Supplemental Medical Review Contract

Summary (Newest Update)

Background The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that administers the Medicare and Medicaid programs. A top priority for CMS is reducing improper payments in the Medicare Fee-for-Service (FFS) program and reducing fraud, waste, and abuse (FWA). To protect the Medicare Trust Fund, CMS must prevent improper payments that result in a loss of taxpayer dollars. The Supplemental Medical Review Contractor (SMRC) is sought to perform post-payment medical reviews and related activities to support initiatives within the Center for Program Integrity (CPI). This includes conducting nationwide comprehensive medical review documentation to identify FWA and protect the Medicare Trust Fund. Work Details The SMRC will perform various tasks including: 1) Conducting PCG Specialty Reviews for issues identified by Federal agencies; 2) Performing Program Integrity Reviews in collaboration with the Fraud Investigations Group; 3) Conducting large volumes of post-payment medical reviews on Medicare FFS claims for Part A, Part B, and durable medical equipment; 4) Assessing compliance with Medicare’s coding, coverage, billing, and payment requirements; 5) Recommending recoupment or adjustment for improperly paid claims; 6) Conducting research and data analysis; 7) Providing customer service support; 8) Defending medical review decisions at ALJ hearings; 9) Managing records and work tracking; 10) Transitioning at contract close-out. Optional tasks may include ad-hoc innovation projects and statistical extrapolation of overpayments. Period of Performance The geographic location(s) the contract will be performed (if provided) Place of Performance The contract will be performed across all fifty states and six territories. Bidder Requirements Bidders must have personnel with relevant healthcare experience, including clinical backgrounds for complex reviews. Key personnel must include a Project Manager with at least five years of experience in healthcare project management, an Assistant Project Manager with three years of experience, a Contractor Medical Director who is a licensed physician with Medicare FFS claim experience, and Medical Review Managers who are registered nurses with extensive knowledge of the Medicare program. All key personnel must not have been sanctioned or excluded from the Medicare Program.