Cherokee Nation Businesses, LLC. Request for Proposal. For Pharmacy Audit

Transcription

1 Cherokee Nation Businesses, LLC Request for Proposal For Pharmacy Audit

2 Purpose & Objectives Cherokee Nation Businesses, LLC ( CNB ) is seeking responses from qualified vendors to perform an audit of the accuracy of claims processed by ExpressScripts on behalf of CNB for period of May 1, 2015 to September 30, The overall objective of the engagement will be to assess the adequacy and effectiveness of operational internal controls relating to the processing and administration of medical claims, reinsurance, flex spending accounts by HBS. A combination of electronic and sampling methodologies are expected to assess the accuracy and timeliness of processes. The audit should be conducted in accordance with the International Standards for the Professional Practice of Internal Auditing. The selected firm will provide its expected timeline for services and demonstrate its ability to complete a successful audit within the parameters outlined in this request. The firm must possess excellent analytical skills, in depth industry knowledge, and the capability to provide expert advice. Client Overview The Cherokee Nation is the largest Native American tribe in the United States. A sovereign government, the Cherokee Nation s historical and modern-day jurisdictional boundaries cover all or part of 14 counties in northeast Oklahoma. The Cherokee Nation has more than 280,000 citizens spread over the United States and plays a vital role in the lives of more than a hundred thousand Cherokee citizens in northeast Oklahoma. As a government entity, the Cherokee Nation administers many typical government functions, including safety, health, infrastructure, education, and economic development services. A major economic driving force in the area, the Cherokee Nation and its business entities employ more than 6,500 people. Cherokee Nation Businesses is the economic engine for the Cherokee Nation. As its sole shareholder, the Cherokee Nation has tasked CNB with developing sustainable businesses that create profit and job opportunities within the Cherokee Nation. Structured as a holding company, CNB owns subsidiary companies, segmented by industry portfolios and focused in Gaming & Hospitality, Property Management, Aerospace Manufacturing, Telecom, Office Supply & Electronics Distribution, Information Technology & Research, Healthcare, Environmental & Construction and Security & Defense. CNB Benefits Overview Cherokee Nation Businesses strives to provide a comprehensive benefits package that is competitive, cost-effective for both the company and our employees, and strives to embrace a healthy culture. Our goal is to support the health and well-being of our employees by offering high quality, cost effective benefits and services that respond to the diverse needs 2 P a g e

3 of our workforce. Our benefits are a key component to total compensation. CNB provides three different employee benefit plans across its businesses. All three plans are self-insured, preferred provider plans, using the extensive BlueCross BlueShield of Illinois network. Plan 1 has approximately 3,700 participants. Plan 2 has approximately 1000 participants. The third plan has approximately 200 participants. The plans are employee welfare benefit plans within the meaning of the ERISA. The plans are self-insured medical plans intended to meet the requirements under Sections 105(b), 105(h) and 106 of the Code. CNB has contracted with a TPA to perform certain consultative and management services related to the plans. CNB is the plan administrator and named fiduciary of the plans and retains ultimate authority. HealthSmart Benefit Solutions, Inc. (HBS) is the TPA and will process claims and answer benefit and claim questions. The plans are group health plans for purposes of HIPAA and should be administered in a manner consistent with HIPAA. The plans are not grandfathered plans under the Affordable Care Act. Guidelines for Proposal Submission Vendor s proposal in response to this RFP will be incorporated into the final agreement between CNB and the selected vendor. The submitted proposals should include each of the following sections: 1. Executive Summary 2. Company Overview 3. Scope, Approach and Methodology 4. Project Deliverables 5. Project Management Approach 6. Detailed and Itemized Pricing 7. Project Team Staffing 8. References The detailed requirements for each of the above-mentioned sections are outlined below. Detailed Response Requirements Executive Summary This section will present a high-level synopsis of the Vendor s response to the RFP. The Executive Summary should be a brief overview of the engagement, and should identify the main features and benefits of the proposed work. Company Overview Provide the following for your company: 3 P a g e

4 Official registered name (Corporate, D.B.A., Partnership, etc.), address, main telephone number, toll-free number, and facsimile number. Key contact name, title, address (if different from above address), direct telephone and fax number. Person authorized to contractually bind the organization for any proposal against this RFP. Brief history, including year established and number of years your company has been offering TPA audits. Scope, Approach, and Methodology Include high-level testing procedures and technical expertise. This section should include a description of work being requested of the vendor. All information that is provided will be held in strict confidence. Project Deliverables Include descriptions of the types of reports used to summarize and provide detailed information on project plan including milestones, periodic updates to CNB on status and findings, a final report including executive summary, audit methodology, detailed findings, and recommended corrective actions. Include a sample report as an attachment to the proposal to provide an example of the type of report that will be provided for this engagement. Project Management Approach Include the method and approach used to manage the overall project and client correspondence. Briefly describe how the engagement proceeds from beginning to end. Detailed and Itemized Pricing Include a fee for audit services and if applicable, estimates of travel expenses. Project Team Staffing Include biographies and relevant experience of key staff and management personnel. Describe the qualifications and relevant experience of the types of staff that would be assigned to this project by providing biographies for those staff members. References Provide three current corporate references for which you have performed similar work, including name of principle, title and phone number. Proposal Format 1) Proposal Response a. Bid responses are to be sealed and labeled NP&V Assessment b. Responses must include the following or otherwise will be disqualified: 4 P a g e

5 i. Executed Business Collusion Affidavit ii. Executed Business Relationship Affidavit iii. Three hard copies and one electronic copy (USB drive) of bid response c. Front and back copies of Cherokee Nation Tribal Employment Rights Office certification (if awarded contract) Proposals are due no later than 2:00pm CST on Wednesday, November 16, ) No electronic submissions will be accepted. A total of 3 hard copies and one soft copy (USB drive) is required. 3) Proposals are to be either hand delivered or mailed to: Cherokee Nation Businesses, LLC ATTN: Tina Jones Senior Buyer IV 777 W. Cherokee Street Catoosa, OK IF HAND DELIVERY, DELIVER TO: Cherokee Nation Businesses, LLC ATTN: Tina Jones Senior Buyer IV Corporate Building # N. 193 rd East Ave. Catoosa, OK ) Questions are to be submitted via to Tina Jones, tina.jones@cnent.com, no later than 3:00PM CST on Wednesday, November 2, All questions will be answered, compiled and then posted on the website with all other RFP documents. 5) Awarded party will be required to execute a CNB Non-Disclosure Agreement. (Sample Attached) 6) Awarded party will be required to execute a CNB Consulting Services Agreement. (Sample Attached) Please note that bidders may be asked to participate in a conference call or potentially come on site for an interview and presentation of their bid response. TERO This procurement is subject to Cherokee Nation Tribal Employment Rights Office ( TERO ) regulations that include a fee of ½ of 1% of total contract award and, if applicable, the completion of a TERO Labor Agreement and payment of associated fees. The successful bidder s award will be published on the Cherokee Nation s procurement website and their performance will also be measured, recorded, and reported to the Cherokee Nation. The 5 P a g e

6 complete Act is available by contacting the TERO OFFICE at Tahlequah TERO bidders are required to provide a copy, front and back, of their TERO certificate with return bid(s) and failure to do so will result in such bidders not receiving the TERO preferences afforded TERO bidders under the CNB procurement and contracting policies and procedures. DEBARMENT By submitting a response to this Request for Proposal, the Contractor certifies to the best of their knowledge and belief that the Contractor, the firm, or any of its principals are not presently debarred, suspended, or proposed for debarment by any federal, state, local or tribal entity. This certification is a material representation of fact upon which reliance was placed when making award. If it is later determined the Contractor rendered an erroneous certification, in addition to other remedies available to CNB or its entities, CNB may terminate the contract resulting from this Request for Proposal for default. Pharmacy audit - scope items for RFP: The primary objective of our audit is to estimate, with a high degree of statistical significance, the accuracy of claims processed by ExpressScripts on behalf of CNB. Scope will include: Verify the average wholesale price (AWP) with outside pricing guides on the date dispensed for 100% of the transactions Verify that the retail, mail order, specialty pricing for brand drugs are taken in accordance with the contract terms Verify that the maximum allowable cost (MAC) list is performing in accordance with plan provisions or at least at AWP 65% for retail and AWP 80% for mail order Verify all aspects of plan design including copays, limits, exclusions and prior authorizations Electronically audit 100% of pharmacy claims to ensure payment accuracy Verify the plan is being administered in compliance with contractual obligations and that the plan sponsor is receiving all benefits of the contracted arrangement Confirm the proper application of various pricing elements related to claim cost determination, such as negotiated discounts and MAC applications Validate benefits are managed accurately and in accordance with the plan document Validate that pricing and discount guarantees are in place applied appropriately Rebates are transparent, calculated correctly and being passed thru in accordance with the contract Overpayment recoveries being reported to CNB and being recouped in an accurate and timely manner Review policies, procedures and internal controls to identify fraud, waste and abuse both internally and with plan participants Review process to evaluate and determine formulary list 6 P a g e

7 Review specialty pharmacy protocols and determine if proper internal controls are adequate Report Format and Content A written report of findings shall be presented in draft form CNB for its review. After CNB s review, audit firm will provide draft audit report to ExpressScripts for comments back within 10 business days. This written evaluation shall include: Objectives of the audit Audit methodology Evaluation of the ExpressScripts policies and administration for managing claims costs to ensure that procedures support maximized savings Number of claims examined and total paid amount of the claims Number and dollar value of claims with financial errors and/or procedural errors expressed both in total dollars and as a percentage of the total claims audited A description of the error categories found during the review with attention to systemic or human cause and required corrective measures Identify error patterns or trends, identify causes, assess effects, and provide recommendations for corrections Provide a table of payment errors with a clear description of the sampled error and/or other errors detected through review of the patient s history; the report should clearly identify those errors that were subject to internal audit but bypassed detection An action plan for overpayment recovery should be included within the report recommendations Comparison of audit results to performance guarantees and industry standards Recommendations to improve overall administration and/or claims processing accuracy Assess the ExpressScripts quality control and audit program, including in-house training programs, frequency of audits, and types of audits performed. 7 P a g e