City and County of San Francisco RFP#DHR Workers Compensation Bill Review, Utilization Review and Medical Case Management Services

Transcription

1 UPDATED Questions and Answers Monday, January, 13, 2014 Acronyms: BR = Bill Review CCSF = City and County of San Francisco CE = Claims Examiner CM = Case Management FCM = Field Case Management FY12/13 represents July 1, 2012-June 30, 2013 IMR = Independent Medical Review MCM = Medical Case Management MOUs = Memoranda of Understanding MPN = Medical Provider Network PPO = Preferred Provider Organization RFA = Request for Authorization RTW = Return to Work TPA = Third Party Administrator UR = Utilization Review URO = Utilization Review Organization; for the purposes of this RFP, also refers to the Contractor for services. Page 1 of 9

2 Question #1: Is the City and County looking for a bundled response (BR, UR and CM) or will a single source response (BR only) be acceptable? Answer: The CCSF will require the selected Contractor to provide the full range of all requested services and prefers for the selected Contractor to provide all requested services directly. Proposals that do not include all services requested in the RFP will be deemed non-responsive and will not be evaluated. Question #2: Does the City and County expect the UR company to be the Prime Contractor with this RFP? Answer: The CCSF prefers for the selected Contractor to provide all requested services directly. Bill Review services comprise the larger volume of work contemplated. However, if partnering is proposed, to ensure appropriate allocation of contractual responsibility, the CCSF expects the Prime Contractor to be the vendor providing Bill Review services. Question #3: Will the selected vendor also conduct these services for the claims that are managed by Intercare? If so, does the volume of 71,000 bills include the Intercare claims? Answer: Yes to both questions. Question #4: Will there be bonus points applied to a bidders score if the bidder works with a Local or Minority Business Enterprise? Answer: Pursuant to Chapter 14B, rating bonuses will be in effect for the award of this project for any Proposers who are certified by CMD as an LBE, or joint ventures where the joint venture partners are in the same discipline and have the specific levels of participation as listed in the RFP. Question #5: Is outreach to Local and/or Minority Business Enterprises mandatory? Answer: There is no local business enterprise ( LBE ) subcontracting goal for this RFP or the contract awarded from this RFP. However, outreach to City-certified Local Business Enterprises for partnering is encouraged. Question: #6: From Section B, please detail the days and times that are considered to be "offhours". Answer: Monday through Friday from 7:00 a.m. to 8:00 a.m., and 5:00 p.m. to 7:00 p.m., and Saturdays from 7:00 a.m. to 8:00 p.m. Page 2 of 9

3 Question #7: Is CCSF looking for a single price estimate for all services described in the RFP for the length of the contract or can we submit a fee for each service, individually priced at a set flat fee or hourly rate? For example, peer review services would be priced at a single flat fee per referral and bill review priced at per line or per invoice. Answer: CCSF is looking for both; a single total for all services for the length of the contract, as well as annual subtotals, AND line-item details to support subtotals for each service and methodology, whether flat fee, hourly rate or other. Question #8: Who are your current vendors for UR, CM and Bill Review? Answer: Current vendor for (UR) Utilization Review and (BR) Bill Review is Intermed. We do not have an independent contract for (CM) case management (nursing); it is a new service request. Question #9: What is your current pricing for your services? UR, CM, and Bill Review? Answer: We do not have a contract for Case Management Services. For UR and Bill Review, the pricing is as follows: Bill Review - Utilization Review - UR Peer/Clinical Review - $7.50 per bill $90.00 per review $ per review Question #10: What is the average gross % saved per year, not including duplicate bills? Answer: Assuming that this question refers to the Bill Review services provided, gross percentage savings not including duplicate bills were 67.10% in FY12/13. Question #11: What is the average net (savings after fees) % saved per year, not including duplicate bills? Answer: Assuming that the question refers to Bill Review services provided, the net savings were also 67.10% in FY12/13. CCSF does not currently track average net savings. Question #12: What are the bill review fees for fee schedule review? Answer: $7.50 per bill. Question #13: For 2013, what were the total bill review fees? Answer: For calendar year 2013, $587, Question #14: How much has CCSF paid its vendor for fee schedule review for the last 12 month period? Answer: For calendar year 2013, $587, Page 3 of 9

4 Question #15: How much has CCSF paid its vendor for inpatient and outpatient bill review for the last 12 month period? Answer: Inpatient and outpatient bill review fees are not currently separately tracked and reported because the fees for the review are the same as for nonhospital bills. Total fees for bill review were $587, in the last 12 months. Question #16: What is the fee for hospital bill (inpatient and outpatient) bill review? Answer: $7.50 per bill, regardless of the number of items on the bill. Question #17: What did CCSF pay for negotiated bills, hospital bill audit, and other bill review activities (not including fee schedule review or PPO access fees) in each of the last three years? Answer: Unknown. Hospital audit and other bill review activities are not currently separately reported. Question #18: What is the fee for PPO access? Answer: Twenty (20) % of savings that result from PPO discount, capped at $2000 per bill. Question #19: How much has CCSF paid its vendor for PPO access for the last 12 month period? Answer: CCSF tracks costs by fiscal year. For FY12/13, PPO access fees are 20% of savings. PPO savings were $400,627, 20% of which is $80,125. Question #20: What PPO(s) are accessed? Answer: Unknown, the current contract does not require the contractor to disclose its PPO agreements. Question #21: What has been the PPO savings percentage for the last 12 month period? Answer: One (1) % in FY12/13. Question #22: For 2013, what were the total PPO reductions? Answer: CCSF data for calendar year 2013 has not yet been compiled. For FY12/13, total PPO reductions were $400, Page 4 of 9

5 Question #23: For 2013, what were the total PPO fees? Answer: CCSF does not have this information for the calendar year. PPO access fees are 20% of savings, capped at $2000 per bill. In FY12/13, PPO savings were $400,627. Total fees are estimated to be approximately $80,000. Question #24: For 2013, what were the total audit/other reductions? Answer: CCSF data for calendar year 2013 has not yet been compiled. For FY12/13, there were no additional reductions beyond fee schedule and PPO savings. Question #25: Does CCSF have a system that assists Claims Examiners in authorizing medical treatment? If so, please describe how it works, how the data is shared with the URO vendor, the name of the system and the fees charged. Answer: No, the CCSF is not aware of a system that assists Claims Examiners in authorizing medical treatment other than a policy document that identifies some services that should be considered for formal review. Claims examiners are provided with broad authority to approve medical treatment requests without the need for formal review. Approvals of requests for authorization without formal UR review are simply documented in the ivos system. The data is not shared with the URO vendor. Question #26: What is your current IMR process with your URO? What part, if any, does your URO play in responding to IMR requests? Answer: The claims examiners respond directly to requests for IMR. The URO does not play a role. Question #27: Does CCSF utilize the deferral process in which the requests are NOT sent to the URO? If not, does that mean the URO shall process whatever is sent for review? Answer: Yes, the claims examiner will determine whether to defer review of a Request for Authorization for medical treatment. The URO is expected to process all reviews sent for that purpose. Question #28: Does CCSF utilize the Incomplete Referral process? Will the CE or the URO vendor make the determination as to what constitutes an incomplete? Answer: Generally, claims examiners do not rely on technicalities where requests for medical treatment are incomplete, but will make a decision as to whether the request can be approved or should be sent to the URO. The URO will perform the review and, where requests are incomplete but can still be reviewed, will attempt to educate the physician so that future referrals are complete. CCSF sets guidelines for when to rely on technicalities. Page 5 of 9

6 Question #29: How many utilization reviews were sent to CCSF s utilization review vendor in the last 12 month period? The RFP states 3,938 but later states 1,300. Can you please clarify the difference? Answer: There were 1,290 formal reviews sent to the URO in FY12/13. The higher number (3,938 total) represents all RFAs sent to the URO for formal review (1,290) by both Intercare and CCSF adjusters, plus those authorized without a formal review by Intercare Adjusters (2,648) and sent to the URO for tracking purposes only. Those authorized by CCSF adjusters are not sent to the URO for tracking, but are independently tracked in ivos claims system. Question #30: How many utilization reviews went to Peer Review? Answer: Seven hundred ten (710) in FY12/13. Question #31: What are the fees per UR? Does each fee represent 1 treatment request or does each fee represent 2 or more treatment requests? Answer: Fees for prospective, concurrent and retrospective review are currently $90.00 per review. Each treatment request is currently billed at this rate. Question #32: Percentage of UR treatment requests denied and percent overturned. Answer: For FY12/13, 28.7% of UR requests were denied. Of those denied, approximately 4% were overturned on appeal. Question #33: How many telephonic case management assignments were made in the last 12 month period? What were the fees paid? Answer: Unknown. This information is not currently separately tracked. Assignments are done on a case by case basis. Fees vary depending on the firm used. Question #34: How many field case management assignments were made in the last 12 month period? What were the fees paid? Answer: Unknown. Field case management referrals are done on a case-by-case basis to different firms and are not currently separately tracked. We estimate 1% of cases may at some time involve a field case manager. Fees vary depending on the firm used. CCSF is thus including FCM services in this RFP. Question #35: What is the total number of FCM cases referred in 2013 and total fees? Answer: Unknown. Field case management referrals are done on a case-by-case basis to different firms and are not currently separately tracked. We estimate 1% of cases may at some time involve a field case manager. Page 6 of 9

7 Question #36: Does CCSF have any current business relationships with any ancillary network providers that CCSF would like to continue with? Answer: Yes. We have a non-exclusive agreement with PTPN for the provision of physical therapy services. We do not, at this time, have ancillary service providers as part of the CCSF MPN. Question: #37: Does CCSF own the MPN? In other words, are the contracted providers contracted directly with CCSF and if not, what company are they contracted with? Answer: Yes, CCSF owns the MPN and the providers enter into agreements directly with CCSF. Question: #38: Do the MPN provider contracts have treatment allowances and/or limitations language? Answer: No, not at this time. However, new MOUs are being developed that could potentially include some limited preauthorized services. Question: #39: Will the selected vendor have access to the MPN providers contact information and treatment allowances and limitations (if there are any) to assist the selected vendor apply utilization review in accordance with that language and the UR Plan and in directing care to the MPN via MCM? Answer: Yes. Question: #40: What are the total MPN fees paid each year for the past 3 years? Answer: Zero. Question: #41: What is the penetration rate into the MPN? In other words, out of all the bills, how many bills are received from providers that are in the MPN and how many are not? Answer: The penetration rate is unknown, but is estimated to be approximately 80%. Question: #42: Is CCSF interested in bidder information regarding its recommended MPN? Answer: The question is unclear. CCSF maintains its own MPN and has no plans to contract for an outside network. Question #43: Who is the current administrator or manager of the MPN(s) for CCSF? Answer: Robin Nagel, a CCSF employee. Question #44: For 2013, what were the total fee schedule reductions? Answer: CCSF data for calendar year 2013 has not yet been compiled. For FY12/13 total fee schedule reductions were $38,357, Page 7 of 9

8 Question #45: For 2013, what was the total paid? Answer: The question is not specific enough to answer. See responses to other questions. Question #46: For 2013, what were the total audit/other fees? Answer: Zero. Question #47: Does the CCSF have a RTW program? Answer: Yes. CCSF has a return to work unit to facilitate disability management. Question #48: Are there any areas of the current program you are specifically looking to enhance/improve? Answer: The CCSF is open to Proposer suggestions and recommendations. This information may be provided in RFP Attachment V, Section D, Sub-section 7 of your proposal. Question #49: Can CCSF provide more specifics regarding the interface being requested? Are you talking about establishing an EDI to provide bill/attachments/eor images to the TPA or are you looking for some sort of link into the vendor s management system from the ivos system? Answer: The CCSF is open to Proposer suggestions and recommendations on how to efficiently interface between the Contractor s management system and the CCSF ivos system to ensure that UR determinations are linked to bill review decisions. Note that both the TPA and CCSF in-house programs are managed via the ivos claims management system. Question #50: Does CCSF or Intercare expect to change claim systems in the next 3-5 years? Answer: The CCSF is not expecting a change in claim systems at this time, but may consider a change within 3-5 years. Question #51: Will the selected vendor be interfacing with CCSF s claims system and Intercare s claim system? If so, what claims system does Intercare use? Answer: Yes, however, both administrators use ivos, the administration of which is managed by CCSF. Question #52: Is it possible to get a copy of the current contract? Answer: Yes. The current contract is attached. Page 8 of 9

9 Question #53: The pricing page in the RFP looks a lot like a software pricing worksheet, rather than for services. We can provide you with costs for UR, CM and Bill Review, based on estimates you have provided, and we can therefore come up with annualized projections for services, but we are not quite sure what you have in mind with the software/maintenance/hosting type questions. Answer: In the Program Cost Estimate section (last page) of the Attachment V, the software/maintenance/hosting examples are provided in the event they are applicable for any Proposer in order to provide the full range of services described in the RFP. It is up to each Proposer to determine whether they are applicable or not. Page 9 of 9