(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

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Underpayment amounts shall only be on this report if the identified underpayments have been paid to the provider by HHSC (in summary and detail); c. The net recovery amount (overpayments minus underpayments) must be itemized on each monthly bill. It was the intention of the federal government and HHSC that the contingency fee amount not be greater than the revenue generated from such reviews; therefore, the majority of the work shall be geared toward the identification and recovery of overpayments; d. Total amount of payments received by the RAC contractor from HHSC since the previous invoice; e. Net amount due the RAC contractor as of the date of the invoice; and, f. The selected RAC will not receive reimbursement for overpayments identified, only on amounts actually collected from the Medicaid providers. The collection process can be delayed based on provider appeals. Predicated on HHSC’s past experience, the appeal process normally takes between four to six months. HHSC’s decision on any provider appeal is the final decision and the case will be considered closed. Additionally, there is no further avenue for the RAC to appeal the final decision made by HHSC. 6.3.1 Contingency Fees The RAC shall be paid a percentage of the actual overpayment recoveries by HHSC, in addition to an underpayment contingency or fixed fee, based on amounts actually paid by HHSC to the providers during each preceding month. Actual recoveries are the overpayment amounts refunded to HHSC by the providers, whether by check or through a debit adjustment to their Medicaid reimbursement. If the provider is refunding the overpayment in installments, the RAC fee will be based on the actual amounts paid as they are received by HHSC. The RAC payments will only be based on a contingency fee payment for overpayment amounts recovered plus contingency or fixed fees on underpayments discovered that are paid to the providers, not on overpayments or underpayments identified. In its separate sealed Cost Proposal (see Section 3.15.10), the RAC should propose percentage rate(s) (which must not exceed the lower of 12.5%, or the highest rate paid to Medicare RACs, as published in the Federal Register) using the pricing matrix provided with this RFP (Attachment A) for the contingency fee of overpayments collected, and underpayments discovered that are paid to the providers based on the three payment methodologies listed below. The first payment methodology listed in the pricing matrix takes into consideration the audit result (overpayment or underpayment) and the level of difficulty of the review (automated or complex). A review will be considered automated if the RAC did not need to examine medical documentation to determine the existence of an improper payment, and it will be considered complex if the RAC did examine medical documentation to determine the existence of an improper payment. Based on the audit result and level of difficulty, the appropriate contingency percentage will be located on the fee table provided by the RAC. This percentage will be applied to 50
the overpayments recovered or the underpayments discovered and paid to determine the contingency fee payable by HHSC to the RAC for that specific improper payment audit. The second payment methodology listed, “Blended Rate”, is defined as a single contingency percentage that will be applied to all reviews regardless of the audit result (overpayment or underpayment) or the level of difficulty of the review (automated or complex). This percentage will be applied to the total overpayments recovered and the underpayments discovered and paid to determine the contingency fee payable by HHSC to the RAC for all applicable improper payment audits. The third payment methodology, “Tiered”, provides numerous possible contingency percentages that each take into consideration a specific audit result (overpayment or underpayment), level of difficulty of the review (automated or complex), and the dollar value of the recovery audit under review. Based on these three variables, the appropriate contingency percentage will be located on the fee table provided by the RAC. This percentage will be applied to the overpayments recovered or the underpayments discovered and paid to determine the contingency fee payable by HHSC to the RAC for that specific improper payment audit. Based on the contingency fee percentage(s) proposed by the RAC and accepted by HHSC, HHSC will calculate the payment due the RAC and will remit to the RAC on a monthly basis. If the provider refuses to pay, collection will be handled through the HHSC collections process, which can include using legal means to collect the overpayment. The RAC will not be paid until actual funds are collected. 6.3.2 Fixed Fees The RAC’s compensation for other audit services related to fraud investigations and program integrity efforts will be based on Fixed Fees mutually agreed upon by HHSC and the RAC. The Fixed Fees will be based on individual Fixed Fee Rates included in the Contract and the level of effort to perform a specific audit, other audit services related to fraud investigations or program integrity efforts, or any other service provided by the RAC that would not be appropriate to utilize a contingency fee to compensate the RAC for those specific services rendered. In its separate sealed Cost Proposal (see Section 3.15.10), the respondent should include the proposed individual Fixed Fee Rates that would be utilized during the initial 12 month operational period of a resulting contract. For subsequent contract years (12 month Operational periods) and any applicable Operational period less than 12 months, the Fixed Fees will be determined by the application of a fixed annual inflator/deflator proposed by the respondent and subject to approval and acceptance by HHSC. In its separate sealed Cost Proposal, the respondent should also provide examples of fixed fee rates received for fraud-related audit services performed under other similar contracts. The respondent must submit one or more monthly invoice(s) following the month in which the respondent provides the required services. HHSC will process and pay Fixed Fee invoices in accordance with Chapter 2251, Texas Government Code. Invoices must be submitted by the 51
Page 1 and 2: Tom Suehs, Executive Commissioner R
Page 3 and 4: 4.3 Statewide Annual HUB Utilizatio
Page 5 and 6: define the requirements of Section
Page 7 and 8: Coordination with HHSC in obtaining
Page 9 and 10: due diligence in its efforts to ide
Page 11 and 12: are resolved, whichever happens las
Page 13 and 14: 1.8.2 Conflicts of Interest A confl
Page 15 and 16: 1.13 Protest Procedures Texas Admin
Page 17 and 18: e. Establish a Governance process w
Page 19 and 20: . Notify providers in writing of po
Page 21 and 22: timeline will include reasonable an
Page 23 and 24: . Provide monthly status reports to
Page 25 and 26: 2.6 Location of Services The RAC wi
Page 27 and 28: Respondents must notify HHSC of any
Page 29 and 30: identify trade secret or confidenti
Page 31 and 32: 3.15.1 Part I - Business Proposal T
Page 33 and 34: work as a prime contractor or subco
Page 35 and 36: 3.15.4.6 Section 6 - Proposed Appro
Page 37 and 38: Respondents must base their Cost Pr
Page 39 and 40: 3.15.30 Proposed Compensation Table
Page 41 and 42: 4. Historically Underutilized Busin
Page 43 and 44: 4.6.1 Identify Subcontracting Areas
Page 45 and 46: 4.6.7 Written Justification of the
Page 47 and 48: 5. Proposal Evaluation HHSC will us
Page 49: after HHSC receives payment from th
Page 53: (7) Statistician (8) Other Professi

(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

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