACwillsubmitthedraftAuditReportstoCMSanduponCMSapprovalwillcoordinatethereleaseofthefinalizedreportsviaCDATorothersystemspecifiedbyCMS.ForMAorganizationsthatelectnottoappeal,thePartCRACwillissuedemandlettersperCMSinstruction.ThePartCRACwillpreparedraftlettersforeachauditedMAcontractwithnetoverpayments.UponCMSapproval,thePartCRACwillissuetheletters.ThePartCRACwillupdatetheAuditReportwithrevisedpaymenterrorestimatesandissuedemandletterstoauditedMAorganizations,asapplicablethroughouttheappealprocess.Foreachiteration,thePartCRACwillprepareadraftreportand/ordraftdemandletterforCMSapprovalanduponapprovalwillissuethefinalizedreportsand/ordemandletters.TheamountsidentifiedinthedemandletterswillberecoveredfromMAorganizationsthroughroutineCMSpaymentprocesses. AttheconclusionoftheReconsiderationphaseoftheadministrativeappealsprocess,CMSwillpayPartCRAC’scontingencyfeeaccordingtocontractualterms.ThePartCRACwillprepareaHIPAAcompliantand508compliantversionofeachAuditReport,suitableforpostingtoCDATorothersystemspecifiedbyCMS.ThePartCRACshallnothaveanyauthoritytoreduce,compromise,and/orsettleanyidentifiedorpossibleoverpaymentsorunderpayments.

Subtask1K.Documentation(associatedwithsteps2through5)


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Inadditiontothedocumentationrequirementsdescribedelsewhere,thePartCRACwillbesubjecttoanumberofdocumentationrequirementsperCMSdirection.Theyinclude:

ThePartCRACshallclearlydocumentinCDAT(orothersystemasspecifiedby

CMS)therationaleforitsunderpaymentandoverpaymentdeterminations.ThisrationaleshalllistthereviewfindingsincludingadetaileddescriptionofanyidentifiedICD‐9/10‐CMcodes.ThePartCRACshallensureitisidentifyingpertinentfactscontainedinthemedicalrecordtosupportitsreviewdeterminations.Eachrationaleshallbespecifictotheindividualmedicalrecordreviewed.ThedeterminationofanoverpaymentoranunderpaymentwillbebasedonthedefinitionsandcriteriaspecifiedbyCMS.

Overpayments&UnderpaymentsReport:ThePartCRAC,onamonthlybasis,shall

providetheCORand/orGTLwithdetailedinformationconcerningoverpaymentsandunderpaymentsthathavebeenidentified.ThePartCRACshallhavesupportingdocumentationforalllineitemsonthereport.Thisreportshallbeduenolaterthanthefifth(5th)businessdayofthefollowingmonth.Task3specifiesadditionalinformationrequiredinthemonthlyprogressreports.

StandardOperatingProcedures(SOP)ContributionandImplementation:RADV

ContractorandStaffTraining.ThePartCRACshallprepareandsubmitadraftwrittenplanfortrainingofPartCRACstaff.ThisdocumentmaybeincorporatedintoCMS’SOP.

ContributiontoOverallComprehensiveRADVStandardOperatingPlan(SOP):The

PartCRACshallcollaboratewithCMStocontributetoanoverallcomprehensiveRADVStandardOperatingPlan(SOP).UponCMSrequest,thePartCRACshallsubmitadraftofSOPcontributionstotheCORand/orGTLforcommentandrevision.Itshallbecomprisedofachronologyanddocumentationofplansforactivitiesdescribedinthiscontract,atCMS’discretion,andshallincludeanyotherrelevantinformationandappendices.ThePartCRACshallmakespecifiedchangesandsubmitfinalSOPcontributionsfortheCOR’sand/orGTL’sapproval.ThePartCRACshallsubmitthefinalizedelementsofitsSOPcontributionstoCMS.

Subtask1L.Appeals(associatedwithsteps5)

MAorganizationsmayappealthemedicalrecordreviewdeterminationsand/orthepaymenterrorcalculation.Per§422.311,theRADVauditappealsprocessbeginsattheMAorganization’selectionforReconsideration,inwhichCMSreviewsthemedicalrecordandpaymenterrorcalculationagain.TheReconsiderationresultscanbeappealedtotheOfficeofHearings,whichcanfinallybeappealedtotheCMSAdministrator,whosedecisionisfinal.


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IfanMAorganizationchoosestoappealthemedicalrecordreviewdeterminationsand/orthepaymenterrorcalculation,thePartCRACshallassistCMSwithsupportofthedeterminationthroughouttheapplicableadministrativeappealsprocessand,whereapplicable,anappealtotheappropriateFederalcourt.Specifically,thePartCRACshallprovideRADVappealssupporttoCMSanditsdesignatedcontractorsbyprovidingrelevantinformationuponrequestbytheCORand/orGTL.Thisincludesprovidingsupportingdocumentation(includingthemedicalrecord)withappropriatereferencetoMedicarestatutes,regulations,manualsandinstructions,providingassistance,andsupportingCMSatanyhearingsassociatedwiththedetermination,whenrequestedbyCMS.ThePartCRACshallprovidewrittendocumentationtoclarifyandexplainspecificprotocolsandprocessesthatwereimplemented,andjustificationsfordifferentmedicalrecordreviewfindingsanddecisions,whenrequestedbyCMS.Forexample,thismayincludeprovidingmedicalrecorddocumentationforasampledbeneficiary,ortheactualmedicalrecordreviewedbythePartCRACandcodingopinions.UpondirectionbytheCORand/orGTL,thePartCRACshallprovidetherequesteddocumentationandsupportincludingparticipatinginconferences,hearingsandlitigationrelatedtoRADVmedicalrecordrequest,intake,andreview,andproviderelevantinformationuponCMS’request.ThePartCRACshallhaveanappealoverturnrateoflessthan10%atthefirstlevelofappealofReconsideration.CMSexpectsthePartCRACtofullycooperateinprovidingappealssupport,whichshallcomplywith42C.F.R.§422.311andCMS’protocol.Additionally,thePartCRACshallprovidesupport,asneeded,fordisputesoutsideoftheformaladministrativeappealsprocess.

Subtask1M.CollaborationwithCMSRADVContractors(associatedwithsteps2through5)

ThePartCRACshallcollaborateandcoordinatewithotherCMSRADVcontractors.Thesecontractorsinclude,butarenotlimitedto,theSecondaryReviewContractor,theLeadAnalyticContractor(LAC)andtheCDATcontractor.ThePartCRACwillparticipateinmeetingswithotherRADVcontractorsandwillcollaboratewiththemtoensureaccurateandtimelyintakeandmedicalrecordreviewfindings. TASK2.CONDITIONSPECIFICRADVAUDITSConditionSpecificRADVAuditswillbeconductedforasubsetofMAcontractsnotsubjecttoaComprehensiveAuditforanygivenpaymentyear.ThefocusofConditionSpecificAuditswillbeaset(s)ofHCCsdeterminedtohaveahigherprobabilityofbeingerroneous,forexample,itmaybedecidedthatthehierarchyofHCCsrelatingto‘diabetes’shouldbethesubjectofthistargetedreview.Itmayfurtherbedecidedthatcertainplanshavecharacteristicswhichsuggesttheyaremorelikelytohavediabetescodingdiscrepancies.UnderthisConditionSpecificAuditprotocol,thissubsetofidentifiedplanswouldbesubjecttoatargetedmedicalrecordreviewofdiabetes.


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Thesamplingand,ifapplicable,paymenterrorextrapolationmethodologyforeachConditionSpecificAuditwillbedevelopedbytheLeadAnalyticContractorandmustbeapprovedbyCMS.ThismethodologywillthenbegiventothePartCRACforusetocompletethebelowsubtask.ThePartCRAC’sresponsibilitiesforthistaskarethesameasthoseidentifiedunderTask1,exceptthatStep1underTask1wouldbereplacedbythefollowing:

Step1forCondition‐specificRADVAudit:SelectionofHCCsandMAContractsforAudit.ThePartCRACwillproposecriteriatoidentifydiagnosesand/orconditionsthataremorelikelytobesubjecttoriskadjustedpaymenterrorbecausetheyarenotsupportedbymedicalrecorddocumentation.ThePartCRACwillproposethesecriteria,alongwithsupportanddrawbacks,toCMSforconsideration.ThePartCRACwillalsoprovidetheMAcontractsthatwouldbeselectedifsuchcriteriawereapplied.Underthiscontract,thePartCRACmayseekaccesstoRAPSdataand/orencounterdatatoassistintargetingMAcontractsandspecificHCCs.UponapprovalbyCMS,thePartCRACmayproceedwiththeauditfortheselectedMAcontractsandconditions.ThescopeandnumberofConditionSpecificAuditswillbedeterminedbyCMS.Asaresult,thereisnoguaranteeforthePartCRACofaminimumvolumeofConditionSpecificAudits.

TASK3.MEETINGREQUIREMENTS

Subtask3A.InitialMeetingwithCMSCOR,GTLandCMSStaffProjectPlan‐ThePartCRAC'skeyprojectstaff(includingoverallProjectDirectorandkeysubProjectDirectors)shallmeetinBaltimore,MarylandwiththeCOR,GTL,andappropriateCMSstaffwithintwo(2)weeksofthedateofaward(DOA)todiscusstheprojectplan.Thespecificfocuswillbetodiscussthetimeframesforthetasksoutlinedbelow.ThePartCRACshallprovidetheCORand/orGTLwithminutesfromthemeetingnomorethanforty‐eight(48)hoursafterthecompletionofthemeeting,inaformacceptabletotheCORand/orGTL.Withintwo(2)weeksofthismeeting,thePartCRACshallsubmitaformalprojectplanoutliningtheresourcesandtimeframeforcompletingtheworkoutlined.Theinitialprojectplanwillbeforthebaseperiodofthecontract.ItisthePartCRAC’sresponsibilitytoupdatetheprojectplanasnewissuesariseornewtasksareperformed.TheinitialprojectplanandanysubsequentupdatesshallbeapprovedbyCMSpriortoimplementation.Theprojectplanshallincludethefollowing:ContractorOrganizationalChart–TheorganizationalchartshallidentifythenumberofkeypersonnelandtheorganizationalstructureofthePartCRAC.Adetailedorganizationalchartextendingpastthekeypersonnelshallbesubmittedwithintwo(2)weeksoftheinitialmeeting.ThePartCRACshallinformCMSofanychangestothePartCRAC’s


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organizationalchartwithinseven(7)businessdaysofthePartCRAC’sknowledgeofthechange.

Subtask3B.ConferenceCalls

1.OnaweeklybasisthePartCRAC’skeyprojectstaffshallparticipateinaconferencecall

withCMStodiscusstheprogressofthework,evaluateanyproblems,anddiscussplansforimmediatenextstepsoftheproject.ThePartCRACshallberesponsibleforsettinguptheconferencecalls,preparinganagenda,documentingtheminutesofthemeetingandpreparinganyothersupportingmaterialsasneeded.DraftagendasshallbefurnishedtotheCORand/orGTLatleasttwenty‐four(24)hoursinadvanceofthemeeting.Draftsofmeetingminutesshallbefurnishedwithinforty‐eight(48)hoursofthemeetingtotheCORand/orGTL.

2.OnamonthlybasisthePartCRAC’skeyprojectstaffshallparticipateinaconference

callwithCMStodiscussfindingsandprocessimprovementsthatwillbenefitCMSinRADVauditsinthefuture.ThePartCRACwillberesponsibleforsettinguptheconferencecalls,preparinganagenda,documentingtheminutesofthemeetingandpreparinganyothersupportingmaterialsasneeded.Iftimeallowsduringtheweeklycalls,thisitemmayalsobefulfilledduringoneofthescheduledweeklycalls.

AtCMS’discretionconferencecallsmayberequiredtobecompletedmorefrequently.Also,otherconferencecallsmayberequiredtodiscussindividualitemsand/orissues.TASK4.ADMINISTRATIVEANDMISCELLANEOUSISSUESThePartCRACshallreportpotentialqualityissuesimmediatelytotheCORand/orGTL.

Subtask4A.MonthlyProgressReports1. ThePartCRACshallsubmitmonthlyadministrativedetailedprogressreportsoutlining

allworkaccomplishedduringthepreviousmonth,exceptinthecaseofTask2forwhichweeklydetailedprogressreportsshallbesubmitted.Thesereportsshallincludethefollowing:

b. Reviewaccomplishmentstodate,remainingactivitiestobecompletedand

thestatusoftheprojectcomparedwithitsschedule;c. Discussproblemsencounteredorthatareanticipatedandtheirimpacton

thescheduleoftheproject,orifsevereenough,ontheoverallabilitytoaccomplishtheprojectgoals;

d. IncludethePartCRAC’splanstodealwithanyidentifiedsignificantproblemandifappropriate,newdeliveryorcompletiondatesshallbeproposed;

e. Includeabriefdiscussionofsubstantivefindingstodate;f. Issuesthathavearisenandanyanomaliesrelatedtoanytask;g. Updateofitemsbeingreviewedinthenextweekormonth;


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h. Updateofprojectplan;i. Recommendedcorrectiveactionsforvulnerabilities;j. Updateonhowvulnerabilityissueswereidentified;k. UpdateonJOAs;l. ActionItems

ThePartCRACshallincorporateanyfinalrevisionsasdirectedbytheCORand/orGTLanduponapproval,shallsubmittheMonthlyProgressReporttotheCORand/orGTLinelectronicformwithin10daysofmonthend.

2. ThePartCRACshallsubmitmonthlyfinancialreportsoutliningallworkaccomplished

duringthepreviousmonth.Thereportshallbebrokendownintothefollowingcategories:

a. Overpaymentsidentified(insummaryanddetail)–Thisreportincludes

reviewswherethePartCRACbelievesanoverpaymentexists,buttheamounthasnotyetbeendemandedbyCMS.

b. Underpaymentsidentified(insummaryanddetail)–ThisreportincludesreviewswherethePartCRACbelievesanunderpaymentexists,buttheamounthasnotyetbeendemandedbyCMS.

c. OverpaymentsAdjusted‐AmountsshallbeincludedonthisreportifthePartCRAC’soverpaymentdeterminationhasbeenreversed(decidedintheMAorganization’sfavor)(insummaryanddetail).

d. NumberofreviewsperformedbythePartCRAC(insummaryanddetail).e. Numberofreviewscompletedwithinthe5businessdaytimeframe(in

summaryanddetail).f. Numberofreviewsthatfailedtobecompletedwithinthe5businessday

timeframeandtherationaleforfailuretocompletethereviewstimely.Allreportsshallbeinsummaryformatwithallapplicablesupportingdocumentation.AtCMSdiscretion,astandardizedmonthlyreport(s)mayberequired.Ifastandardizedmonthlyreportisrequired,CMSwillprovidetheformat.Unlessalternativearrangementsareapproved,eachmonthlyreportshallbesubmittedbythecloseofbusinessonthefifthbusinessdayfollowingtheendofthemonth.Themonthlyreportshallbesentviae‐mailtotheCORandtheContractingOfficer.

Subtask4B.SeparateReportingThereportinganddatacollection/analysisforeachofthemajortasksunderthiscontractshallbekeptseparateandsubmittedintheappropriateformatperthestatementofwork.

Subtask4C.CentralizedDataAbstractionTool(CDAT)&DataAccessibility


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ThePartCRACmustfollowCMSinstructiontoobtainandmaintainaccesstotheCentralizedDataAbstractionTool(CDAT)(orothersystemasspecifiedbyCMS).CDATisawebbasedapplicationwhichthePartCRACshallberequiredtousewhenperformingallreviewsforauditedCMS‐HCCsintheMARADVaudits.ForaccessingCDAT,thePartCRACmustbeabletobeflexibleinmanagingstaffschedules,includingconductingmedicalrecordreviewactivitiesduringnon‐businesshours.ThePartCRACshallberesponsibleforhavingtheappropriateequipmentsuchascomputersconfigurabletoaccessCDATwithphoneat‐handtocompletethemulti‐factorauthentication.AllreviewsconductedbythePartCRACshallbeperformedinCDATunlessinstructedotherwisebyCMSinwriting.ThePartCRACshallberesponsibleforallcostsassociatedwiththestorageandprocessing,andprotectionofanydatanecessarytoaccomplishtheworkassociatedwiththiscontract.

Subtask4D.CMSWorkgroupMeetingsThePartCRACshallparticipateinin‐personWorkgroupmeetingswithCMSstaffandotherRADVcontractors.Uptotwelve(12)suchmeetingsmaybescheduledoverthecourseofthecontract.AtthedirectionoftheCORand/orGTL,thePartCRACshalldraft,revise,andproduceagendas,trainingmaterialsandpost‐sessionreportsforallsuchmeetings.ThePartCRACshallalsoparticipateonweeklyscheduleRADVOperationscallswiththeSecondaryReviewContractorand/orotherRADVcontractors.AtthedirectionoftheCORand/orGTL,thePartCRACshalldraft,revise,andproduceagendas,discussionmaterialsandpost‐sessionreportsforallsuchmeetings.

Subtask4E.AdHocMeetingsThePartCRACshallalsobeavailableuptoseven(7)timesperyearfornon‐trivialconsultationwithCMS,itscontractors,and/orselectedMAorganizations.ThismayincludesitevisitstothePartCRAC’slocation.Thesecallsandmeetingsmaybeusedasamechanismfordiscussingandmanagingissuesastheyarise.Non‐trivialconsultationsshallbethosewhichdonotrelatetoongoingoperationsandwhichareexpectedtorequiremorethan20butlessthan60man‐hourstocomplete.

Subtask4F.CorrectiveActionAssociatedwithEvaluationCMSwillperformanevaluationofthePartCRAC.Advancenoticemayormaynotbegiven.TheRACsmustagreetoviewtheevaluationcontractorasarepresentativeofCMSandtoagreenottorequirethattheevaluationcontractorsignanyseparateagreementwiththeRACasaconditionforhavingaccesstothefacilities,dataandemployeesnecessarytoundertakethenecessaryreviews.AnyfindingfromthereviewwillrequirethePartCRACtosubmitacorrectiveactionplantoCMSatthedirectionoftheCORand/orGTL.

Subtask4G.RecalledAuditsCMSmaydeterminethatitisinthebestinterestoftheMARADVRACProgramtoceaseworkincertainareas.CMSmayrecallanauditfromthePartCRACatanytimeandforany


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reason.ShouldCMSinitiatearecall,thePartCRACshallimmediatelystopallactivitiesincludedintherecall.Recallscouldoccurbecauseofadditionalactivitythatisoccurringbyanothercontractor/entityorlackofadherencebythePartCRACofanyprovisionofthiscontractorforsomeotherreason.Recallsareindefiniteandmayrequireacorrectiveactionplantoresumeactivity.RecallscanbeMAorganization,MAcontract,audit,medicalrecord,CoversheetID,auditedCMS‐HCC,orenrolleespecific.UnlessinstructedbyCMSthroughtechnicaldirection,workpreviouslyissuedwillcontinuewithacontingencyfeemodifiedfortherecall,asappropriate.

Subtask4H.CommunicationwithOtherCMSContractorsJointOperatingAgreement:ThePartCRACshallberequiredtocompleteaJointOperatingAgreement(JOA)withallapplicableCMScontractors(asinstructedbyCMS).TheJOAshallencompassallcommunicationbetweenthecontractors.TheJOAshallbeamutuallyagreedtodocumentthatisreviewedquarterlyandupdatedasneeded.TheJOAshallprescribe:1)agreeduponservicelevelsand2)notificationandescalationmechanismswithCMSinvolvement.CMShasthefollowingexpectationswithregardtotheCDATContractor,LeadAnalyticContractor,SecondaryReviewContractor,andPartCRAC:contractorrelationships:

TheCDATContractor,LeadAnalyticContractor,SecondaryReviewContractorsarecontractorsofCMSanddonottakedirectionfromthePartCRAC.

TheCORandGTLforthePartCRACshallbeapartytoanyandallcommunicationissuesbetweenthePartCRACandotherRADVcontractors.

Subtask4I.SupportOIGorOtherAudits

ShouldtheOIG,CMSoraCMSauthorizedcontractorchoosetoconductanauditofthePartCRAC,thePartCRACshallprovideworkspaceandproduceallneededreportsandinformationwithinone(1)businessdayoftherequest,unlessotherwisedetermined.

Subtask4J.AnnualReportsandFinalReportTheannualreportshallincludeasynopsisofactivitiesforagivenaudityearcoveringallprojectsunderthiscontract.Thisincludesadraftannualreportidentifyingalloverpaymentsandunderpaymentsidentified.Itshallincludeabrieflistingoftheidentificationmethodsandtheirsuccessorfailure.ThePartCRACshallincludeanyfeedbackandrecommendationsfortheRACprogram,aswellasanyadvantagesordisadvantagesencountered.Fromacontractorpointofview,thedraftfinalreportshalldetermineifthecontractwasasuccessorafailureandprovidesupportforeitheropinion.


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ThedraftannualreportshallbedeliveredtotheCORandGTLinelectronicformatasonefileinPortableDocumentFormat(PDF),withoneclearly‐markedsectioncontaininga200‐wordabstract/summaryofthefinalreportsuitableforsubmissiontotheNationalTechnicalInformationService.ThedraftannualreportshallbeprovidedtoCMSapproximatelyfour(4)weekspriortofinaldeliverableduedatesunlessotherwiseagreedto.CMSstaffwillreviewthematerialsandprovidecommentsbacktothePartCRAC.ThePartCRACwillmakeallCMSrevisionsandresubmittoCMSforreview.ThedocumentwillbefinalizedatCMSdirection.

Subtask4K.ReturnofMaterialsPartCRACshallreturntoCMSallinformationrelatedtothisSOWinaccordancewithCMSinstructions.Alldatafiles,software,programs,computertapes,interimandfinalfiles,andfiledocumentationcreatedunderthiscontractshallbethesolepropertyofCMS.ThePartCRACshallprovidealloriginalsandcopiestoCMSuponrequestintheappropriateformat.TheyshallnotbeusedforanyotherpurposeotherthanfulfillingthetermsofthiscontractwithouttheexpresspermissionoftheCMSContractingOfficer.AllcasefilesshallmeettherequirementsassetbyOMBCircularA‐130,whichcanbefoundathttp://www.whitehouse.gov/omb/circulars/a130/a130trans4.html.

Subtask4L.Transitions:OutgoingContractorstoIncomingContractorsFromtimetotimeintheMARADVRACprogram,transitionsfromonecontractor/stoanothercontractor/swillneedtooccur(e.g.,whentheoutgoingcontractor/sceasesworkandanewincomingcontractor/sbeginswork).Itisinthebestinterestofallpartiesthatthesetransitionsoccursmoothly.Thetransitionplanshallincludespecificdateswithregardtoeachtaskofthecontract.ThetransitionplanshallbecommunicatedtoallaffectedpartiesbyCMSwithinsixty(60)daysofitsenactment.TheimpacttotheMARADVRACprogramwillbedeterminedwithinsixty(60)daysoftheannouncementoftheupcomingtransition.EachimpactedcontractorwillberequiredtosubmitatransitionplantoCMSforapproval.

IV. ScheduleofDeliverablesThePartCRACshallprovidethenecessarypersonnel,materials,equipment,support,andsuppliestoaccomplishthetasksshownbelowinthespecifiedtime.ThePartCRACshallcompletetheevaluationandreporttoCMSitsfindings.AllworkdoneunderthiscontractshallbeperformedunderthegeneralguidanceoftheSOWsubjecttotheCOR’sapproval.Writtendocumentsforthisprojectshallbedeliveredelectronicallyviasecuree‐mailunlessotherwisespecified.Atpresent,theCMSstandardisMicrosoftWord2010andMicrosoftExcel2010.Thisissubjecttochange,andthePartCRACshallbepreparedtosubmit


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deliverablesinanynewCMSstandard.AlldeliverablesshallmeetallRehabilitationAct,Section508AccessibilityStandards.

BasePeriod:TBD

TaskNumber

DeliverableNumber Deliverable

DueDate(DOA=DateofContractAward)

11

Update,developand/ormaintainCoderGuidancedocument TBD

12

PrepareAuditReportsforeachplancontract TBD

13

IssueDemandLettersforMAorganizationsthatelectnottoappeal TBD

1

4

UpdateAuditReportsandissuedemandletterstoauditedMAorganizations,asapplicable,attheconclusionofReconsideration

TBD

1A 5 SecurityandTrackingPlan TBD

1B6

Planfordocumentationandmedicalrecordmanagementanddestruction TBD

1C7

IntakeDocumentationandMedicalRecordReviewProcessPlan TBD

1D8

CollaborationandSupportforAppealsProcessesPlan TBD

1F9

MedicalRecordReviewStaffTrainingPlan&Materials

TBD

1H10

AgendaanddiscussiontopicsforTechnicalDataandOperationsMeetings TBD

1H11

Writtenfeedbackonproposeddataandoperationalplansandrequirements TBD

1I12

Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports TBD

1J13 PrepareAuditReports TBD

1J 14 DraftDemandLetters TBD

1J

15

UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess

TBD

1K16

Documentrationaleforunderpaymentandoverpaymentdeterminations

TBD

1K17 Overpayments&UnderpaymentsReport TBD

1K 18 WrittenplanforContractorstafftraining TBD1K ContributionstoRADVStandardOperating TBD


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19 Plan(SOP)

1L20

Providesupportingdocumentationandwrittendocumentationforappealssupport

TBD

221

ProposecriteriaforConditionSpecificRADVAudits TBD

222


223

PrepareAuditReportsforeachplancontract TBD

224

IssueDemandLettersforMAorganizationsthatelectnottoappeal

TBD

2

25


TBD

2 26 SecurityandTrackingPlan TBD

227


228

IntakeDocumentationandMedicalRecordReviewProcessPlan TBD

229

CollaborationandSupportforAppealsProcessesPlan

TBD

230

MedicalRecordReviewStaffTrainingPlan&Materials TBD

231


232


233

Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports

TBD

2 34 PrepareAuditReports TBD2 35 DraftDemandLetters TBD

2

36


TBD

237

Documentrationaleforunderpaymentandoverpaymentdeterminations TBD

2 38 Overpayments&UnderpaymentsReport TBD2 39 WrittenplanforContractorstafftraining TBD

240

ContributionstoRADVStandardOperatingPlan(SOP) TBD

241

Providesupportingdocumentationandwrittendocumentationforappealssupport

TBD

3A 42 InitialMeetingMinutes TBD3A ProjectPlanincludingContractor TBD


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43 OrganizationalChart

3B44

Weeklyconferencecallagendas,minutesandsupportingmaterials

TBD

3B45

Monthlyconferencecallagendas,minutesandsupportingmaterials TBD

4A 46 Monthly/WeeklyProgressReports TBD4A 47 MonthlyFinancialReports TBD4C 48 Returnallfiles TBD

4D

49

Prepareagendas,trainingmaterialsandpost‐sessionreportsforCMSWorkgroupMeetings

TBD

4D

50

Prepareagendas,trainingmaterialsandpost‐sessionreportsforRADVOperationcalls

TBD

4F51

CompleteStatementofAuditingStandardsNo.70 TBD

4F52

Correctiveactionplanforcontractorperformanceevaluationfindings TBD

4H 53 CompleteJointOperationAgreement TBD

4I54

Producereportsandinformationforotheraudits TBD

4J 55 AnnualReport TBD4J 56 FinalReport TBD4K 57 ReturnofMaterials TBD4L 58 TransitionPlan TBD

OptionYear:TBD

TaskNumber

DeliverableNumber

Deliverable

DueDate(DOYA=DateofOptionYearAward)

11


12

PrepareAuditReportsforeachplancontract

TBD

13


1

4


TBD

1A 5 SecurityandTrackingPlan TBD1B Planfordocumentationandmedicalrecord TBD


25

6 managementanddestruction

1C7

IntakeDocumentationandMedicalRecordReviewProcessPlan

TBD

1D8


1F9


1H10


1H11

Writtenfeedbackonproposeddataandoperationalplansandrequirements

TBD

1I12

Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports TBD

1J 13 PrepareAuditReports TBD1J 14 DraftDemandLetters TBD

1J

15 UpdateAuditReportsandissuedemandletterstoauditedMAorganizationsasapplicablethroughouttheappealprocess

TBD

1K16

Documentrationaleforunderpaymentandoverpaymentdeterminations

TBD

1K 17 Overpayments&UnderpaymentsReport TBD1K 18 WrittenplanforContractorstafftraining TBD

1K19

ContributionstoRADVStandardOperatingPlan(SOP)

TBD

1L20

Providesupportingdocumentationandwrittendocumentationforappealssupport TBD

221

ProposecriteriaforConditionSpecificRADVAudits TBD

222


223

PrepareAuditReportsforeachplancontract

TBD

224


2

25


TBD

2 26 SecurityandTrackingPlan TBD

227


228

IntakeDocumentationandMedicalRecordReviewProcessPlan

TBD

229



26

230


2

31


232


233

Prepare,interpret,andrespondtoweeklyIRRandcodingconsistencyreports

TBD

2 34 PrepareAuditReports TBD2 35 DraftDemandLetters TBD

2

36


TBD

237

Documentrationaleforunderpaymentandoverpaymentdeterminations TBD

2 38 Overpayments&UnderpaymentsReport TBD2 39 WrittenplanforContractorstafftraining TBD

240

ContributionstoRADVStandardOperatingPlan(SOP) TBD

241

Providesupportingdocumentationandwrittendocumentationforappealssupport TBD

3A 42 InitialMeetingMinutes TBD

3A43

ProjectPlanincludingContractorOrganizationalChart

TBD

3B44

Weeklyconferencecallagendas,minutesandsupportingmaterials TBD

3B45

Monthlyconferencecallagendas,minutesandsupportingmaterials TBD

4A 46 Monthly/WeeklyProgressReports TBD4A 47 MonthlyFinancialReports TBD4C 48 Returnallfiles TBD

4D

49

Prepareagendas,trainingmaterialsandpost‐sessionreportsforCMSWorkgroupMeetings

TBD

4D

50

Prepareagendas,trainingmaterialsandpost‐sessionreportsforRADVOperationcalls

TBD

4F51

CompleteStatementofAuditingStandardsNo.70 TBD

4F52

Correctiveactionplanforcontractorperformanceevaluationfindings

TBD

4H 53 CompleteJointOperationAgreement TBD

4I54

Producereportsandinformationforotheraudits

TBD

4J 55 AnnualReport TBD


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4J 56 FinalReport TBD4K 57 ReturnofMaterials TBD4L 58 TransitionPlan TBD

Documents

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