HHS - Medical Review Accuracy - Market Research

The Center for Program Integrity (CPI) is seeking a contractor to monitor the accuracy of CMS' Medicare and Medicaid Medical Review Contractors (MRCs) in their decision-making processes and implementation of coverage, coding, payment, and billing policies. The contractor will review a representative sample of claims to determine if the MRCs made accurate claim decisions and identify potential fraud, waste, or abuse patterns. The contract will include both Standard medical reviews for MACs, SMRCs, QIC, and RRB, as well as PI medical reviews for UPICs, SMRC PI, and SMRC HFPP. The MRAC will be responsible for conducting the reviews within specified timeframes and reporting any disagreements with the MRCs' decisions. The contract also includes requirements for information security, key personnel qualifications, and regular meetings/conference calls.

The MRAC will be responsible for conducting accuracy reviews of claims processed by Medicare and Medicaid Medical Review Contractors (MRCs). The purpose of these reviews is to measure the accuracy rate of each MRC by evaluating a representative sample of claims. The MRAC will review medical records and related documents to determine if the MRCs made accurate claim decisions in compliance with Medicare and Medicaid coverage, coding, payment, and billing policies. For PI reviews, the MRAC will also evaluate the entire investigation for potential fraud, waste, or abuse patterns. The MRAC will report any disagreements with the MRCs' decisions using Accuracy Review Disagreement Worksheets. The contract includes requirements for JOAs with the MRCs, project plans, IT systems plans, QC/QA plans, and regular meetings/conference calls.

The MRAC will be required to provide administrative support throughout the contract period. This includes communicating with Medicare contractors, providing policy interpretations, and other support deemed necessary by CPI. The MRAC must also comply with information security requirements and possess appropriate hardware, software, and telecommunications equipment. Key personnel positions include a Program Manager, Contract Medical Director, and Medical Review Managers. The MRAC must develop and submit project plans, IT systems plans, QC/QA plans, and reports on accuracy rates and workload. The contract also includes requirements for monthly cost reports, monthly workload tracker reports, and an annual performance evaluation conducted by the MRAC COR/ACOR.