Solicitation of Interest (SOI) for NYS Home Health Medicare Maximization

NOTE: This is NOT a Request for Proposals. Rather, it is an invitation to furnish NYS with information regarding interest and capability to participate in this initiative. Under Federal regulation and New York State law, Medicaid is mandated to be the payor of last resort if any legally liable third party exists that must pay all, or part of a Medicaid client's services covered under the Medicaid State Plan. As such, the purpose of this Solicitation of Interest (SOI) is to identify individuals or organizations that have the capability to ensure that Medicare coverage of home healthcare services is maximized for dual eligible recipients (those who are eligible for both Medicaid and Medicare) through a demand bill and Medicare appeal process. The required capabilities include coordination of home health Medicare maximization procedures with OMIG, the provider community, and the entities involved in the Medicare appeals process which may include the Medicare Administrative Contractors (MAC), the federal Office of Medicare Hearings and Appeals (OMHA), the Departmental Appeals Board (DAB), and Federal District Court (FDC). Specific activities include, but are not limited to, data analysis and case selection to determine which cases are most likely to be eligible for Medicare coverage, giving direction to providers regarding demand billing, collecting and collating documentation for appeals, filing appeals, and representation at Medicare hearings. Work also includes the monitoring and reconciliation of recovered funds, invoicing, and auditing of non-compliant providers. Due to the lengthy Medicare appeals process, recovery often takes in excess of a year to complete and for the contractor to subsequently receive compensation. This OMIG recovery contract is contingency based. The selected vendor will be paid a percentage of the Medicare payment received when demand billing or appeals result in favorable coverage determinations, and/or a percentage of the Medicaid recoveries from audits of non-compliant providers.