**IMPORTANT NOTICE**
- The format of this RFP has been simplified.
- Only the following pages require signatures:
- Exhibit A – Bid Response Packet, Bidder Information and Acceptancepage
- Must be signed by Bidder
- Exhibit A – Bid Response Packet, SLEB Partnering Information Sheet
- Must be signed by Bidder
- Must be signed by SLEB Partnerif subcontracting to a SLEB
Please read EXHIBIT A – Bid Response Packet carefully,INCOMPLETE BIDS WILL BE REJECTED. Alameda County will not accept submissions or documentation after the bid response due date.
COUNTY OF ALAMEDA
REQUEST FORPROPOSAL No. 901149
for
Workers’ Compensation Medical Bill Review and Pharmaceutical Benefit Management
For complete information regarding this project, see RFPposted ator contact the County representative listed below. Thank you for your interest!Contact Person:Michael Lu, Contracts Specialist II
Phone Number: (510) 208-9649
E-mail Address:
RESPONSE DUE
by
2:00 p.m.
on
December 30, 2013
at
Alameda County, GSA–Purchasing
1401 Lakeside Drive, Suite 907
Oakland, CA 94612
Alameda County is committed to reducing environmental impacts across our entire supply chain.
If printing this document, please print only what you need, print double-sided, and use recycled-content paper.
COUNTY OF ALAMEDA
REQUEST FORPROPOSALNo.901149
SPECIFICATIONS, TERMS & CONDITIONS
for
Workers’ Compensation Medical Bill Review and Pharmaceutical Benefit Management
TABLE OF CONTENTS
Page
I.STATEMENT OF WORK
A.INTENT
B.SCOPE
C.BACKGROUND
D.BIDDER QUALIFICATIONS
E.SPECIFIC REQUIREMENTS
F.DELIVERABLES / REPORTS
II.CALENDAR OF EVENTS
G.NETWORKING / BIDDERS CONFERENCES
III.COUNTY PROCEDURES, TERMS, AND CONDITIONS
H.EVALUATION CRITERIA / SELECTION COMMITTEE
I.CONTRACT EVALUATION AND ASSESSMENT
J.NOTICE OF RECOMMENDATION TO AWARD
K.TERM / TERMINATION / RENEWAL
L.QUANTITIES
M.PRICING
N.AWARD
O.METHOD OF ORDERING
P.INVOICING
Q.ACCOUNT MANAGER / SUPPORT STAFF
IV.INSTRUCTIONS TO BIDDERS
R.COUNTY CONTACTS
S.SUBMITTAL OF BIDS
T.RESPONSE FORMAT
ATTACHMENTS
EXHIBIT A -BID RESPONSE PACKET
EXHIBIT B - INSURANCE REQUIREMENTS
EXHIBIT C - VENDOR BID LIST
EXHIBIT D –MEDICAL BILL REVIEW/PREFERRED PROVIDERORGANIZATION/PHARMACEUTICALBENEFIT MANAGEMENT QUESTIONNAIRE
Specifications, Terms & Conditions
for Workers’ Compensation Medical Bill Reviewand Pharmaceutical Benefit Management
I.STATEMENT OF WORK
A.INTENT
It is the intent of these specifications, terms and conditions todescribeworkers’ compensation medical bill review and pharmaceutical benefit management services.
The County intends to award a 3-year contract withone2-year option to renew by mutual consentto the bidder selected as the most responsible bidder whose response conforms to the RFP and meets the County’s requirements.
B.SCOPE
The County of Alameda is seeking a Contractor to provide workers’ compensation medical bill review and pharmaceutical benefit management services. Contractor shall have the technical expertise to interface electronically with, but not limited to, the State reporting system, the Workers’ Compensation Third Party Administrator (TPA), other managed care contractors, and medical providers.
C.BACKGROUND
For the past five (5) years, the County has utilized separate providers for workers’ compensation TPA and workers’ compensation managed care services. Although the jobs were separately bid, the Medical Bill Review / Pharmaceutical Benefit Management (MBR/PBM)and TPA services were coincidentally awarded to the same company while the Utilization Review / Peer Review (UR/PR) and Medical Case Management (MCM)services were awarded to another vendor.
The County is now separatelybidding out the MBR/PBM and the UR/PR/MCM services. Although the County will be contracting with the managed care contractor, the County expects the transition and the on-going relationship between the TPA and the managed care contractor to be seamless and result in timely payment of all invoices.
The TPA shall forward all medical and pharmaceuticalbills to the MBR/PBMcontractor for fee reduction services. Likewise, the UR/PR/MCM contractor shall provide its services and shall communicate with the TPA and the MBR/PBM contractor in a timely and professional manner. It is critical that the MBR/PBMcontractor be able to work with the MCM contractor and with the TPA and have the technical expertise to develop the Electronic Data Interface (EDI) to facilitate data receipt and transmissionwith each other.
The history of the number of transactions by the type of services is as follows:
2010 / 2011 / 2012Number of Transactions / Number of Transactions / Number of Transactions / Average
Total Number of Medical Bills (including Pharmaceutical) / 14,484 / 16,298 / 18,579 / 16,454
Total Number of PharmaceuticalBills / 343 / 1,046 / 1,284 / 891
D.BIDDER QUALIFICATIONS
1.BIDDER Minimum Qualifications
a.Bidder shall be regularly and continuously engaged in the business of providing workers’ compensation medical bill review and pharmaceutical benefit management services for at least five(5) years.
b.Bidder shall be certified by the State of California Department of Insurance as required in accordance with section 11761 of the California Insurance Code.
c.Bidder shall possess all permits, licenses and professional credentials necessary to perform services as specified under this RFP.
E.SPECIFIC REQUIREMENTS
1.MEDICAL BILL REVIEW (MBR), PREFERRED PROVIDER ORGANIZATION (PPO), PHARMACEUTICAL BENEFITS MANAGEMENT (PBM):
a.MBR Contractor Services
(1)Contractor shall provide workers’ compensation medical bill review services. The bill review services shall include, but are not limited to:
(a)mail intake operations, scanning, indexing, imaging and Optical Character Recognition (OCR) operations,
(b)application of the Official Medical Fee Schedule (OMFS) for California Workers’ Compensation, manual technical review (i.e. level of service adjustments),
(c)application of fair and reasonable standards, PPO discount, Usual and Customary schedules, negotiated rates, and other pricing services.
Invoices for scheduled and non-scheduled services as well as in- patient and outpatient hospital services shall be subject to bill review.
(2)Contractor shall identify and correct fee schedule excesses, duplicate charges (full and partial), and billing infractions, and recognize and unbundle service codes as appropriate.
(3)Contractor shall integrate the recommendations of utilization review and physician review findings into its system to manage utilization according to evidence based guidelines. This integration and data exchange shall include application of prospective utilization review determinations as well as identification of treatment requiring formal application of clinical utilization review. The above applies to all types of billings including, but not limited to: medical, legal, treatment or pharmaceutical billings.
(4)The tentative workflow for bills is expected to be as follows:
(a)Contractor receives bills from the County’s TPA and within 24 hours, identifies bills by such fields as claim number, social security number and/or claimant name.
(b)Contractor shall review and process all bills within 10 days of receipt and send to County’s TPA, via Electronic Data Interface (EDI), the imaged copy of the bill and the preliminary Explanation of Benefits/Explanation of Remittance (EOB/EOR) using an interface to the County’s TPA claims management system. The bills must be sent at the line item level to the claims management system.
(c)Contractor shall send a file daily with objection letter image files and EOB/EOR’s to the TPA via EDI.
(d)Contractor shall also be responsible for reporting partial payments, reconsidered bills and full payment status to the State of California via EDI.
(5)Contractor and TPA will also develop procedures for other types of review such as those for Rushes (e.g. advance payment) and Review-Only bills (e.g. settlement negotiation) at no additional cost to the County.
(6)Contractor shall have the capability to report payment information to the State of California as required by the California Department of Industrial Relations, Division of Workers’ Compensation, Workers’ Compensation Information System (DWC/WCIS) and provide California Electronic Data Interface reporting of all paid billings of all types as well as zero pay billings as outlined in International Association of Industrial Accident Boards and Commissions, ANSI format 837 (IAIABC 837). Any future EDI requirements for communication such as electronic billing and EOB transmittal shall be included in the Contractor’s base bill review proposal. Contractor will have the obligation to audit and reconcile the County payment record with its records.
(7)Contractor shall receive from and return files to the TPA by File Transfer Protocols (FTP). The return files shall capture the disposition status of each bill (i.e. whether it was paid in full, partial paid, denied, etc.). Contractor shall integrate data from said return file into its State EDI reporting file.
(8)Contractor shall be able to process and receive bills from a variety of sources including, but not limited to, the TPA, the provider submitted electronic format,as well as those processed from the Workers’ Compensation Electronic Data Interface (WCEDI) system without further processing or programming from the TPA.
(9)Contractor shall develop an EDI with the TPA’s current claims management systemfor both receipt and delivery of bills submitted for review. Should TPA implement a new system, Contractor shall develop a new EDI at no additional cost to the County.
(10)Contractor shall provide customer service and quality control personnel to manage and resolve medical provider re-evaluations, inquiries, and complaints.
(11)Contractor shall own or lease its bill review software.
(12)Contractor shall upload three (3) years of County of Alameda payment history data, available from the prior bill review contractor, regardless of amount of data or payment date, at no additional cost to the County.
(13)Contractor shall have an auditable comprehensive quality control and quality assurance program.
(14)Contractor will provide adequate staff and resources, as required, to provide timely service to the County account.
b.MBR Contractor’s PPO / PBM Services
Contractor shall ensure that the PPO will include providers offering traumatic accident psychiatric injury care (post-traumatic stress disorder) with 24/7 availability from at least five(5) separate County wide locations.
(1)The physicians that participate in the PPO and PBM shall be credentialed and qualified medical providers.
(2)Contractor shall establish a network that encompasses ancillary services including, but not limited to:
(a)Durable Medical Equipment,
(b)Imaging, and
(c)All Diagnostics
Contractor shall ensure that pharmacy benefit management services provide effective and necessary drug therapies at the lowest net cost to the County.
F.DELIVERABLES/REPORTS
The Contractor must have information technology resources adequate to support imaging/indexing of all workers’ compensation correspondence and interfaces between its system and the TPA system as well as be compliant with all State reporting requirements. The State requirements include, but are not limited to, integrating data feeds from all ancillary service providers and TPA’s claims management system into one (1) State Electronic Data Interface (EDI) feed to comply with California Workers’ Compensation Information System (WCIS) regulations for medical bill/payments and UR reporting requirements.
1.Contractor will provide monthly reports that contain the following data elements:
a.Net full and partial duplicate charges and savings;
b.Net all charges and savings related to examiner-directed bill payments, review-only bills, and non-reviewable documents such as provider appeal letters;
c.Net all charges and savings related to disallowances due to enforcement of Utilization Review and case management treatment limitations/denials;
d.Net all charges and savings related to enforcement of California 24-visit cap to Physical Therapy/Occupational Therapy/Chiropractic Services (PT/OT/CS) medical treatment utilization; and
e.The net impact of reconsiderations (i.e. savings are adjusted to reflect the impact of reconsiderations). Results must reflect the final determination only.
II.CALENDAR OF EVENTS
EVENT / DATE/LOCATIONRequest Issued / November 7, 2013
Written Questions Due / by 5:00 p.m. onNovember 27, 2013
Networking/Bidders Conference #1 / November 26, 2013@ 10:00a.m. / at: Public Works Agency
Room 230 A/B
951 Turner Court
Hayward, CA 94545
Networking/Bidders Conference #2 / November 27, 2013@ 2:00 p.m. / at:Lakeside Plaza Building
1107, 11th Floor
1401 Lakeside Dr.
Oakland, CA 94621
Addendum Issued / December 12, 2013
Response Due / December 30, 2013by2:00 p.m.
Evaluation Period / December 30, 2013 – January 24, 2014
Vendor Interviews / January 16 – January 17, 2014
Board Letter Recommending Award Issued / February 24, 2014
Board Consideration Award Date / March 25, 2014
Contract Start Date / April 1, 2014
Note:Award and start dates are approximate.
G.NETWORKING / BIDDERS CONFERENCES
Networking/bidders conferences will be held to:
1.Provide an opportunity for Small Local Emerging Businesses (SLEBs) and large firms to network and develop subcontracting relationships in order to participate in the contract that may result from this RFP.
2.Provide an opportunity for bidders to ask specific questions about the project and requestRFP clarification.
3.Provide the County with an opportunity to receive feedback regarding the project and RFP.
All questions will be addressed, and the list of attendees will be included, in an RFPAddendum following the networking/bidders conferences.
Potential bidders are strongly encouraged to attend networking/bidders conferences in order to further facilitate subcontracting relationships. Vendors who attend a networking/bidders conference will be added to the Vendor Bid List. Failure to participate in a networking/bidders conference will in no way relieve the Contractor from furnishing services required in accordance with these specifications, terms and conditions. Attendance at a networking/bidders conference is highly recommended but is not mandatory.
III.COUNTY PROCEDURES, TERMS, AND CONDITIONS
H.EVALUATION CRITERIA / SELECTION COMMITTEE
All proposals will be evaluated by a County Selection Committee (CSC). The County Selection Committee may be composed of County staff and other parties that may have expertise or experience in workers’ compensation medical bill review,preferred provider organization and pharmaceutical benefit management. The CSC will score and recommenda Contractor in accordance with the evaluation criteria set forth in this RFP. The evaluation of the proposals shall be within the sole judgment and discretion of the CSC.
All contact during the evaluation phase shall be through the GSA–Purchasing Department only. Bidders shall neither contact nor lobby evaluators during the evaluation process. Attempts by Bidder to contact and/or influence members of the CSC may result in disqualification of Bidder.
The CSC will evaluate each proposal meeting the qualification requirements set forth in this RFP. Bidders should bear in mind that any proposal that is unrealistic in terms of the technical or schedule commitments, or unrealistically high or low in cost, will be deemed reflective of an inherent lack of technical competence or indicative of a failure to comprehend the complexity and risk of the County’s requirements as set forth in this RFP.
Bidders are advised that in the evaluation of cost it will be assumed that the unit price quoted is correct in the case of a discrepancy between the unit price and an extension.
As a result of this RFP, the County intends to award a contract to the responsible bidder whose response conforms to the RFP and whose bid presents the greatest value to the County, all evaluation criteria considered. The combined weight of the evaluation criteria is greater in importance than cost in determining the greatest value to the County. The goal is to award a contract to the bidder that proposes the County the best quality as determined by the combined weight of the evaluation criteria. The County may award a contract of higher qualitative competence over the lowest priced response.
The basic information that each section should contain is specified below, these specifications should be considered as minimum requirements. Much of the material needed to present a comprehensive proposal can be placed into one of the sections listed. However, other criteria may be added to further support the evaluation process whenever such additional criteria are deemed appropriate in considering the nature of the services being solicited.
Each of the Evaluation Criteria below will be used in ranking and determining the quality of bidders’ proposals. Proposals will be evaluated according to each Evaluation Criteria, and scored on the zero to five-point scale outlined below. The scores for all Evaluation Criteria will then be added, according to their assigned weight (below), to arrive at a weighted score for each proposal. A proposal with a high weighted total will be deemed of higher quality than a proposal with a lesser-weighted total. The final maximum score for any project is five hundred fifty (550) points, including the possible fifty (50) pointsfor local and small, local and emerging, or local preference points(maximum 10% of final score).
The evaluation process may include a two-stage approach including an initial evaluation of the written proposal and preliminary scoring to develop a short list of bidders that will continue to the final stage of oral presentation and interview and reference checks. The preliminary scoring will be based on the total points, excluding points allocated to references, oral presentation and interview.
If the two-stage approach is used, the five bidders receiving the highest preliminary scores and with at least 200 points will be invited to an oral presentation and interview. Only the bidders meeting the short list criteria will proceed to the next stage. All other bidders will be deemed eliminated from the process. All bidders will be notified of the short list participants; however, the preliminary scores at that time will not be communicated to bidders.
The zero to five-point scale range is defined as follows:
0 / Not Acceptable / Non-responsive, fails to meet RFP specification. The approach has no probability of success. If a mandatory requirement this score will result in disqualification of proposal.1 / Poor / Below average, falls short of expectations, is substandard to that which is the average or expected norm, has a low probability of success in achieving objectives per RFP.
2 / Fair / Has a reasonable probability of success, however, some objectives may not be met.
3 / Average / Acceptable, achieves all objectives in a reasonable fashion per RFP specification. This will be the baseline score for each item with adjustments based on interpretation of proposal by Evaluation Committee members.
4 / Above Average / Good / Very good probability of success, better than that which is average or expected as the norm. Achieves all objectives per RFP requirements and expectations.
5 / Excellent / Exceptional / Exceeds expectations, very innovative, clearly superior to that which is average or expected as the norm. Excellent probability of success and in achieving all objectives and meeting RFP specification.
The Evaluation Criteria and their respective weights are as follows: