Notice ID: 220374
The Centers for Medicare & Medicaid Services (CMS) is hereby conducting market research to identify 8(a) small businesses to support informed decisions to procure an Independent Coding Consultant (ICC) for their services to support CMS, and specifically the Center for Program Integrity (CPI), in its Medicare Risk Adjustment Data Validation (RADV) program. The purpose of the ICC is to provide expert coding support for the Medical Record Reviews (MRR) for the Contract-Level RADV.
The Contract-Level RADV project includes the following processes:
Sampling. For the Contract-Level RADV audit, CMS uses defined criteria by which to select statistically valid samples of enrollees for the purpose of estimating payment error. For the contract-specific samples, CMS may target and/or randomly select MA contracts to undergo RADV audits. A random sample of enrollees is selected from each audited contract. The enrollee samples selected for the Contract-Level audits are used for estimating payment error with the intent of conducting payment recovery based on MRR findings for individual contracts.
Medical Record Request. CMS notifies MA organizations of their selection for RADV and requests primary points of contact that will be responsible for facilitating the RADV process on behalf of the MA organization. CMS then sends each selected MA contract a medical record request for submission of medical records to support the CMS-HCCs for each enrollee in the MA contract’s sample.
Medical Record Submission and Receipt. MA organizations are required to submit the requested enrollee medical records to CMS’ designated contractor for medical record receipt and intake. The records go through a logging and technical assistance process, where necessary, in preparation for MRR.
Medical Record Review (MRR). Certified medical record ICD-9/10-CM coders review the medical records submitted by the MA organizations and abstract diagnoses in accordance with the ICD-9/10-CM coding guidelines.
Medical Record and Payment Error Findings. Corrected enrollee CMS-HCC profiles are developed based on the MRR results. These findings are used to develop corrected payment error results for each sampled enrollee. CMS sends MA organizations in the Contract-Level samples the MRR results for their sampled enrollees. CMS also gives the organizations the opportunity to submit a dispute, which provides an explanation from the plan as to why a discrepant MRR finding is incorrect.
Medical Record Disputes (MRD). MA organizations who wish to dispute discrepant CMS-HCC results may submit their disputes, following CMS official guidelines for this process. The organization-submitted disputes are then reviewed by medical record reviewers and final determinations to either uphold or overturn a CMS-HCC discrepancy are made.
Final RADV Medical Record and Payment Error Findings. CMS re-establishes individual CMS-HCC profiles and correct payments based on the results from the MRDs. The revised enrollee-level results are then extrapolated to estimate payment error for the Contract-Level population, and a payment recovery amount is established based on CMS’ policies.
