Updated August 25, 2021
Notice ID: OIG260145
“Description of Amendment/ Modification: New Medical Review IDIQ, Period of Performance: Twelve (12) months from the date of award, Plus four (4) Option Years.”
“C.1 STATEMENT OF OBJECTIVES
1.1 Medical Review of Claims
The resulting contract(s) will require medical review of claims and the supporting medical record documentation as part of audits and less frequently other OIG activities (e.g., evaluations or investigations). Prior to the medical review, the OIG will select the claims for review and in all cases collect the medical documentation. The number of claims and timeframes will vary by review. Claim reviews require, at a minimum, the clinical evaluation of medical records and related documents to determine whether Medicare claims were billed and paid in compliance with Medicare’s coding, coverage, billing and payment requirements.”
“A medical record is the systematic documentation of a single beneficiary’s medical history and care across time. Medical record review is the evaluation of the beneficiary’s information and medical records to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements. When clinical judgment is needed, a medical record review must be performed by appropriate licensed professionals within the scope of their practice.”
“The Contractor(s) will perform medical record review of claims that are generated from all fifty (50) States and in six (6) territories. The Contractor(s) shall develop medical record review instruments for each review (e.g., audit) firmly grounded in correct and applicable Medicare criteria. The Contractor(s) shall provide a detailed final review results letter for each sampled claim. The final review results letter must contain an accurate and appropriate summary of all facts needed to support the determination and correctly summarize Medicare requirements. The letter should clearly explain the basis for each decision in a logical, thorough and fact-based manner. The letter should be written in plain English with all medical terminology that would be unfamiliar to a layman defined…”
Posted September 4, 2020
Notice ID: OIG260145
The scope of the resulting contract(s) will include medical review and consultative services associated with the oversight activities of the OIG primarily involving Medicare fee-for-service payments. Occasionally it may include assessment of services and claims for Medicaid or Medicare Part D. Based on prior experience, the resulting contract(s) will require medical review of approximately 100-200 claims and associated medical records per audit and approximately 2,000-3,000 claims and associated medical records per annum, but actual workload under the resulting contract(s) could fluctuate based on potential future changes in OIG’s budget, shifts in OIG’s priorities, and other factors.
The scope of the resulting contract(s) will not include determining OIG priorities; identifying auditees and subject matter of audits; claims sampling; and establishing audit objectives, scope and methodology; however, OIG may in its discretion ask for input on these matters as part of consultative services (see below). OIG will collect claims data, medical records and other supporting documents in accordance with each audit’s objectives. OIG will transmit those documents electronically through its secure file transfer system or occasionally in hard copy through the U.S. Postal Service or other parcel delivery service. The resulting contract(s) will not include responsibility for those functions.
The Contractor(s) will perform medical record review of claims that are generated from all fifty (50) States and in six (6) territories. The Contractor(s) shall develop medical record review instruments foreach review (e.g., audit) firmly grounded in correct and applicable Medicare criteria. The Contractor(s) shall provide a detailed final review results letter for each sampled claim. The final review results letter must contain an accurate and appropriate summary of all facts needed to support the determination and correctly summarize Medicare requirements. The letter should clearly explain the basis for each decision in a logical, thorough and fact-based manner. The letter should be written in plain English with all medical terminology that would be unfamiliar to a layman defined.
1.2 Consultative Services
Consultative services will consist of oral and written interactions with the OIG during all phases of the audit. Consultative services also will consist of assisting the OIG both orally and in writing in responding to auditee comments and other information received by the OIG pertaining to work previously conducted by the awardee, as well as making available for discussions with the OIG and CMS or an auditee, the professional personnel who performed said work in support of any given audit. In the foregoing instances, consultative services may not necessarily involve a separate task order from the medical review; the OIG looks forward to solutions proposed by Offerors during the Oral Presentations and PWS/QCP and Price Proposal phases of this award.
