Description
The Centers for Medicare & Medicaid Services (CMS) is seeking information from potential contractors to determine their capability to perform post-payment medical reviews and related tasks for the Medicare program. The work includes performing medical reviews, data analysis, and claim scrubbing, as well as providing appeals support and educating providers on claim review findings. The contractor must have experience with operating a similar healthcare-related medical review operation and integrating and managing all components outlined in the Sources Sought Notice.
Some key requirements for potential offerors include:
• Demonstrating extensive knowledge and experience with operating a similar healthcare-related medical review operation
• Experience with performing high volumes of post-payment medical review for Medicare FFS claims
• Capability to perform program integrity medical reviews to identify fraud, waste, and abuse
• Experience with data analysis to identify a claims sample and performing claim scrubbing activities
• Knowledge of the Medicare program and related coverage, coding, and billing criteria
• Capability to handle high-volume document management functions and provide appeals support