R710--Third Party Billing

Consolidated Patient Account Center (CPAC) Revenue Operations (RO) Performance Work Statement (PWS) SCOPE The Contractor shall provide all labor and equipment required for generation of Veteran Affairs (VA) and Non-VA outpatient claims to third party healthcare insurance carriers for CPAC sites nationwide. BACKGROUND The Department of Veterans Affairs (VA) has historically relied on contract services to improve collections through timely and accurate billing of third-party claims. VA’s CPACs are responsible for billing and collecting from insurance companies for medical treatment provided to veterans for Non-Service Connected (NSC) conditions. There are 7 regional CPACs located as follows: Station 730, Asheville, NC- Mid-Atlantic CPAC (MACPAC)Station 731, Smyrna, TN- Mid-South CPAC (MSCPAC)Station 732, Middleton, WI- North Central CPAC (NCCPAC)Station 733, Orlando, FL- Florida Caribbean CPAC (FCCPAC)Station 734, Lebanon, PA- Northeast CPAC (NECPAC)Station 735, Leavenworth, KS- Central Plains CPAC (CPCPAC)Station 736, Las Vegas, NV- West CPAC (WCPAC) The Department of Veterans Affairs (VA) is currently undergoing a reorganization that may result in future changes to its organizational structure, processes, responsibilities, and priorities. Such changes could affect the customers, services, or support described in this Performance Work Statement (PWS). Accordingly, the Contractor shall remain adaptable and responsive to evolving VA requirements and work in close coordination with the Government to assess and implement necessary adjustments, as needed. Any resulting changes will be completed by bilateral contract modification. Public Law 99-272 grants VA authority to seek reimbursement from third party health insurers for the cost of medical care furnished to an insured non-service connected (NSC) veteran. Public Law 101-508 expanded VA's recovery program by providing authorities to seek reimbursement from third party payers for the cost of medical care provided to ensure service-connected veterans treated for their NSC conditions. OBJECTIVES The primary objective of this Performance Work Statement (PWS) is to outline the medical billing services for VA Care and VA Care in the Community to generate accurate and timely third-party claims for CPAC sites nationwide. TASKS AND DELIVERABLES Contractors shall provide services to establish and authorize outpatient medical claims to third party insurance carriers in the VA Veterans Health Information Systems and Technology Architecture (VistA) information system or the most current system in accordance with VA established guidelines. Please be aware, VISTA is a Disk Operating System (DOS) based system, minimum expectation is to manually process 16-25 for VA Care claims, and approximately 12-18 Community Care claims per hour per biller. Our legacy VA systems do not interface with modern Graphical User Interface billing software. Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. Timely completion: Medical claims will be completed by the last calendar day of the month that patient service encounters are assigned. Contractor and employees of contractor cannot utilize VA proprietary tools, such as MACROS or automation tools while performing work. Deliverable – Authorization and release of outpatient medical claims Medical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. The estimated timeframe to complete one claim is approximately 3 minutes. Timely completion of outpatient medical claims: Medical claims are generated within the month they are received from CPAC Billing Accuracy: Medical claims are authorized and released in accordance with CPAC guidebooks and VA policy and directives Work claims rejections: Rejected claims will have an initial review within 5 business days, with follow-up every 15 days. Accurate canceling claims and assigning correct Reason Not Billable (RNB): Claims are appropriately canceled in VistA or most current system and correct RNB is assigned in Claims Tracking Resolving billing related questions and concerns: Open lines of communication are always maintained between Contractor and CPAC Conference call participation: Contractor participates in conference calls, as needed, to improve billing performance Maintain VistA access (or current system): Contractor shall log onto the VistA system for each CPAC Medical Center at least once every 14 days to maintain this access. If an individual worker does not log on to our systems for a length of 30 days or more, their access must be reset. Resetting access is a time consuming process on our end. For this reason, the company must ensure that all workers log in at least once every 14 days. Confidentiality: Contractor shall ensure all claims are released in compliance with VA specific requirements. Deliverable – Authorization and release of outpatient medical claims tasks for VA Care in the CommunityMedical billing is to be performed within industry standards and in accordance with VA Guidebooks and policies. The estimated timeframe to complete one claim is approximately 4 minutes. Timely completion of outpatient medical claims: Medical claims are generated within the month they are received from CPAC Billing Accuracy: Medical claims are authorized and released in accordance with CPAC guidebooks and VA policy and directives Work claims rejections/denials: Rejected/denied claims will have an initial review within 5 business days, with follow-up every 15 days. Accurate canceling claims: Claims are appropriately canceled in VistA or most current system Assigning correct activity code: Encounters are assigned appropriate activity code. Resolving billing related questions and concerns: Open lines of communication are always maintained between Contractor and CPAC Conference call participation: Contractor participates in conference calls, as nee…