Riverbend

Tennessee

AdvanceMed
P.O. Box 148089
Nashville, Tennessee 37214
Web site: none available

In April 2003, the Centers for Medicare & Medicaid Services (CMS) awarded a Program Safeguard Contractor (PSC) Task Order to AdvanceMed, a subsidiary of Computer Science Corporation (CSC), to perform as the PSC for the Riverbend Government Benefits Administrator Part A workload in the State of Tennessee. Riverbend Government Benefits Administrator will remain as the Medicare Part A Intermediary and will maintain many of their current functions including claims processing, customer service, prepayment and post payment medical review and data analysis to support these activities, appeals, provider enrollment, financial accounting, Medicare Secondary Payer, and related provider education and beneficiary outreach activities. As the PSC, AdvanceMed will be responsible for benefit integrity (BI) functions, medical review to support BI activities, data analysis and related provider education and beneficiary outreach activities. In order to ensure a seamless transition and to maintain the same high level of customer service, AdvanceMed will closely coordinate with Riverbend Government Benefits Administrators on all Part A activities under a mutually agreed upon Joint Operating Agreement (JOA). Additionally, AdvanceMed will have an office in Nashville, TN, where most of the Benefit Integrity functions will be performed. Information technology and data analysis support will be provided by AdvanceMed's Columbia, MD office.

AdvanceMed, Riverbend Government Benefits Administrator, and CMS are working closely to ensure an orderly transition of the Part A Benefit Integrity duties and responsibilities, effective July 1, 2003.

About AdvanceMed

AdvanceMed is a subsidiary of Computer Sciences Corporation (CSC). CSC is a leading provider of information technology services to commercial and government markets worldwide. CSC has approximately 90,000 employees, of which more than 40,000 are serving U.S. federal customers in 750 locations worldwide. AdvanceMed currently employs over 700 healthcare information management professionals, including clinicians, analysts, investigators, IT systems and administrative support personnel. It is also affiliated with more than 350 board-certified, actively practicing medical specialists, and sub-specialists. The company has extensive experience in the areas of healthcare data management, health information services, assessment of healthcare quality, analysis of Medicare and Medicaid clinical and claims data, waste fraud and abuse detection, payment error prevention, Medicare policy and coverage issues, and development of training programs and educational materials. Seventy percent of AdvanceMed's business is with CMS programs. AdvanceMed also had an 11-year tenure with the Department of Defense (DOD) in support of quality assessment and improvement for approximately 100 hospitals, including the development of cost effective, accurate, and meaningful analytic and web-based reporting tools. Other customers have included Health and Human Services, Office of the Inspector General, the Consumer Product Safety Commission, and eight state Medicaid agencies.

AdvanceMed's Current Relationships Within CMS

Program Safeguard Contractor

AdvanceMed has served as a PSC for CMS since 1999, and has managed the following PSC operations:

• Statistical Analysis Center (SAC)
• Therapy Review Program (TRP)
• Comprehensive Error Rate Testing (CERT)
• Systems Security Requirements (SSR)
• Ohio/West Virginia Part B PSC
• Tennessee/North Carolina Part B PSC
• Arkansas/Louisiana/Oklahoma Part A and Part B PSC

Activities under these operations include:

• Medical review of Medicare Part A and Part B claims
• Analysis of Part A and Part B claims data for utilization analysis and identification of patterns of potential fraud and/or abuse
• Analysis of the impact of policy changes on the delivery of Medicare services
• Development of recommended medical review strategies for intermediaries and carriers
• Development of educational and research materials for providers, Medicare contractors, and beneficiaries, including establishment of an educational website
• Assisting CMS with replies to complex policy and coverage issues raised by contractors, providers and beneficiaries
• Working with stakeholder groups, including representatives from intermediaries and carriers, provider and beneficiary advocacy groups, and professional associations.
• Part A/B/DME cross claims statistical analysis and reporting
• Development and operation of data security systems
• Post payment medical review
• Fraud case detection and development
• Provider education and beneficiary fraud awareness activities
• Start-up and transition management

Clinical Data Abstraction Centers (CDAC)

AdvanceMed has managed this operation since 1994, processing high volume random claim samples. Activities have included:

• Evaluation of claims' coding
• Beneficiary and provider surveys
• Development of training plans for interviewers and abstractors
• Classroom and workstation training
• Well established QA procedures

Other CMS Programs

AdvanceMed has conducted several other specialized projects for CMS. These include participation with an expert panel to develop CMS Protocols for State Medicaid Agencies and a more recent pilot program to coordinate CMS Medicare Centers of Excellence protocol (criteria and metrics) development and implementation.

Questions and Answers Regarding a New Program Safeguard Contractor for Riverbend Government Benefits Administrator

What is a Program Safeguard Contractor (PSC)?

The Health Insurance Portability and Accountability Act of 1996 created the Medicare Integrity Program (MIP). MIP was established, in part, to strengthen CMS's ability to deter fraud and abuse in the Medicare program. This provision gives CMS specific contracting authority, consistent with Federal Acquisition Regulations, to enter into contracts with entities to promote the integrity of the Medicare program. CMS calls these MIP specialty contractors Program Safeguard Contractors (PSCs). PSCs can take on some, all, or any subset of the work associated with the following payment safeguard functions: medical review, cost report audit, data analysis, provider education and fraud detection, and prevention. For additional information regarding the MIP authority and/or PSCs visit CMS's MIP website at www.cms.gov/medicare.

What Medicare providers are affected by this change?

The providers in the state of Tennessee that bill Medicare will be affected by this announcement.

How was the PSC contractor selected?

CMS awarded the task order to AdvanceMed to better align the Benefit Integrity work for Tennessee.

When will this transition occur? How will providers and beneficiaries be impacted in Tennessee?

The transition period began immediately upon contract award and the workload transfer will be completed on July 1, 2003. At that time, AdvanceMed will begin performing benefit integrity activities aimed to reduce fraud and abuse in the Medicare program. Activities associated with this workload may include fraud case development, data analysis, medical review to support fraud and abuse cases, complaint processing, etc. Riverbend Government Benefits Administrator will remain as the Part A Intermediary for Tennessee. Riverbend Government Benefits Administrator will maintain its claims processing activities and certain program integrity functions aimed at reducing the Medicare fee-for-service error rate. Riverbend Government Benefits Administrator, AdvanceMed, and CMS will work closely to ensure minimal impact on both beneficiaries and the provider community. Under this new arrangement, Riverbend Government Benefits Administrator will maintain the traditional provider relations and beneficiary service functions. Advanced Med will contact providers directly in the event that it requires information from you in carrying out its activities, and any such request will contain instructions on when, where, and how to respond.

Why did CMS decide to enter into this arrangement?

This contract arrangement is consistent with CMS's business plan for Medicare fee-for-service claims operations and supports CMS's efforts to improve its oversight of Medicare contractors. Using the PSCs to creatively partner with traditional Medicare contractors is a win-win situation for all involved, CMS, the PSC, the Intermediary, and Medicare providers and beneficiaries, because it allows all parties to focus on their strengths and provide quality services to our Medicare providers and beneficiaries.

What is the relationship between Riverbend Government Benefits Administrator, as the Part A Carrier and AdvanceMed as the Part A PSC?

Riverbend Government Benefits Administrator will remain as the Medicare Part A Intermediary in Tennessee. As the Intermediary, Riverbend Government Benefits Administrator will continue to perform both program management (i.e., claims processing and administrative) and program integrity functions aimed at reducing the Medicare fee-for-service error rate (i.e., Medical Review, Medicare Secondary Payer, and Local Coverage Determination Policy development). As the PSC, AdvanceMed will be responsible for performing appropriate activities to reduce fraud and abuse in the Medicare Program in Tennessee. These activities may include fraud case development, data analysis, medical review in support of fraud and abuse cases and complaint development.

What activities will each contractor be performing?

Riverbend Government Benefits Administrator will continue to perform both program management (i.e., claims processing and administrative) and program integrity functions aimed at reducing the Medicare fee-for-service error rate (i.e., Medical Review, Medicare Secondary Payer, and Local Coverage Determination development). AdvanceMed will be responsible for performing appropriate activities to reduce fraud and abuse in the Medicare Program. See chart below for illustration of the MIP activities CMS expects to be performed by the PSC and Riverbend Government Benefits Administrator MIP Operations as of July 1, 2003.

AdvanceMed Activities

• Fraud Case Development
• Data Analysis
• Law Enforcement Support
• Medical Review to Support Fraud and Abuse Cases
• Civil Monetary Penalties
• Fraud Prevention/Detection Education
• Fraud Complaint Processing

Riverbend Government Benefits Administrator Activities

• Medical Review to Support the Identification of Payment Errors
• Education to Reduce Payment Error
• Contractor Medical Director Activities
• Local Coverage Determination Policy development
• Consent Settlement
• Clearinghouse Activities
• Initial Complaint Screening
• Harkin Grantee Process and Tracking System

How is CMS assuring that Medicare beneficiaries and providers experience no interruption in service during the transition of activities from Riverbend Government Benefits Administrator to AdvanceMed?

CMS has transitioned workload on a number of occasions. CMS will require that Riverbend Government Benefits Administrator and AdvanceMed work together to ensure that all key Medicare functions be maintained during the transition.

How is CMS going to ensure that Riverbend Government Benefits Administrator, the Part A Intermediary, and AdvanceMed, the new PSC, properly coordinate their activities and respond to provider needs?

The accountability for ensuring that the two contractors coordinate properly rests with CMS. Through active involvement in the transition process, CMS will ensure that both parties understand their individual and collective roles and responsibilities. In addition, CMS will require both contractors to enter into a Joint Operating Agreement. This document will delineate each contractor's roles and responsibilities, including how each will operate and coordinate activities and data between them. CMS will monitor both contractors and the Joint Operating Agreement throughout the life of both parties' contracts.

Will AdvanceMed establish operations in Tennessee?

AdvanceMed has an office in the Nashville, TN area. Most of the activities under this task order will be performed in the Nashville office, with data analysis and IT systems support provided by AdvanceMed's Baltimore, MD PSC operations.

Will AdvanceMed retain current Riverbend Government Benefits Administrator Integrity staff?

AdvanceMed intends to interview current, qualified Riverbend Government Benefits Administrator staff that is interested as candidates for potential positions within its Nashville PSC operations.

When will the transition of the Riverbend Government Benefits Administrator benefit integrity activities be completed?

The transfer activities will be completed on July 1, 2003