Department of Health and Human Services (HHS), Office of Inspector General (OIG), Acquisitions Division (AD), Washington, DC is pursuing the acquisition of medical review (MR) and consultative services to assist the OIG in conducting its’ oversight responsibilities regarding the programs operated by the Department of Health and Human Services.
The acquisition will primarily result in services that support the OIG’s auditing function and the production of audit reports.
The resulting contract will include professional services to determine whether selected medical services and claims pertaining to beneficiaries of Medicare (and occasionally Medicaid) complied with coverage, coding, payment, and billing requirements and to provide medical consultative services to the OIG with respect to such services and claims. The acquisition is primarily to assess services and claims for Medicare fee-for-service payments for Part A and Part B. Other analyses on an infrequent basis may include assessment of services and claims for Medicaid or the Medicare Prescription Drug Plan (Part D).
Vendors will be required to perform medical review of claims and the supporting medical record documentation as part of the development of audits and other OIG activities (e.g., evaluations or investigations). Prior to the medical review, the OIG will select the claims for review and in most 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…
The Contractor will perform medical record review and/or support a large volume of claims that are generated from all fifty (50) States and in six (6) territories.
Consultative services will primarily 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. In addition, consultative services may include providing expertise on a wide variety of medical related issues including assistance in assessing risk in designing future oversight activities or in assessing the Medicare program to identify fraud, waste, and abuse vulnerabilities.