RFQ 2025-03 Second Pass Data Mining Services

CareOregon, Inc. is seeking a qualified vendor to provide second pass data mining services to help reduce claim overpayments. The selected vendor will be responsible for providing a data mining solution that can handle second pass for all claims submitted to CareOregon for payment, integrate seamlessly into the existing claims processing system, and provide a rapid solution with the ability to assess the risk of providers and target specific provider types. The vendor will also be required to provide customizable reporting, support for fraud, waste, and abuse investigations, and access to provider contracts and compliance requirements. Some key features of the desired solution include: • Data mining solution functionalities: handle second pass for all claims, integrate into existing claims processing system, provide rapid solution for risk assessment, limit manual effort, utilize statistically sound data mining technologies, process historical transaction data, and link to third-party systems and data sources. • Improper payment data mining service: identify improper payments, provide detailed analysis and auditing, and cover claims with a paid date within the previous 365 days. • Post-pay services and responsibilities: review post-pay claims for potentially improper billing practices, waste, error, mismanagement, contractual discrepancies, and other issues that could lead to improper payments. • Analytic and medical coding expertise requirements: demonstrate experience and expertise in identifying analytics related to overpayments, pinpoint and coordinate edits to prevent future errors, and utilize qualified coders in data mining activities. • Volume and opportunity expectations: anticipate steady volumes as data mining issues transition into pre-payment claims corrections, and new data mining activities are expected to continuously identify additional areas of opportunity. • Exclusion of clinical chart audits: second pass data mining activities do not include clinical chart audits, and there will be no requests for medical records for second pass data mining services. • Collaborative and transparent approach: work collaboratively, flexibly, and transparently with CareOregon, hold monthly meetings with the CareOregon Contract Administrator, and provide customizable reporting to meet CareOregon's specific needs.