Specifications include, but are not limited to: The Wisconsin Department of Health Services (DHS) is seeking proposals for Health Maintenance Organization (HMO) payment auditing services from a certified Independent Public Accounting (IPA) firm and intends to use the results of this process to award a single Contract. Under the new Centers for Medicare and Medicaid Services (CMS) Managed Care Organization (MCO) Rule for auditing requirements, 438.602 - State Responsibility - Periodic Audits. Division of Medicaid Services (DMS) has identified the need to complete audits for 16 health plans over a period of three years. DMS anticipates the resulting vendor to begin work July 2024. Auditing services will be used by DHS Bureau of Rate Setting (BRS) for External Quality Review (EQR) audits to review State Fiscal Years (SFY) 2025, 2026, 2027, 2028, 2029, 2030 and 2031. Approximately six (6) MCO’s or Prepaid Inpatient Health Plan’s (PIHP) will be audited annually. See Appendix 1 for the Audit Schedule. The Wisconsin SFY runs from July 1 through June 30. All audits under this RFP are to be conducted within an eight (8) month period after the start of that fiscal year. The initial Contract term commences July 1, 2024, and concludes June 30, 2026, with the final report for the 2025 fiscal year due April 20, 2025. If the optional renewals in the Contract term are utilized, the resulting Contract extensions would extend the Contract based on State Fiscal Year (SFY) terms to 2027, 2028, 2029, 2030, and 2031.
