A. RFP Objective and Project Overview The purpose of this Request for Proposals (RFP) is for the Department of Medical Assistance Services (DMAS) to solicit proposals from qualified and innovative health care auditing firms that can deliver the services requested in an efficient and effective manner while ensuring the highest standards of performance, integrity, customer service, and fiscal accountability. As a result of this RFP, DMAS intends to select a qualified Supplier to perform audits of all Fee for Service (FFS) providers that participate in the Virginia Medicaid program, including in and outof-state providers. The Supplier selected will also provide comprehensive Managed Care Organization (MCO) oversight as it relates to DMAS program integrity efforts, including all relevant contractual deliverables. The Supplier shall have access to FFS claims information and MCO encounter data that may help identify trends in their data analysis efforts, including across the FFS and managed care delivery systems. Specifically, DMAS is utilizing RFP# 44362 to solicit proposals for a qualified Supplier to perform the following: 1. Provide comprehensive general auditing services as required by the Division of Program Integrity (PI) for all DMAS service provider types that participate in the Virginia Medicaid program to include both fee-for-service (FFS) and managed care. a. Introduce prevention and deterrence activities, where applicable, to safeguard the program and ensure the appropriate use of Medicaid funding. b. Provide recommendations that will expand program integrity efforts for both FFS and MCO high-risk providers. To that end, the Supplier shall, in parallel, present mitigation plans and corrective course of action plans to ensure vulnerabilities are addressed. c. Conduct focused reviews rendered by fee-for-service and managed care provider networks, and specialty provider services such as behavioral health. d. Utilize technology and operating systems for real-time reporting, data mining, recoveries and investigations. e. Utilize technology solutions that will be used for documentation repositories specifically being able to extract documentation and make it readily available to end users. f. Ensure staffing includes a team of highly skilled, technically competent, ethical, and professional auditing personnel, trained in identifying fraud, waste and abuse, in both Medicaid FFS and managed care programs. g. Provide comprehensive behavioral health provider auditing services as required by the Division of Program Integrity (PI) for all Virginia Medicaid behavioral health service providers (additional service types may be added or substituted at a later date at DMAS’ discretion); h. Ensure that the personnel assigned to the contract by the Supplier have a comprehensive working understanding of State and federal Medicaid laws and regulations, to include all provider manual policies and procedures for FFS and managed care programs. Personnel shall consistently apply such laws and regulations when performing audits of selected Medicaid enrolled providers. i. Ensure that personnel assigned to the contract by the Supplier are trained on Virginia Medicaid Service Authorization criteria and coverage rules.
