Colorado Department of Health Care Policy and Financing. Solicitation #: HCPFRFPSF13EHRATTAUDIT Electronic Health Record Attestation Auditing

Transcription

1 Colorado Department of Health Care Policy and Financing Solicitation #: HCPFRFPSF13EHRATTAUDIT Electronic Health Record Attestation Auditing

2 Table of Contents SECTION 1.0 INTRODUCTION GENERAL INFORMATION... 2 SECTION 2.0 TERMINOLOGY ACRONYMS, ABBREVIATIONS AND OTHER TERMINOLOGY... 2 SECTION 3.0 BACKGROUND INFORMATION THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING PROJECT BACKGROUND... 4 SECTION 4.0 OFFEROR S MANDATORY REQUIREMENTS ORGANIZATION QUALIFICATIONS STAFFING QUALIFICATIONS... 5 SECTION 5.0 STATEMENT OF WORK CONTRACTOR S GENERAL REQUIREMENTS ELECTRONIC HEALTH RECORD AUDIT STRATEGY DEVELOPMENT AUDIT PROGRAM PROCEDURES CREATION AND REVIEW PRE-PAYMENT AUDIT RESPONSIBILITIES POST-PAYMENT AUDIT RESPONSIBLITIES ADVERSE DESK AUDIT RESULTS - PROCEDURES AUDIT APPEAL ASSISTANCE MEETING REQUIREMENTS AUDIT RESULT REPORTING START-UP AND CLOSEOUT PERIODS SECTION 6.0 COMPENSATION AND INVOICING COMPENSATION INVOICING PAYMENT BUDGET SECTION 7.0 EVALUATION METHODOLOGY EVALUATION PROCESS EVALUATION COMMITTEE COMPLIANCE RFP # HCPFRFPSF13EHRATTAUDIT Page 1 of 24

3 7.4. EVALUATION CRITERIA APPENDIX A - ADMINISTRATIVE INFORMATION DOCUMENT APPENDIX B - RFP SIGNATURE PAGE APPENDIX C W-9 APPENDIX D - DRAFT CONTRACT APPENDIX E RISK STRATA ASSIGNMENT FOR ELIGIBLE PROVIDERS APPENDIX F - PRE-PAYMENT AUDIT RESULTS TEMPLATE APPENDIX G POST-PAYMENT AUDIT RESULTS TEMPLATE SECTION 1.0 INTRODUCTION 1.1. GENERAL INFORMATION The Colorado Department of Health Care Policy and Financing (Department) is soliciting competitive, responsive proposals from experienced and financially sound organizations to perform as Electronic Health Record Incentive Payment Program auditors for the Department General solicitation information, timelines and proposal submission requirements are available in Appendix A, Administrative Information Document. To be considered responsive, an Offeror shall comply with all of the requirements and timelines contained in Appendix A. SECTION 2.0 TERMINOLOGY 2.1. ACRONYMS, ABBREVIATIONS AND OTHER TERMINOLOGY Acronyms, abbreviations and other terminology are defined at their first occurrence in this Request for Proposals (RFP). The following list is provided to assist the reader in understanding acronyms, abbreviations and terminology used throughout this document AIU Adoption, implementation, or upgrade of EHR technology ARRA - American Recovery and Reinvestment Act of Business Day - Any day in which the Department is open and conducting business, but shall not include weekend days or any day on which one of the Department s holidays are observed. The Department observes all holidays listed in C.R.S (1) CHP+ - The Colorado Child Health Plan Plus Closeout Period - The period from the earlier of ninety (90) days prior to the end of the last renewal year of the Contract or notice by the Department of non- RFP # HCPFRFPSF13EHRATTAUDIT Page 2 of 24

4 renewal until the day that the Department has accepted the final deliverable for the Closeout Period and has determined that the final transition is complete CMS - Centers for Medicare and Medicaid Services Contract - The agreement that is entered into as a result of this solicitation Contractor - The individual or entity selected as a result of this solicitation to complete the Work contained in the Contract Department - The Colorado Department of Health Care Policy and Financing, a department of the government of the State of Colorado Effective Date - the effective date defined in the Contract EH Eligible Hospital. An eligible hospital as specified in 42 C.F.R and 42 C.F.R EHR - Electronic Health Record EHR Incentive Program - the state of Colorado Medicaid Electronic Health Record Technology Incentive Program EP - Eligible Provider. An eligible provider must be an eligible professional or eligible hospital as specified in 42 C.F.R and 42 C.F.R EP Group - means a group composed of Eligible Providers and/or Eligible Hospitals which meet the qualifications as specified under 42 C.F.R and 42 C.F.R HIPAA - the Health Insurance Portability and Accountability Act of HITECH - Health Information Technology for Economic and Clinical Health Act Hospital - Any eligible hospital subject to the prospective payment system as specified under 42 C.F.R and 42 C.F.R Key Personnel - The position or positions that are specifically designated as such in the Contract Meaningful Use - Standard described for eligible providers and hospitals per 42 C.F.R (a), (b), (c), (d) and (e) Offeror - Any individual or entity that submits a proposal, or intends to submit a proposal, in response to this solicitation Operational Start Date - when the Department authorizes the Contractor to begin fulfilling its obligations under the Contract Other Personnel - Individuals and Subcontractors, in addition to Key Personnel, assigned to positions to complete tasks associated with the Work outlined in this solicitation PHI - Protected Health Information Program Participant - Any individual or entity applying for or receiving an incentive payment under the Electronic Health Record Incentive Program. RFP # HCPFRFPSF13EHRATTAUDIT Page 3 of 24

5 Program Year One (1) of the first through six (6) incentive payment years Provider - Any eligible provider or eligible hospital receiving an incentive payment under the Electronic Health Record Incentive Program SFY - State Fiscal Year Start-Up Period - The period from the execution of the Contract, until the Operational Start Date State Fiscal Year - The twelve (12) month period beginning on July 1st of a year and ending on June 30th of the following year Subcontractor - Third-parties, if any, engaged by Contractor to aid in performance of its obligations under the Contract Work - The tasks and activities Contractor is required to perform to fulfill its obligations under the Contract, including the performance of any services and delivery of any goods. SECTION 3.0 BACKGROUND INFORMATION 3.1. THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING The Department serves as the Medicaid Single State Agency, as defined by Code of Federal Regulations (CFR) Title 45 Section (45 CFR ) and develops and implements policy and financing for the Medicaid and Child Health Plan Plus (CHP+) programs as well as a variety of other publicly funded health care programs for Colorado's low-income families, children, pregnant women, the elderly and people with disabilities. For more information about the Department, visit The Department is a Covered Entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (United States Code [U.S.C.] Title 42 Section 1320d-1320d-842 [U.S.C. 1320d-1320d-8]) and its implementing regulations PROJECT BACKGROUND The Electronic Health Record Incentive Payment Program (EHR Incentive Program) is designed to provide incentive payments to Medicaid providers for the adoption, implementation or upgrade of certified Electronic Health Record technology, and the meaningful use of that technology under 42 C.F.R. 495 (2010) as incorporated by state Medical Services Board Rule In order to ensure that the state and federal funds are paid appropriately, accounted for transparently, and are in accordance with the Centers for Medicare and Medicaid Services (CMS) Final Rule for the EHR incentive program, the Department is soliciting a Contractor to assist in conducting pre-payment activities and post-payment audit functions. SECTION 4.0 OFFEROR S MANDATORY REQUIREMENTS 4.1. ORGANIZATION QUALIFICATIONS Mandatory Organization Experience or Qualification Requirements RFP # HCPFRFPSF13EHRATTAUDIT Page 4 of 24

6 Offeror s organization shall meet all mandatory experience and/or qualification requirements to be considered for award of a Contract from this solicitation Any Offeror that does not demonstrate that its organization meets all stated requirements will be disqualified Offeror s organization shall have all of the following: The Offeror shall have five (5) years of experience, in the last seven (7) years, developing and monitoring audit plans for Health care providers The Offeror shall have five (5) years of experience, in the last seven (7) years, auditing health care providers STAFFING QUALIFICATIONS Mandatory Key Personnel Experience and/or Qualification Requirements Offeror shall designate staff to hold the Key Personnel positions as specified in this solicitation. The Contractor shall not allow for any individual to fill more than one of the roles defined as Key Personnel Offeror s Key Personnel shall meet all mandatory experience and/or qualification requirements for Offeror to be considered for award of the Contract Any Offeror that does not designate Key Personnel or is unable to demonstrate that their Key Personnel meet all stated requirements will be disqualified The Key Personnel identified for this Contract are: Project Lead Offeror s Project Lead shall have all of the following: A valid Certified Public Accountant (CPA) license Three (3) years of experience, in the last seven (7) years, managing health care audits Experience monitoring all project activities for a project of similar scope, including timelines, resources, and budgets, to ensure that contract requirements, milestones and deliverables are met Experience ensuring that all deliverables meet the requirements and are submitted on time Experience performing recoupment procedures in cases of adverse auditing findings Experience assisting with audit result appeals Must be a full-time employee of the Contractor Mandatory Other Personnel Requirements Offeror shall provide Other Personnel, individuals in addition to Key Personnel, to ensure Offeror s ability to complete the Work. RFP # HCPFRFPSF13EHRATTAUDIT Page 5 of 24

7 Offeror shall use its discretion to determine all Other Personnel it will require to complete the Work Offeror shall ensure that the Other Personnel have previous experience, education and/or training that demonstrate that they are qualified for the positions on this project to which they will be assigned Any Offeror unable to demonstrate that it has sufficient Other Personnel to complete the Work will be disqualified. OFFEROR'S RESPONSE 1. Provide details that demonstrate how Offeror meets all mandatory experience and/or qualification requirements. Offeror s response should list each stated experience and/or qualification requirement separately and follow the listed requirement with the details that demonstrate how Offeror meets that specific requirement. OFFEROR'S RESPONSE 2. Provide the name and resume for each person to be assigned to a Key Personnel position. In addition to the name and resume, include a summary for each person that demonstrates how that person meets the experience and/or qualification requirements stated for the Key Personnel position for which the person is to be assigned. OFFEROR'S RESPONSE 3. Provide a summary that explains Offeror s plans for providing sufficient experienced Other Personnel to ensure Offeror s ability to complete the Work outlined in this solicitation. In addition to the summary, for all positions to be held by Other Personnel, provide the following: Position Title and Number of People to Hold that Position Title. Estimated Number of Hours Per Week Each Person in the Position Will Be Dedicated to this Project. General work/duties/responsibilities to be assigned to Position. NOTE: If any positions are to be held by an employee of a Subcontractor or if any work/duties/responsibilities are to be completed by a Subcontractor, information about the Subcontractor s organization must be provided. For each Subcontractor, provide the following: Legal and Trade name of Subcontractor. General work/duties/responsibilities to be assigned to Subcontractor. Brief description of each Subcontractor s skills and experience that make that Subcontractor qualified to perform the Work. RFP # HCPFRFPSF13EHRATTAUDIT Page 6 of 24

8 SECTION 5.0 STATEMENT OF WORK 5.1. CONTRACTOR S GENERAL REQUIREMENTS The Department will contract with only one (1) organization, the Contractor, and will work solely with that organization with respect to all tasks and deliverables to be completed, services to be rendered and performance standards to be met The Contractor may be privy to internal policy discussions; contractual issues; price negotiations; confidential medical information; Department financial information; and advance knowledge of legislation. This information shall be considered confidential The Contractor shall work cooperatively with key Department staff and, if applicable, the staff of other contractors in the course of the Contract period to ensure the success of the Work. The Department may, in its sole discretion, use other contractors to perform activities related to the Work that are not contained in the Contract The Contractor shall maintain complete and detailed records of all meetings, system development life cycle documents, presentations, project artifacts and any other interactions or deliverables related to the project described in the Contract. The Contractor shall make such records available to the Department upon request, throughout the term of the Contract All activities and Work in this solicitation shall be completed in accordance with an Audit Guide as approved by CMS Project Personnel Personnel General Requirements The Contractor shall provide qualified Key Personnel and Other Personnel to perform the Work. The Contractor shall provide a final list of individuals assigned to the Contract DELIVERABLE: Final list of names of the individuals assigned to the Contract DUE: Within five (5) business days of the Effective Date The Contractor shall obtain written approval from the Department for individuals proposed for assignment to Key Personnel positions. The Department reserves the right to approve or disapprove all of the Contractor s staff assigned to the Contract or to require the reassignment of any Contractor employee found unacceptable by the Department. The Department has the right to request that any personnel be removed or replaced at any time, for any reason, if it is determined to be in the best interest of the Department The Contractor shall not change individuals in Key Personnel positions without prior written approval of the Department. The Contractor shall supply the Department with the name(s), resume and references for any proposed replacement whenever there is a change to Key Personnel. Any individual replacing Key Personnel shall have qualifications that are equivalent to or RFP # HCPFRFPSF13EHRATTAUDIT Page 7 of 24

9 exceed the stated qualifications for the position, unless otherwise approved by the Department DELIVERABLE: Name(s), resume(s) and references for the person(s) replacing anyone in a Key Personnel position DUE: At least five (5) business days prior to the change in Key Personnel The Contractor s Key Personnel shall perform the majority of their work and responsibilities on this project in the Denver metropolitan area, unless the Department grants permission otherwise The Contractor shall maintain appropriate staffing levels throughout the term of the Contract If any of the Contractor's Key Personnel, or Other Personnel, are required to have and maintain any professional licensure issued by any federal, state or local government agency, then the Contractor shall submit copies of such current licenses to the Department DELIVERABLE: All current professional licensure documentation as specified for Key Personnel or Other Personnel DUE: Within five (5) business days of receipt of updated licensure or upon request by the Department Personnel Availability The Contractor shall ensure Key Personnel and other personnel assigned to the Contract are available for meetings with the Department during the Department s normal business hours. The Contractor shall also make these personnel available outside of the Department s normal business hours and on weekends with prior notice from the Department The Contractor s Key Personnel and other operational staff shall be available for all regularly scheduled meetings between the Contractor and the Department, unless the Department has granted prior approval otherwise The Contractor shall ensure that the staff attending all meetings between the Department and the Contractor have the authority to represent and commit the Contractor regarding work planning, problem resolution and program development At the Department s direction, the Contractor shall make its Key Personnel and other personnel assigned to the Contract available to attend meetings as subject matter experts with stakeholders both within the State government and external or private stakeholders All of the Contractor s personnel that attend any meeting with the Department or other Department stakeholders shall be physically present at the location of the meeting, unless the Department gives prior permission to attend by telephone or video conference. In the event that the Contractor has any RFP # HCPFRFPSF13EHRATTAUDIT Page 8 of 24

10 personnel attend by telephone or video conference, the Contractor shall be responsible for providing the conference line or virtual meeting place The Contractor shall respond to all telephone calls, voic s and s from the Department within one (1) Business Day of receipt by the Contractor Key Personnel Responsibilities Project Lead The Project Lead shall: Monitor all phases of the project in accordance with work plans or timelines or as determined between the Contractor and the Department Serve as Contractor s primary point of contact for the Department Be responsible for completion and/or submission of all tasks and deliverables in the Contract Quality Control Analyst The Quality Control Analyst shall: Develop a uniform quality control process to determine proper procedure for addressing adverse audit findings Other Personnel Responsibilities The Contractor shall ensure that all Other Personnel have sufficient training and experience to complete all portions of the Work assigned to them The Contractor may subcontract to complete a portion of the Work required by the Contract. The conditions for using a Subcontractor(s) are as follows: The Contractor shall not subcontract more than forty percent (40%) of the Work The Contractor shall provide the organizational name of each Subcontractor and all items to be worked on by each Subcontractor to the Department DELIVERABLE: Name of each Subcontractor and items on which each Subcontractor will work DUE: The later of thirty (30) days prior to the Subcontractor beginning work or the Effective Date The Contractor shall obtain prior consent and written approval for any change in the use of Subcontractor(s) Deliverables RFP # HCPFRFPSF13EHRATTAUDIT Page 9 of 24

11 All deliverables shall meet Department-approved format and content requirements. The Department shall specify the number of copies and media for each deliverable Each deliverable shall be reviewed by the Department and shall require formal approval from the Department before acceptance of the deliverable. The Contractor shall allow for a minimum ten (10) Business Days following receipt, per deliverable, for the Department to review each deliverable and document its findings, except as specified herein. Based on the review findings, the Department may accept the deliverable, reject portions of the document, reject the complete document or require that revisions be made. Unless otherwise agreed to by the Department in writing, the Contractor shall be required to submit replacement pages or a complete revised version of the deliverable within five (5) Business Days following receipt of Department comments. The Department shall have an additional five (5) Business Day review period whenever replacement pages or a complete revised version of a deliverable is resubmitted The Contractor shall employ an internal quality control process to ensure that all deliverables, documents and calculations are complete, accurate, easy to understand and of high quality. The Contractor shall provide deliverables that, at a minimum, are responsive to the specific requirements, organized into a logical order, contain no spelling or grammatical errors, formatted uniformly and contain accurate information and correct calculations. The Contractor shall retain all draft and marked-up documents and checklists utilized in reviewing documents for reference through the duration of the project and project acceptance Deliverables of low quality or those that are otherwise unacceptable to the Department shall be rejected by the Department and shall be rewritten and resubmitted by the Contractor The Contractor shall document, in writing, and deliver to the Department its responses to the Department s comments and requests for revisions or clarification of deliverable contents At the Department s request, the Contractor shall be required to conduct a walkthrough of Department-selected deliverables to facilitate the Department's review and approval process. The walk-through shall consist of an overview of the deliverable, explanation of the organization of the deliverable, presentation of critical issues related to the deliverable and other information as requested by the Department. It is anticipated that the content of the walk-through will vary with the deliverable presented In the event that any due date for a deliverable falls on a day that is not a Business Day, then the due date shall be automatically extended to the next Business Day, unless otherwise directed by the Department All due dates or timelines that reference a period of days shall be measured in calendar days, months and quarters unless specifically stated as Business Days or otherwise. All times stated in the Contract shall be considered to be in Mountain Time, unless specifically stated otherwise. RFP # HCPFRFPSF13EHRATTAUDIT Page 10 of 24

12 No deliverable, report, data, procedure or system created by the Contractor for the Department that is necessary to fulfilling the Contractor's responsibilities under the Contract, as determined by the Department, shall be considered proprietary Stated Deliverables and Performance Standards Any section within this Statement of Work headed with or including the term "DELIVERABLE" or "PERFORMANCE STANDARD" is intended to highlight a deliverable or performance standard contained in this Statement of Work and provide a clear due date for deliverables. The sections with these headings are not intended to expand or limit the requirements or responsibilities related to any deliverable or performance standard Communication Requirements with the Department The Contractor shall enable all Contractor staff to exchange documents and electronic files with the Department staff in compatible formats. The Department currently uses Microsoft Office 2007 for PC. If the Contractor uses a compatible program that is not Microsoft Office 2007 for PC, then the Contractor shall ensure that all documents or files delivered to the Department are completely transferrable and reviewable, without error, on the Department s systems Intellectual Property Ownership In addition to the intellectual property ownership rights in the Contract, the following subsections describe the intellectual property ownership requirements that the Contractor shall meet during the term of the Contract in relation to federal financial participation To facilitate obtaining the desired amount of federal financial participation under 42 CFR , the Department shall have all ownership rights, not superseded by other licensing restrictions, in all materials, programs, procedures, etc., designed, purchased, or developed by the Contractor and funded by the Department. The Contractor shall use contract funds to develop all necessary materials, programs, products, procedures, etc., and data and software to fulfill its obligations under the Contract. Department funding used in the development of these materials, programs, procedures, etc. shall be documented by the Contractor. The Department shall have all ownership rights in data and software, or modifications thereof and associated documentation and procedures designed and developed to produce any systems, programs reports and documentation and all other work products or documents created under the Contract. The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract. The Department reserves, on behalf of itself, the Federal Department of Health and Human Services and its contractors, a royalty-free, non-exclusive and irrevocable license to produce, publish or otherwise use such software, modifications, documentation and procedures. Such data and software includes, but is not limited to, the following: RFP # HCPFRFPSF13EHRATTAUDIT Page 11 of 24

13 All computer software and programs, which have been designed or developed for the Department, or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract All internal system software and programs developed by the Contractor or subcontractor, including all source codes, which result from the performance of the Contract; excluding commercial software packages purchased under the Contractor s own license All necessary data files User and operation manuals and other documentation System and program documentation in the form specified by the Department Training materials developed for Department staff, agents or designated representatives in the operation and maintenance of this software Performance Reviews The Department may conduct performance reviews or evaluations of the Contractor in relation to the Work performed under the Contract The Department may work with the Contractor in the completion of any performance reviews or evaluations or the Department may complete any or all performance reviews or evaluations independently, at the Department's sole discretion The Contractor shall provide all information necessary for the Department to complete all performance reviews or evaluations, as determined by the Department, upon the Department's request. The Contractor shall provide this information regardless of whether the Department decides to work with the Contractor on any aspect of the performance review or evaluation The Department may conduct these performance reviews or evaluations at any point during the term of the Contract, or after termination of the Contract for any reason The Department may make the results of any performance reviews or evaluations available to the public, or may publicly post the results of any performance reviews or evaluations Compliance with Federal and State Regulations The Contractor shall abide by all Federal rules and regulations governing the audit, including those rules promulgated by the Secretary of Health and Human Services enacted to carry out the American Recovery and Reinvestment Act of 2009 (ARRA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) and any amendments made thereto Informal Reconsideration Procedures: The Contractor shall follow the informal reconsideration procedures consistent with those stated in Colorado Revised Statute (C.R.S.) Section RFP # HCPFRFPSF13EHRATTAUDIT Page 12 of 24

14 301(3)(a)(VII) and 10 Colorado Code of Regulations (C.C.R.) , Section ELECTRONIC HEALTH RECORD AUDIT STRATEGY DEVELOPMENT The Contractor shall design an Electronic Health Record (EHR) strategic audit plan. The strategic audit plan shall include separate strategies and processes for desk audits and on-site audits of Program Participants The Contractor shall review Program Participant attestations of EHR technology when developing the strategic audit plan The Contractor shall, in accordance with CMS, review Program Participant Meaningful Use of EHR technology when developing the strategic audit plan The Contractor shall use the attestations, documentation and other information generated by the Providers subject to audit in the development of the strategic audit plan. The Department will deliver this information to the Contractor in electronic format The Contractor shall ensure that the strategic audit plan accounts for the CMS required audit data described and detailed in Section , and that this data is collected when the audits are performed The Contractor shall provide the Department with a pre-audit report including the following information: The Program Participant The estimated date of each audit The estimated expenses for each audit, including whether these expenses cover more than one Program Participant at a time The estimated time to complete the audit The city where the audit took place The Program Participant's Program Year Any other information as requested by the Department The Contractor shall ensure that the strategic audit plan contains defined deliverables and defined data benchmarks The strategic audit plan is subject to Department approval and is to be modified at the Department's request DELIVERABLE: Complete strategic auditing plan outlining the methodology the Contractor shall use when conducting both desk and on-site audits of Eligible Providers (EPs), Eligible Provider Groups and Eligible Hospitals (EHs) DUE: Within thirty (30) days of the Execution Date of the Contract AUDIT PROGRAM PROCEDURES CREATION AND REVIEW RFP # HCPFRFPSF13EHRATTAUDIT Page 13 of 24

15 The Contractor shall assist the Department in defining a fixed time period for which the first audits will be selected, and to determine the probability EPs and EHs who applied in that time period have for being selected The Contractor shall work with the Department to update any audit guide with specific information on post-payment audit algorithms DELIVERABLE: Audit guide update DUE: Quarterly, within fifteen (15) days of the end of the Fiscal Quarter The Contractor shall consult with the Department in order to create the most effective and efficient methodology for post-payment audit selection The Contract shall meet with the Department annually to evaluate the overall audit strategy DELIVERABLE: Annual meeting to evaluate and discuss overall audit strategy DUE: March15 th of each Contract year PRE-PAYMENT AUDIT RESPONSIBILITIES The Contractor shall be available to assist the Department on a case-by-case basis with pre-payment audit verifications. The Eligible Provider case load sample shall include pre-payment desk audits, totaling fifty percent (50 %) of EPs whose variance between reported Medicaid encounters and MMIS data is greater than fifteen percent (15%) The Eligible Hospital sample shall include one hundred percent (100%) of EHs that have a variance greater than ten percent (10 %) The Contractor shall be available to help conduct provider outreach on a case-by-case basis when additional information is needed for any given attestation POST-PAYMENT AUDIT RESPONSIBLITIES Selection of EPs and EHs for audit The Contractor shall select EPs and EHs for either desk or on-site audits as outlined in the Audit Strategy The Contractor shall select EPs and EHs using Department-approved Risk Strata assignments contained in attached Appendix E, Risk Strata Assignment for EPs Conducting Desk Audits of EPs and EHs The Contractor shall be responsible for conducting all post-payment desk audits of both EPs and EHs Program Year One desk audits shall include auditing and reviewing the following EP and EH information: Documentation to support eligibility Documentation to support hospital incentive payments. RFP # HCPFRFPSF13EHRATTAUDIT Page 14 of 24

16 Documentation to support Medicaid volumes proof of adoption, implementation, or upgrade of EHR technology Audits taking place in subsequent years shall include all of the information contained in Section , as well as obtaining documentation to ensure that EPs and EHs have meaningfully used certified EHR technology Desk Audit Review Performance The Contractor shall perform desk audits of EPs and EHs according to the steps described in this Section The Contractor shall request that all EPs and EHs selected for audit to submit documentation supporting the following information, if applicable: Denominator Numerator Discharges Charges AIU (Adoption, Implementation, or Upgrade) information Out of state encounter volume Acute Medicaid days Charity care charges Any additional information reported The Contractor shall ensure that the EP or EH being audited has provided documentation for assertions where the variance identified in the pre-payment review was greater than ten percent (10%) of the relevant database or other reference document The Contractor shall review all EP and EH documentation to determine whether the AIU of EHR technology supports the Provider attestation On-Site Review Performance The Contractor shall select for audit 2% of total providers that receive an incentive payment in a given payment year or when the desk review procedures do not adequately provide sufficient and appropriate audit evidence to support assertions made by EPs and EHs who received an incentive payment, whichever is greater The Contractor shall conduct an on-site review of any individual EP or EH that has failed to provide reasonable assurance that it should have received an incentive payment while undergoing a desk review The Contractor shall, when appropriate, review to compare the EHR technology being used by the attesting EP or EH to the AIU documentation and with the certified EHR technology to which the provider attested. RFP # HCPFRFPSF13EHRATTAUDIT Page 15 of 24

17 After Year One reviews, the Contractor shall also include a determination of whether documentation provides reasonable assurance that EPs meaningfully use certified EHR technology The Contractor shall, once the meaningful use reviews begin, be responsible for conducting the following checks: Confirm that clinical quality measures have been submitted to the state and/or CMS Review aggregate or statistical reports generated by the EHR confirming that the measures of meaningful use match those indicated via attestation Review documentation confirming the exchange or testing of electronic health information ADVERSE DESK AUDIT RESULTS - PROCEDURES Issuance of Corrective Action Plans Under Department advisement, the Contractor shall, in cases of adverse audit outcomes, issue the Department s corrective action plan that guides the EP or EH to meet requirements and retain incentive payments Corrective action plans shall include a date that the EP or EH should have implemented any recommended corrective action The Contractor shall submit each corrective action plan to the Department for approval before it is implemented by the EP or EH The Contractor shall follow-up on outstanding corrective action plans to determine if the EP or EH has implemented corrective action within ninety (90) days The Contractor shall notify the Department within thirty (30) days of any case where an EP or EH disregards an issued corrective action plan The Contractor shall, when appropriate, recommend to the Department that a recoupment of payment action should be taken DELIVERABLE: Issuance of corrective action plan DUE: When necessary, within fifteen (15) of the adverse finding Assistance with Reduction of Fraud, Waste, or Abuse The Contractor shall assist the Department in activities around reducing fraud, waste, or abuse using information collected during desk or on-site reviews The Contractor shall report to the Department, within seven (7) days of discovery, any instances of fraud, waste, or abuse in order to determine the next course of action The Contractor shall, when directed by the Department, issue recommendations for violating EPs and EHs of sanctions and/or immediate payment recoupment AUDIT APPEAL ASSISTANCE RFP # HCPFRFPSF13EHRATTAUDIT Page 16 of 24

18 The Contractor shall follow the formal appeals procedures consistent with those stated in C.R.S (3)(a)(VIII), C.R.S , and 10 C.C.R The Contractor shall inform a Provider who requests an appeal of the appropriate procedures The Contractor shall provide to the Department any information the Department determines is pertinent to the appeals process. The nature and amount of information that shall be produced is within the Department's discretion The Contractor shall provide the Department with an executive summary of the appealed case within thirty (30) days of notice of appeal. The executive summary shall contain the following information: A chronological narrative of Contractor s activities A statement of the nature of the dispute A summary of the Provider s basis and rationale for appeal A point-by-point refutation of, or agreement with, the Provider s basis and rationale for appeal with specific citation to supporting evidence in the record Copies of the rules, regulations, policies and/or statutes upon which the Contractor relied, if applicable to the issue of the appeal Explanations for how the Contractor made its calculations, if applicable to the issue of the appeal Any additional information the Department finds necessary MEETING REQUIREMENTS Planning and Preparation Meetings The Contractor shall schedule and conduct planning meetings with key Department staff, including the Colorado Medicaid EHR Incentive Program manager, Division Director, pre-payment audit staff, post-payment audit staff, and additional staff as applicable The Contractor shall conduct planning meetings via conference call or, when necessary, in a format as approved by the Department The Contractor shall schedule an annual yearly strategy meeting DELIVERABLE: Annual yearly strategy meeting DUE: April of each effective Contract year AUDIT RESULT REPORTING The Contractor shall provide the reports listed in this section in the format directed by the Department and containing the information requested by the Department Post-Audit Reports RFP # HCPFRFPSF13EHRATTAUDIT Page 17 of 24

19 The Contractor shall deliver to the Department a post-audit report after completion of each desk and on-site audit on a monthly basis The monthly post-audit reports shall include all of the following: The results from the month-to-date and year-to-date audits of all pre-payment reviews and post-payment desk reviews and on-site audits Number of attestations received Number of pre-payment reviews performed Number of provider payments issued Number of post-payment reviews performed Standard information on all pre-payment and post-payment audit results recorded by the Department in accordance with Appendix F, Pre-Payment Audit Results Template and Appendix G, Post-Payment Audit Results Template Any changes or adjustments made to risk assessment and EP or EH assignment to risk strata Distribution of attestations by provider type Distribution of eligible versus non-eligible by provider type Summary of pre-payment and post-payment audit findings DELIVERABLE: Monthly post-audit reports DUE: Monthly, by the 30 th of each month of the Contract term The Contractor shall deliver to the Department and CMS yearly post-audit reports The yearly post-audit reports shall include all of the following: The results from the year-to-date audits of all pre-payment reviews and postpayment desk reviews and on-site audits Number of attestations received Number of pre-payment reviews performed Number of provider payments issued Number of post-payment reviews performed Standard information on all pre-payment and post-payment audit results recorded by the Department in accordance with Appendix F, Pre-Payment Audit Results Template and Appendix G, Post-Payment Audit Results Template Any changes or adjustments made to risk assessment and EP or EH assignment to risk strata Distribution of attestations by provider type. RFP # HCPFRFPSF13EHRATTAUDIT Page 18 of 24

20 Distribution of eligible versus non-eligible by provider type Summary of pre-payment and post-payment audit findings The Contractor shall perform reporting to the Colorado registration and attestation system pursuant to the policies and procedures of that system DELIVERABLE: Yearly post-audit report DUE: January 15th START-UP AND CLOSEOUT PERIODS The Contract shall have a Start-Up Period and a Closeout Period The Start-Up Period shall begin on the Effective Date. The Start-Up Period shall end on the Operational Start Date of the Contract The Operational Start Date shall not occur until the Contractor has completed all requirements of the Start-Up Period, including, but not limited to, the completion of the operational readiness review contained in the start-up plan The Contractor shall not engage in any Work under the Contract, other than the Work described below in the Start-Up Period, prior to the Operational Start Date. The Department shall not be liable to the Contractor for, and the Contractor shall not receive, any payment for any period prior to the Operational Start Date under the Contract The Closeout Period shall begin on the earlier of ninety (90) days prior to the end of the last renewal year of the Contract or notice of by the Department of non-renewal. The Closeout Period shall end on the day that the Department has accepted the final deliverable for the Closeout Period, as determined in the Department-approved and updated closeout plan, and has determined that the closeout transition is complete This Closeout Period may extend past the termination of the Contract and the requirements of the Closeout Period shall survive termination of the Contract. Any requirements of the Closeout Period that survive termination of the Contract shall be requirements in addition to the Work, and the term of the Contract shall not include any period of time after the termination of the Contract Start-Up Period During the Start-Up Period, the Contractor shall complete all of the following: Create a policy and procedures manual that contains the policies and procedures for all systems and functions necessary for the Contractor to complete its obligations under the Contract Prepare all documents, forms, training materials, and any other documents, information and protocols that require approval by the Department. The Contractor shall deliver all documents, forms, training materials, and any other documents, information and protocols that require approval by the Department to the Department for review and approval in a timely manner RFP # HCPFRFPSF13EHRATTAUDIT Page 19 of 24

21 that allows the Department to review and approve those documents prior to end of the Start-Up Period Identify risks associated with the transition to the Contractor and create a plan to mitigate risks Create and implement the Start-up plan described in section Complete all steps, deliverables and milestones contained in the Departmentapproved Start-up plan The Contractor shall provide weekly updates, to the Department, throughout the Start-Up Period, that show the Contractor s status toward meeting the timelines and milestones described in the Department-approved transition plan The Contractor shall ensure that all requirements of the Start-Up Period are complete by the deadlines contained in the Department-approved Start-up plan and that the Contractor is operationally ready by the Operational Start Date Closeout Period During the Closeout Period, the Contractor shall complete all of the following: Implement the most recently updated closeout plan that has been approved by the Department, as described in section Complete all steps, deliverables and milestones contained in the most recently updated closeout plan that has been approved by the Department Provide to the Department, or any other contractor at the Department's direction, all reports, data, systems, deliverables and other information reasonably necessary for a transition Ensure that all responsibilities under the Contract have been transferred to the Department, or to another contractor at the Department's direction, without significant interruption Continue meeting each requirement of the Contract as described in the Department-approved and updated closeout plan, or until the Department determines that specific requirement is being performed by the Department or another contractor, whichever is sooner. The Department will determine when any specific requirement is being performed by the Department or another contractor, and will notify the Contractor of this determination for that requirement The Department will perform a closeout review to ensure that the Contractor has completed all requirements of the Closeout Period. The Contractor shall ensure that all responsibilities of the Closeout Period shall be complete by the termination of the Contract. In the event that the Contractor has not completed all of the requirements of the Closeout Period by the date of the termination of the Contract, then any incomplete requirements shall survive termination of the Contract Start-Up and Closeout Planning RFP # HCPFRFPSF13EHRATTAUDIT Page 20 of 24

22 Start-Up Plan During the Start-Up Period, the Contractor shall create a start-up plan that contains, at a minimum, all of the following: A listing of all personnel involved in the start-up and what aspect of the start-up for which they are responsible An operational readiness review for the Department to determine if the Contractor is operationally ready to begin performance under the Contract The operational start date, by which the Contractor will be operationally ready to begin performance under the Contract The Contractor shall not implement this plan until the Department has approved the plan. The Contractor shall begin completing all requirements of the Department-approved Start-up plan once the Department has approved the plan DELIVERABLE: Start-up plan DUE: Within five (5) Business Days of the Effective Date Closeout plan The Contractor shall create a closeout plan that describes all steps, timelines and milestones necessary to fully transition the services described in the Contract from the Contractor to the Department to another contractor selected by the Department to be the EHR Attestation Audit contractor after the termination of the Contract. The closeout plan shall also designate an individual to act as a transition coordinator, who will ensure that all steps, timelines and milestones contained in the closeout plan are completed and work with the Department and any other contractor to minimize the impact of the transition on Clients. The Contractor shall deliver the closeout plan to the Department for review and approval. No date in the closeout plan shall be scheduled to extend past the termination of the Contract DELIVERABLE: Closeout plan DUE: Thirty (30) days from the Effective Date The Contractor shall update the closeout plan, at least annually, to include any technical, procedural or other changes that impact any steps, timelines or milestones contained in the closeout plan, and deliver this closeout plan update to the Department for review and approval DELIVERABLE: Closeout plan update DUE: Annually, by June 30th of each year Upon review of the initial or closeout plans, or any closeout plan update, the Department may require the Contractor to make changes to the plan before the Department will approve the plan. The Contractor shall make all changes to these plans as required by the Department. RFP # HCPFRFPSF13EHRATTAUDIT Page 21 of 24