rfp question answer 1. 2. 1 of 3 3. 1 of 3 4. 1 of 3 5. 2

# RFP Section RFP Page # Question Answer

1.

Attachment A Section 1.0

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Who were the last award-winning bidders for this RFP?

Health Management Systems, Inc.

2.


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Who are the current vendors providing these services and how long have they been the incumbent?

Health Management Systems, Inc. since 2015.

3.


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Which insurance companies are involved in this audit?

Aetna, AvMed, Florida Blue, and United HealthCare.

4.


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Are there any contractual agreements between the insurance companies and the Agency in place? If so, will this information be available for review to verify overpayments?

Please see the summary plan descriptions at https://www.mybenefits.myflorida.com/health/resourc

es. Please see TPA contracts at https://www.dms.myflorida.com/workforce_operations/state_group_insurance/legislative_and_policy_resour

ces/vendor_contracts. It should be noted that this audit will only include Aetna, AvMed, Florida Blue

and, United HealthCare. 5.


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How many claims are involved in this audit and how old are these claims?

In 2020, approximately 362,525 claims were processed with a total dollar amount of $112,955,194. The Department currently operates on a fiscal year audit period with ability to look back 12 months. If there are widespread issues we will look back up to three or four years. Lookback periods can change with TPA/HMO contract language changes

6.


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What challenges have the agency faced in the past while conducting such audits?

Audit period, final report timing, processes to transfer information, tracking return of funds back to the State of Florida.

7.


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How many overpaid claims were detected prior and what were those amounts?

For fiscal year 2019-2020 approximately 744 claims totaling $340,111.00 was determined overpaid.

8.


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Will there be access to ALL necessary documentation needed to complete the audit in each claim?

Yes, within the scope of applicable authority.

Questions and Answers DMS-21/22-186

Post Payment Claim Audit Services

DMS-21/22-186 Qusetions and Answers

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https://www.mybenefits.myflorida.com/health/resources


https://www.dms.myflorida.com/workforce_operations/state_group_insurance/legislative_and_policy_resources/vendor_contracts



9. Forms Form 5 Mandatory Responsiveness Requirement

3.6 Once awarded, would the Respondent need to obtain a Performance Bond?

Yes, please refer to Attachment B – Draft Contract, Section 8.2, Performance Bond

10. RFP Sec. 1.1 4 of 25 Would you please confirm the historical value of this contract is $90,000 per annum? If not, would you please provide an updated annual spend?

Please see the contract payment details which are public record at: https://facts.fldfs.com/Search/ContractDetail.aspx?AgencyId=720000&ContractId=SI036

11. RFP, Sec. 3, Q. #10

Please clarify Section 3, Question 10, “Please describe your Post Payment Claims Audit Plan solution, including the specific details for detecting overpaid claims based on the plan design.” • “Based on plan design” could be interpreted as overpayments specific to “Summary Plan Description”. Is this the intent? • We assume that “Plan design" varies across the 6 or 7 unique TPAs that the State currently contracts with. Is this accurate?

Plan design is interpreted as overpayments specific to the Summary Plan Description. The plan design does vary. Please see all Summary Plan Descriptions pertaining to the “plan design” at: https://www.mybenefits.myflorida.com/health/resources.

12. SOW What is the plan period (fiscal years) open for review? I.e. a. 1 Year (July 1st, 2020 to June 30th 2021) b. 2 Years (July 1st, 2019 to June 30th 2021) c. 3 Years (July 1st, 2018 to June 30th, 2021) d. 3+ years

Plan periods for audit are based on the fiscal year. A three year contract would result in three audit periods: 07/01/2021-06/30/2022 07/01/2022-06/30/2023 07/01/2023-06/30/2024 Additional audit periods may or may not be included depending on any potential contract amendments.




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https://facts.fldfs.com/Search/ContractDetail.aspx?AgencyId=720000&ContractId=SI036




13. SOW Does the review include all covered participants? i.e. a. Active Employees and dependents b. Retired Members c. COBRA Members d. All the Above

D. All of the above.

14. SOW Does the review include all health plans? I.e.

a. Standard PPO b. Standard HMO c. High Deductible PPO (including

HSA)? d. High Deductible HMO e. All of the above f. Other

E. All of the above; for vendors: Aetna, AvMed, Florida Blue, and United HealthCare.

15. SOW Which of the following does the review include? i.e.

a. Medical b. Dental c. Vision d. Pharmacy

Medical

16. SOW What administrators does the review include, and what plans by those administrators? I.e. • Florida Blue

a. Standard PPO b. High Deductible PPO

• Aetna

a. Standard HMO b. High Deductible HMO

• AvMed

Aetna – All plans AvMed – All Plans Florida Blue – All Plans United HealthCare – All Plans




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• Capital Health Plan a. Standard HMO b. High Deductible HMO

• UnitedHealthcare


• UnitedHealthcare

a. MA-PD PPO Plan

• Humana a. MA-PD HMO Plan

• Other dental and vision administrators

17. SOW What restrictions (if any) do the Administrative Service Agreements with the third-party administrators place on review activities? I.e.

b. Limit the type of audit c. Limit access to key data

elements d. Limit access to the provider

contracts e. Limit access to network payment

policies

Please see all TPA contracts located at: https://www.dms.myflorida.com/workforce_operations/state_group_insurance/legislative_and_policy_resources/vendor_contracts.

18. SOW Does the review consider “ASO” agreement terms (i.e., additional cost containment fees, or other vendor fees associated with plan administration, etc.)

No. This is post payment claims only.




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19. SOW Is the State considering the review of data to identify price gouging?

Please see scope of work in RFP.

20. SOW Is the State interested in determining not only what the plan was overcharged, but what the member was specifically overcharged?


21. SOW Is the State interested in benchmarking price disparities between in-network and out of network services?


22. SOW Is the State interested in reviewing the efficacy of “cost containment programs” provided by the third-party administrators and their vendors?


23. N/A Is there opportunity in this RFP to propose Onsite Credit Balance Review services?


24. For calendar years 2019 and 2020, respectively, how many audits/reviews were performed by category/claim type?

One audit is produced annually. TPA’s are notified of potential overpayments monthly in order to reconcile. Categories vary according to contractor’s filters and findings.

25. For calendar years 2019 and 2020, respectively, what were the total findings/dollars recovered by category/claim type?

Categories vary year to year.

26. How many third-party administrators (TPAs) are involved in processing claims?

4, for this audit.

27. How many claims systems are utilized for claim processing? Does each system provide claims data to the vendor separately, or is all claims data provided in one combined data set and consistent format?

TPA’s administer the claims processing.

28. Does the vendor recover all identified overpayments, or does the state offset?

Vendor tracks all recoveries returned the State of Florida and reports the amount and method recovered.




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29. Would you please confirm the historical value of this contract is $90,000 per annum? If not, would you please provide an updated annual spend?

See answer to #10 above.

30. RFP Sec. 3.6 Please clarify how the Department would like respondents to “tab” electronic responses. For example, would the Department prefer a single document with “tab” pages between each part, or would the Department prefer respondents to submit each tabbed item as a separate document?

Submit each tabbed item as a separate document.

31. Attch. G - Subs Would the Department please provide Attachment G in an editable format (e.g., Excel) for ease of entering responses into the document?

Respondents may convert Attachment G – Subcontractors to Word or Excel and submit as converted.

32. Attachment A, Section 1.0

1 of 3 Will the State please provide the number of TPAs and HMOs this audit will encompass?

Four (4).


1 of 3 Will this audit include the fully insured HMOs?

No.


1 of 3 Will the State please provide the annual claim counts and dollars paid for the plans that will be included?

Annual claim count is 362,525 and a total dollar amount of $112,955,194


1 of 3 Is the State interested in claims that may be overpaid due to clinical reasons, such as DRG and Place of Service reviews?

Yes.


2 of 3 Will the Contractor recover the overpaid claims directly from the provider or will the TPA/HMO initiate and maintain the recovery process?

The contractor MUST be able to provide the Department with recovery tracking. The funds are transferred directly from the TPA/HMO to the State of Florida.


2 of 3 Is the TPA/HMO required to return the agreed-upon overpayment to the State within a specified period? If yes, will the State please provide that timeframe?

TPA/HMO's are required to return all identified confirmed overpayments to the State of Florida within 90 days.




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2 of 3 If the TPA/HMO is handling the recovery process from their providers, will the State please further explain the Contractor’s responsibilities for bullets 4, 5, and 6 of this section? (Notification of overpaid amounts to providers/subscribers (all notifications must be approved by the State), Recovery of overpayments in compliance with state and federal rules and regulations regarding the recovery of overpaid claims, Develop recovery process, including but not limited to the generation of recovery letters, lag reports, etc.)

The Division of State Group Insurance (DSGI) must approve the method of notification of overpayments to the TPA/HMO. Each claim that is a potential overpayment needs to be tracked through completion. This is currently done on a monthly revolving basis because claims take time to recover. The vendor will secure the date, amount, and method of all funds returned to the state before a bill can be sent to the State of Florida.


1 of 3 Is the State interested in the Contractor setting up a process with the TPA/HMOs for the review of claims on a prepayment basis? If yes, would the State apply the contingency fee proposed for overpayment recovery to the identified savings from this process?

We do not have statutory authority for prepayment recovery, at this time.


1 of 3 Do the TPA/HMOs have other parties actively reviewing and auditing the claims processed on behalf of the State Health Plans? If yes, will the State please provide the annual overpayment amounts from these TPA/HMOs?

The TPA/HMO's do their own internal auditing and DSGI does not retain or request this information.


1 of 3 Will the State consider adding pharmacy claims to this scope of work?

It is a possibility but at this time the post payment claims audit is done separately.


1 of 3 Any significant business requirements that HMS should understand regarding your business? If yes, do these requirements vary by review type (i.e. Clinical, Data Mining, Pharmacy

Our business requirements would rest on Florida Statute and the contract language in the TPA/HMO Contracts.


1 of 3 Are all 3 lines of business in scope? (Commercial, Medicare, Medicaid)?

Commercial. Coordination of Benefits with Medicare is encompassed.




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1 of 3 Do you have multiple vendors in place? Are you looking for a 2nd or 3rd pass vendor? Provide for each Solution

There is one vendor. We will not be using more than one vendor. However, Pharmacy claims are audited separately on a different contract.

45. Attachment E 2 of 4 For each of the Performance Guarantees that are measured at 100%, is the State be willing to reduce this amount to 95%?

No.

46. RFP, Section 1.3.6

4 of 25 Are there limits to the format and/or size of an attachment that a bidder can submit via MyFloridaMarketPlace?

The MyFloridaMarketPlace (MFMP) Sourcing application requires that submissions be in PDF, Word, or Excel formats. Upload size is restricted to 20 MB.


2 of 3 Does the State have the ability to dictate pass position of audit to the TPAs? i.e. HMS would receive preference over internal TPA audits or their third-party vendors.

No.


2 of 3 Can the State provide the number of other audit vendors (including internal teams withing TPAs and their third parties for this scope for each TPA)?

That information is not available to the State of Florida.


2 of 3 Will the State allow for continuous identification of overpayments up to as frequently as weekly?

Yes. This is currently done monthly but the State of Florida is open to negotiation of frequency.


2 of 3 Will HMS have remote, read-only access to each of TPAs claim processing system?

No.


2 of 3 Will hard copy provider contract (e.g. pdfs) be available to review by the vendor?

These contracts are available at: https://www.dms.myflorida.com/workforce_operations/state_group_insurance/legislative_and_policy_resources/vendor_contracts.


2 of 3 Will the State provide the membership enrollment volume by TPA/Plan and the dollar spend by claims type for each TPA/Plan for the last State Fiscal Year (July 2020-June 2021)?

PPO (Florida Blue): Avg Monthly Enrollment 82,372 AvMed HMO Avg Monthly Enrollment: 25,388 UHC HMO Avg Monthly Enrollment: 7,222 Aetna HMO Avg Monthly Enrollment: 28,079 DSGI does not retain YTD spend broken down by each individual HMO plan. Spend is as follows:




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PPO (Florida Blue) Medical Costs only: $746,829,039.00 HMO (Aetna, AvMed, & UHC): $809,212,616

53. Att. B - Draft Contract

10 of 35 What is the estimated number of years expected to maintain Retention of Records.

The State of Florida follows the record retention schedule located at: https://files.floridados.gov/media/703328/gs1-sl-2020.pdf

54. Att. D - Administrative Requirements

3 of 4 Has the department identified prior audit methodologies that have worked with their requirements? Ex. AICPA methodologies

The methodology for this particular audit is unique to the data set, TPA’s analyzed, and the respective contract requirements.

55. 1. RFP No. DMS-2122-186

7 of 25 Based on the respective Section, it appears the department is encouraging use of diversity in its procurements. However, it does not appear the Evaluation score card is awarding points for use of Prime contractors or subcontractors who are MWBE. Would the Department consider adding to the evaluation score card points for utilization of MWBE at the Prime Contractor and/or Subcontractor level?

The Department will take this into consideration for future procurements. Visit the below link for current opportunities: https://www.dms.myflorida.com/agency_administration/office_of_supplier_diversity_osd/vendor_resources2/current_bid_opportunities

56. 1. RFP No. DMS-2122-186

11 of 25 Will the contract resulting from this procurement serve as a backdrop contract the Department of Management Services can use to acquire services for related future initiatives?

No. The result of this solicitation will not be a state term contract.

57. 1. RFP No. DMS-2122-186

11 of 25 Is there an incumbent firm for these services or similar type of services? If so, what is the current dollar amount and effective dates of the contract?

Please see the contract information located at: https://facts.fldfs.com/Search/ContractDetail.aspx?AgencyId=720000&ContractId=SI036

58. 1. RFP No. DMS-2122-186

11 of 25 Is the Department working with a current vendor on services similar to those described in the scope of work? If yes, who

Yes. Health Management Services. The contract is currently at 18.7% fixed fee pricing. Please see contract information at:




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https://files.floridados.gov/media/703328/gs1-sl-2020.pdf

https://files.floridados.gov/media/703328/gs1-sl-2020.pdf

https://www.dms.myflorida.com/agency_administration/office_of_supplier_diversity_osd/vendor_resources2/current_bid_opportunities





is the vendor and what is the annual contract amount?


59. 2. DMS-2122-186 Att. A - Statement of Work

1 of 3 Is there anticipated/ budgeted number of post payment claims to be reviewed?

No. Currently 100% of all claims are reviewed for exceptions and further investigation.

60. 2. DMS-2122-186 Att. A - Statement of Work

1 of 3 Is there an anticipated/ budgeted number of hours per post payment claim review?

No. Please see Florida Statute 110.12301 which states, in part: “……Compensation under the contract shall be paid from amounts identified as claim overpayments that are made by or on behalf of the health plans and that are recovered by the vendor. The vendor may retain that portion of the amount recovered as provided in the contract. The contract must require the vendor to maintain all necessary documentation supporting the amounts recovered, retained, and remitted to the division…..”

61. 6. DMS-2122-186 Att. E - Performance Guarantees

All Pages (4)

Is there an anticipated/ budgeted total number of hours for each of the following sections: 1) Implementation and Planning 2) Deliverables 3) Reporting

No. Please see Florida Statute 110.12301 which states, in part: “……Compensation under the contract shall be paid from amounts identified as claim overpayments that are made by or on behalf of the health plans and that are recovered by the vendor. The vendor may retain that portion of the amount recovered as provided in the contract. The contract must require the vendor to maintain all necessary documentation supporting the amounts recovered, retained, and remitted to the division…..”

62. 9. DMS-2122-186 Att. H - Technical Questions

1 of 2 Is software required to be created to fulfill the requirements of the proposal such as implementation, planning, delivery, and reporting?

It is not required but, the vendor must provide a efficient and effective method for delivering information to all parties.




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63. 3. DMS-2122-186 Att. B - Draft Contract

14 of 35 Does the department anticipate any required in person meetings; whether with the departments of the Claimants under review?

No. However, a in person meeting may be required by the department at its discretion.

64. General If any firms are interested with partnering with our firm (Rosales Financial Group) for this opportunity, a certified FL MWBE firm, may the department advise of our interest?

Please see information at the below link: https://www.dms.myflorida.com/agency_administration/office_of_supplier_diversity_osd/events

END of Q&A




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