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

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HHSC invites qualified RACs to submit proposals in accordance with this RFP. HHSC plans to contract with one or more successful RAC(s) to perform the recovery audit and fraud-related audit services. The contract activities are anticipated to begin on or about September 1, 2012, or as soon thereafter as practical. The requested improper payment audit services include the detection, validation, and tracking and reporting of improper payments made by Texas Medicaid to providers resulting from: (i) duplicate payments; (ii) pricing errors; (iii) payments for services not provided; (iv) non-covered services (including services that are not reasonable and necessary under Section 1862(a) (1) (A) of the Social Security Act); or (v) any other errors resulting in improper payments. The RAC will be required to determine the causes of the improper payments, suggest recommendations to remedy those causes, and issue formal reports to HHSC documenting the results of each audit performed. Additionally, the other requested audit services include recovery projects or other initiatives related to fraud investigations and program integrity efforts as determined by HHSC. It is expected that one award will be made from this RFP; however, HHSC reserves the right, in its sole discretion, to make more than one contract award as a result of the issuance of this RFP. All questions in this RFP must be answered with information that is responsive to the request or item. The RAC, as an independent contractor, shall provide improper payment and other fraud-related audit services under the contract at its facilities and with its own personnel. The initial term of the contract is expected to be about September 1, 2012, through August 31, 2015. HHSC shall have the option, in its sole discretion, to extend the contract for up to three additional one (1) year periods, one (1) year at a time. 1.5. Mission Objectives The Texas Health and Human Services Commission’s (HHSC) mission in this Request for Proposals (RFP) is to award a contract to a qualified RAC to conduct payment recovery audit services for improper payments made by the State of Texas (State) to its Medicaid-enrolled providers for services provided under the Medicaid State Plan or a waiver of the Medicaid State Plan based on a contingency fee, as well as a fixed fee for other audit services related to fraud investigations and program integrity efforts as determined by the HHSC. The RAC should be knowledgeable of Expansion of the Recovery Audit Contractor Program as outlined in Section 6411 of the ACA, which amends Section 1902(a)(42), Social Security Act (42 U.S.C. Section 1396a(a)(42) by adding 42 C.F.R. Sections 455.500-455.518, as well as applicable guidance established by the Centers for Medicare & Medicaid Services (CMS). To gain additional knowledge, potential bidders may research: RAC Status Document (see www.cms.hhs.gov/rac). The RAC will identify underpayments and overpayments to support Texas implementation of healthcare reform. Qualified RACs are to present the state with a proposal for: Detection of Medicaid improper payments; Validation of Medicaid improper payments; Tracking and reporting of Medicaid improper payments; and 6
Coordination with HHSC in obtaining approval of recoupment/repayment of identified improper payments, to include providing all supporting documentation obtained by the RAC from Medicaid providers necessary for HHSC to conduct appeals. Additionally, qualified RACs shall present a description and examples of experience and services provided related to program integrity and fraud-related activities under similar type contracts and the scope of this contract. The description should include proposed strategies that may be beneficial to the State in its on-going program integrity efforts. Throughout this document, the term “improper payment” is used to refer collectively to overpayments and underpayments. Situations where the provider submits a claim containing an incorrect code but the mistake does not change the payment amount are NOT considered to be improper payments. 1.6. Background 1.6.1 Overview of the Health and Human Services Commission Since 1991, the Texas Health and Human Services Commission (HHSC) has overseen and coordinated the planning and delivery of health and human service programs in Texas. HHSC is established in accordance with Texas Government Code Chapter 531, and is responsible for the oversight of all Texas health and human service agencies (HHS Agencies). HHSC’s chief executive officer is Thomas M. Suehs, Executive Commissioner of Health and Human Services. As a result of the consolidation due to House Bill 2292 (HB 2292), some of the contracting and procurement activities for the HHS Agencies have been assigned to the Enterprise Contracting and Procurement Services (ECPS) section of HHSC. As such, ECPS will administer the initial stages of the procurement process, prior to the contract award, including RFP announcement and publication, handling of communications from the respondent, as well as managing the receipt and handling of valid responses for final review and evaluation. ECPS directs the execution of the contract after the awarded vendor has been selected. The contract issued as a result of this solicitation may be utilized by one or all of the Texas Health and Human Services (HHS) agencies listed below: Health and Human Services Commission (HHSC) Department of Family and Protective Services (DFPS) Department of State Health Services (DSHS) Department of Assistive and Rehabilitative Services (DARS) Department of Aging and Disability Services (DADS) HHSC/ECPS will issue an individual purchase order, contract or release for each HHS agency, region, city, or location-requiring goods or services under the contract. Each purchase order will include the delivery/service location and bill to address for the HHS agency requesting goods/services. 1.6.2 Project Overview The 82nd Legislature established a requirement (House Bill 1720, Tex. Gov. Code §531.117 (relating to Recovery Audit Contractors)) for implementation of a recovery audit program for Texas Medicaid, pursuant to Section 1902(a)(42), Social Security Act (42 U.S.C. Section 7
Page 1 and 2: Tom Suehs, Executive Commissioner R
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(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

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