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The Centers for Medicare

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... Contractor (PM) - evaluation conducted by Blue Cross Association ... Blue Cross Association recommendation for Program Management Contractor approved ... – PowerPoint PPT presentation

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Title: The Centers for Medicare


1
The Centers for Medicare Medicaid Services (CMS)
  • North Carolina Transition
  • September 6 7, 2001

2
BackgroundLegislative Authority - Fiscal
Intermediaries
  • Section 1816 of the Social Security Act
    authorizes the use of fiscal intermediaries to
    make Medicare payments to institutional providers
    of health care services, such as hospitals and
    nursing facilities.
  • This section entitles providers to nominate the
    entity to serve as their Medicare fiscal
    intermediary.
  • The Secretary is not bound to accept all
    nominations, but has no authority to contract
    outside the nomination process.
  • In 1966, the American Hospital Association
    nominated BCBSA to be the prime fiscal
    intermediary contractor -- an arrangement that
    continues today.

3
Selection Mechanism for Fiscal Intermediaries
  • For Blue Cross Plans (Part A Fiscal
    Intermediary), Blue Cross and Blue Shield
    Association subcontracts to local Blue plan with
    HCFA approval

4
General Selection Process(For new contractor or
replacement contractor)
  • Issue Request for Proposal (RFP)
  • Receive Technical and Cost Proposals
  • Convene Evaluation Board
  • Read and evaluate proposals
  • Rank offerors based on technical merit
  • Recommend awardee to selecting Officer
  • Select contractor

5
Selection Process for North Carolina
  • 2 RFPs
  • 1. Program Safeguard Contractor (PSC) -
    evaluation conducted by CMS
  • 2. Program Management Contractor (PM) -
    evaluation conducted by Blue Cross Association
  • Both procurements ranked offerors by the
    soundness of technical proposal
  • Blue Cross Association recommendation for Program
    Management Contractor approved by CMS

6
Selections for North Carolina
  • Process worked well
  • Selectees (CBA and Palmetto GBA) very
    experienced
  • in Medicare operations
  • in Part A
  • in transitions

7
Medicare Integrity Program (MIP) Background
  • Created Under The Health Insurance Portability
    and Accountability Act of 1996 (HIPAA)
  • Gives CMS Specific Contracting Authority,
    Consistent with Federal Acquisitions Regulations
    (FAR), to Enter Into Contracts with New Entities,
    not Excluding Current Fiscal Intermediaries
    Carriers, to Promote the Integrity of the
    Medicare Program.
  • CMS Awarded 13 Indefinite Delivery-Indefinite
    Quantity (IDIQ) Contracts for the PSC Effort in
    May 1999.

8
Opportunities...
  • PSCs Bring Extensive Medicare Experience and New
    Innovative Approaches to Safeguard the Medicare
    Trust Fund.
  • Partnering PSCs with Traditional Medicare
    Contractors Fosters a Commitment to Customer
    Service and Provider and Beneficiary Relations.

9
PSC Background
  • Under the PSC Umbrella Statement of Work (SOW),
    Specific Task Orders are Awarded by CMS or Other
    Government Agencies for Some/All of the
    Activities Identified in the Umbrella SOW.
  • The Western Integrity Center (WIC) PSC the
    Region A DMERC PSC are Two Examples of Task
    Orders That Have Been Awarded Implemented
    Through Successful Workload Transitions.

10
The North Carolina PSC
  • Spring 2001, BCBS of North Carolina Announced
    They Were Leaving the Medicare Program
  • CMS Saw This as an Opportunity to Create a New
    Innovative Relationship Between the Incoming
    Fiscal Intermediary a New PSC

11
The North Carolina PSC
  • This Initiative Supports CMSs Overall
    Contracting Reform Strategy Allows each
    Contractor to Focus its Strengths within its
    Current Operations.

12
Current MIP Activities
  • The Following MIP Functions are Currently
    Performed by BCBS of NC
  • Cost Report Audit, Reimbursement, Settlement
  • Prepayment Postpayment Medical Review
  • Medicare Secondary Payer
  • Contractor Medical Director
  • Local Medical Review Policy Development
  • Benefit Integrity Functions
  • Provider Education Training

13
What is the Relationship between Palmetto GBA
CBA?
  • Palmetto GBA will be the Medicare Fiscal
    Intermediary for the State of North Carolina
  • Will Perform Program Management (i.e., claims
    processing administrative functions) also
    Certain Program Integrity Activities
  • As the PSC, CBA will be Responsible for the
    Remainder of Program Integrity Functions.

14
Workload Division under the NC PSC
15
Transition Cut-Over Dates
  • In an effort to Mitigate the Risks of Concurrent
    Transitions, CMS has Decided to Transition the
    PSC Workload on October 1, 2001.
  • The Claims Processing workload will be
    Transitioned to Palmetto on October 31, 2001.

16

Provider Beneficiaries in NC
  • BCBS of NC, Palmetto, CBA, CMS are Working very
    Closely to Ensure Minimal Impact on both
    Beneficiaries the Provider Community
  • Under this new relationship, Palmetto will
    Maintain the Traditional Provider Relations
    Beneficiary Service Functions.
  • CBA, as the new PSC, will Undertake the Remainder
    of Program Integrity Functions. CBA will contact
    Providers Directly In the Event that it Requires
    Information from You in Carrying Out its
    Activities.
  • Palmetto CBA are Developing a Joint Operating
    Agreement that Defines Processes, Roles,
    Responsibilities for the New Environment.

17
Transition OversightA CMS Priority
  • We Are Committed to Making this a Seamless
    Successful Transition for Our North Carolina
    Providers Beneficiaries.
  • 5 Central Office Several Atlanta Regional
    Office Staff Members are Dedicated to Transition
    Oversight.
  • We Have Daily Weekly Calls With All Three
    Contractors Involved with this Transition are
    Ready to Handle Any Issues as They May Arise.
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