RFI 002-13/14 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION REQUEST FOR INFORMATION Medicaid Recovery Audit Contractor (RAC) to provide on a contingency fee basis recovery audit services for the fee-for-service model of the Medicaid program as directed under s. 6411(a) of the Affordable Care Act and 42 CFR 455 A. REQUEST FOR INFORMATION (RFI) This is a Request for Information (RFI). The Agency for Health Care Administration (Agency) is seeking information regarding a vendor s capability of performing audit and recovery activities in accordance with s. 6411(a) of the Affordable Care Act and 42 CFR 455 which refers to a Medicaid Recovery Audit Contractor (RAC) and in accordance with Agency requirements. The purpose of the program is to audit Medicaid enrolled providers being paid under the fee-for service model to identify overpayments on noncompliance issues that result in collections and to identify underpayments. Subsequently, the Agency may impose sanctions and recover costs related to recoupments. Findings may result in administrative litigation and judicial appeals. A RFI is not a method of procurement. Responses to a RFI are not offers and shall not be accepted by the Agency to form a binding contract. This RFI shall not directly result in the execution of a contract with the Agency. The Agency reserves the right to utilize the information gathered through the RFI process to develop a scope of services which may be incorporated into a contract using a statutorily approved method of procurement. B. BACKGROUND/OVERVIEW The Agency is the single state agency responsible for administering the Florida Medicaid Program. Medicaid providers are enrolled by the Agency and paid through the Agency. Recipient eligibility for Medicaid services is administered by the Department of Children and Families. Florida Medicaid serves approximately 3.4 million children, families, seniors and disabled adults. The 2013-2014 budget was approximately $23.8 billion. Up until 2006, the Florida Medicaid program consisted of services paid by the fee-forservice model, the capitated managed care model and the provider service network model. In 2006, the State of Florida, via a waiver launched a pilot program to reform the Florida Medicaid program. In 2013 the federal government approved the statewide expansion of Florida s Medicaid reform program. In 2014, it is anticipated that approximately eighty-five percent (85%) of the Florida Medicaid recipients will be enrolled in a managed care plan. As required by federal law, Florida operates a fraud and abuse prevention and detection program through Medicaid Program Integrity (MPI) in the Agency s Office of the Inspector General. It recovers overpayments and works with the Medicaid Fraud Control Unit (MFCU) in the Office of the Attorney General, which prosecutes cases involving Medicaid fraud. The Agency and the MFCU work together annually to prepare and AHCA RFI 002-13/14, Page 1 of 5
submit to the Governor and Florida Legislature a report titled, The State s Efforts to Control Medicaid Fraud and Abuse. The report for the FY 2012-13 has been released and can be found at the following address: http://ahca.myflorida.com/executive/inspector_general/docs/fraudreports/fraudreport2 012-13.pdf The Agency contracts with HP Enterprise Services (HP) to serve as its fiscal agent for managing the Florida Medicaid Management Information System (FMMIS) and Decision Support System (DSS). FMMIS, a claims processing system, contains a comprehensive solution providing fraud and abuse detection (FAD) and surveillance and utilization review system (SURS) capabilities. The FAD/SURS are fully integrated within the Medicaid fiscal agent s data warehouse. In addition, MPI is in the process of procuring a contract for advanced data analytics services, which will expand the capacity for identifying potential provider fraud/abuse and is also in the process of procuring a new case management system for tracking MPI files and cases. The primary tasks conducted by MPI include, but are not limited to, receiving and evaluating complaints, performing claims data analysis, identifying audit issues or providers for audit, conducting field initiatives to assess compliance, performing case management, auditing Medicaid providers to identify and recoup overpayments, imposing sanctions and audit costs, making referrals to the MFCU and licensing entities, recommending Terminations for Cause, performing managed care oversight, defending case findings in the administrative and judicial hearing process, preparing Final Orders and creating various standard and ad hoc reports. MPI currently has approximately ninety-four (94) full-time employees devoted to combating fraud, abuse and waste in the Florida Medicaid Program. The scope of the oversight duties include both managed care plans and enrolled providers paid by fee-forservice. A Medicaid RAC vendor will supplement the existing audit programs. Approximately fifty percent (50%) of MPI s full-time employees participate in the detection, investigation and identification of overpayments by providers paid by the fee-for-service model. MPI s investigation and recovery efforts include: Comprehensive audits involving reviews of professional records; Generalized analyses involving computer-assisted reviews of paid claims within the context of Medicaid policies; Paid claims reversals involving adjustments to incorrectly billed claims; and Focused audits involving reviews of certain types of providers or issues. In addition to MPI staff members, two (2) additional parties coordinate with MPI to conduct audits for the purpose of identifying overpayments. They are the Third Party Liability contractor, ACS State Healthcare, Inc. and The Centers for Medicare and Medicaid Services Medicaid Integrity Contractor, Health Integrity, LLC. If fraud is suspected during the course of a review, MPI makes referrals to the MFCU for investigation. AHCA RFI 002-13/14, Page 2 of 5
C. MINIMUM REQUIREMENTS OF A MEDICAID RAC VENDOR A Medicaid RAC vendor must comply with requirements set forth under s. 6411(a) of the Affordable Care Act and 42 CFR 455, applicable Florida Statutes, Medicaid handbooks incorporated by reference in the Florida Administrative Code (F.A.C.), Medicaid policy, the F.A.C. and the Agency s auditing requirements. The Medicaid RAC vendor must recommend and perform audits on Medicaid providers paid by the fee-for-service model for the purpose of identifying and collecting overpayment based on non-compliance with Medicaid policies. The Medicaid RAC vendor is paid on an established contingency fee based on collected overpayments and after any appeal rights have been exhausted. The Medicaid RAC vendor must have a minimum of at least three (3) years experience in conducting Medicaid recovery audits. The Medicaid RAC vendor must comply with and perform the functions listed in Section D: KEY FUNCTIONS. D. KEY FUNCTIONS Key Functions include, but are not be limited to: Staffing Training Project Implementation Data Assessment Identification of Audit Candidates or Audit Issues Case Tracking Data Connectivity and Exchange Processes Compliance with Applicable Federal, State and Agency Regulations, Laws, Policies Audit Types, Methods and Descriptions Used to Issue Preliminary and Final Audits Records Required and Records Retention Work Product Quality Assurance Health Insurance Portability and Accountability Act (HIPAA) Compliance Litigation and Hearings Preparation and Support Referrals Reporting Invoicing and Refunds Process Improvements Disaster Recovery E. RFI RESPONSES Qualified and interested vendors should submit a company profile, including information indicating the company s capabilities for successfully completing a project as described in this RFI. Respondents to this RFI are asked to be thorough, but concise. The response should include, at a minimum, the following information: 1. The respondent s name, place of business address, mailing address, contact information including the name of a representative(s), telephone number(s) and e-mail address(s). 2. A statement indicating interest in any subsequent competitive solicitation for the services outlined in this RFI if the Agency determines that a competitive solicitation will be pursued. AHCA RFI 002-13/14, Page 3 of 5
3. A statement of personnel expertise and a description of past experiences in providing services described in this RFI and the outcomes. Include when, for whom, audit methodologies used (e.g., claim by claim, statistics, on-sight audits, desk reviews), types of audits performed (e.g., comprehensive, single or limited issues), provider types audited, claims volume evaluated, number of audits completed, outcomes, etc. 4. A description of how the respondent would complete or fulfill the functions displayed in this RFI with emphasis placed on Section D. 5. A projection of overpayments to be identified and collected in first year, second year, and third year. 6. A brief discussion how the contingency fee should be determined and a potential range for which the contingency fee may fall. F. PROPRIETARY INFORMATION Any portion of the submitted response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be clearly marked exempt, confidential, or trade secret (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secrets shall be marked trade secret as defined in Section 812.081, Florida Statutes. Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the respondent. Designating material simply as proprietary will not necessarily protect it from disclosure under Chapter 119, Florida Statutes. An entire response should not be considered trade secret. G. RESPONSES Respondents to this RFI shall submit one (1) electronic copy of its response. The response shall not exceed ten (10), single-sided, pages in length. The electronic format shall be submitted on CD-ROM. The software used to produce the electronic files must be Microsoft Word 97 and/or Excel 97 or newer. The electronic files must be logically named. The respondent shall also submit one (1) electronic redacted copy of the response suitable for release to the public. Any confidential or trade secret information covered under Section 812.081, Florida Statutes, should be either redacted or completely removed. The redacted response shall be marked as the redacted copy and contain a transmittal letter authorizing release of the redacted version of the response in the event the Agency receives a public records request. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA RFI 002-13/14, Page 4 of 5
Responses should address each RFI request point by point. Responses to this RFI shall be provided no later than 5:00 PM, Eastern Time, May 23, 2014. Agency for Health Care Administration Procurement Office Attn: LeAnn Clayton Building 2, Suite 203 2727 Mahan Drive, MS 15 Tallahassee, FL 32308 H. VENDOR COSTS Vendors are responsible for all costs associated with preparing a response to this RFI. The State of Florida, Agency for Health Care Administration, will not be responsible for any vendor costs associated with preparing a response to this RFI. I. QUESTIONS Questions concerning this RFI can be submitted in writing via email to LeAnn Clayton, at Leann.Clayton@ahca.myflorida.com. All responses to questions received will be made, in writing, directly to the sender. J. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE Additional information about the Florida Agency for Health Care Administration can be found on the Agency s website at: http://ahca.myflorida.com/ REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA RFI 002-13/14, Page 5 of 5