Title: The Centers for Medicare
1The Centers for Medicare Medicaid Services (CMS)
- North Carolina Transition
- September 6 7, 2001
2BackgroundLegislative 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.
3Selection 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
4General 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
5Selection 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
6Selections for North Carolina
- Process worked well
- Selectees (CBA and Palmetto GBA) very
experienced - in Medicare operations
- in Part A
- in transitions
7Medicare 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.
8Opportunities...
- 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.
9PSC 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.
10The 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
11The North Carolina PSC
- This Initiative Supports CMSs Overall
Contracting Reform Strategy Allows each
Contractor to Focus its Strengths within its
Current Operations.
12Current 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
13What 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.
14Workload Division under the NC PSC
15Transition 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.
16Provider 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.
17Transition 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.