Ohio Public Employees Retirement System REQUEST FOR PROPOSAL (RFP) For. MEDICAL AUDITOR of OPERS HealthCare Vendors/Products

Transcription

1 Ohio Public Employees Retirement System Request for Proposal Ohio Public Employees Retirement System REQUEST FOR PROPOSAL (RFP) For MEDICAL AUDITOR of OPERS HealthCare Vendors/Products Date: June 30, East Town Street Columbus, Ohio PERS (7377)

2 Table of Contents A. BACKGROUND... 3 B. OVERVIEW... 3 C. MINIMUM REQUIREMENTS... 4 D. SCOPE OF ENGAGEMENT... 4 D1 - D8. D9 - D18. D19 - D25. NON-MEDICARE AUDIT 5 MEDICARE AUDIT..7 GENERAL...8 E. PROPOSAL CONTENT E1. COVER LETTER E2. QUESTIONNAIRE E3. UNDERSTANDING OF ENGAGEMENT E4. WORK PLAN (including timeline with details of hours) E5. DELIVERABLES E6. AUDITOR PERSONNEL E7. REFERENCES E8. COST E9. SAMPLE CONTRACT E10. ADDITIONAL INFORMATION F. SELECTION CRITERIA G. GENERAL TERMS AND CONDITIONS FOR SUBMITTING PROPOSALS H. INSTRUCTIONS FOR SUBMITTING PROPOSALS EXHIBIT A... 22

3 A. BACKGROUND Retirement System In 1935, the Ohio Public Employees Retirement System (OPERS) began a tradition of providing excellent retirement benefits for state employees. With approximately $88.6 billion in assets as of 12/31/13, the System provides retirement, disability, and survivor benefit programs for public employees throughout the state who are not covered by another state or local retirement system. OPERS serves more than 814,000 members of more than 3,700 public employers and over 193,000 participants and surviving beneficiaries who receive monthly benefits. Financial Information The most recent OPERS Comprehensive Annual Financial Report is available on the OPERS website at: B. OVERVIEW The purpose of this Request for Proposals (RFP) is to seek proposals from qualified firms to conduct the two (2) audits described in this RFP over a period of three (3) years. OPERS seeks one (1) firm to conduct both the audits; for this RFP, OPERS will not consider awarding contracts to more than one firm to conduct fewer than both audits. A responding vendor must include both audits in its proposal for its proposal to be considered. See Section C, Minimum Requirements (and RFP process discussed below). A responding vendor also must include in its proposal pricing information using the form attached as Exhibit A to this RFP. A responding vendor will be referred to as You, Your or Your Organization throughout this RFP, as the context indicates. The firm that may be selected as a result of this RFP (Selected Auditor) must have the demonstrated experience and expertise to conduct both audits. The Selected Auditor also must possess excellent analytical skills, in-depth medical, and Medicare Advantage industry knowledge, and the skills necessary to provide OPERS with expert advice. The Selected Auditor will be expected to provide regular updates to OPERS while conducting the audits. Any audit exceptions will be identified and reviewed with the non-medicare Administrator or Medicare Administrator (see further below) to confirm the findings. The OPERS retiree health care program provides health care coverage to eligible OPERS retirees and their eligible dependents (collectively Participants ), and includes prescription drug (for all Participants) medical (for non-medicare and Medicare-eligible Participants) and voluntary dental and vision. (Prescription drug, dental and vision coverage are not included in this RFP.) As of March 1, 2015, OPERS had 224,832 Participants with health care coverage. The majority of these Participants are located in Ohio, and nearly all of the rest are located throughout the United States, with a few Participants living abroad. Medical Mutual Services, LLC (Medical Mutual of Ohio or MMO) currently administers the medical coverage for non-medicare eligible Participants and Humana Insurance Company (Humana) administers the medical coverage for the Medicare-eligible Participants. MMO administers a self-funded preferred provider organization (PPO) medical plan design for non-medicare Participants. The audit of OPERS non-medicare medical coverage will be referred to as the non-medicare Administrator audit in this RFP. And, Humana administers Medicare Advantage (MA) and Medicare secondary coverage for Medicare-eligible Participants. The audit of OPERS Medicare medical coverage will be referred to as the Medicare Administrator audit. 6/29/2015 Medical Auditor RFP Page 3

4 The specific details for the non-medicare Administrator and the Medicare Administrator audits are provided in Section D, Scope of Engagement. This RFP will include four (4) phases: Phase 1 Minimum Requirements: Proposals must meet the Minimum Requirements contained in Section C, which OPERS will verify. Proposals that meet the Minimum Requirements will advance to Phase 2. Proposals that do not meet the Minimum Requirements will not be considered, reviewed, or evaluated. Phase 2 Written Proposals: OPERS will review and evaluate written proposals that meet the Minimum Requirements and determine, in its sole discretion, whether any Phase 2 vendors will be asked to make oral presentations. These vendors will advance to Phase 3. Phase 3 Oral Presentations: OPERS will provide clarifying questions to Phase 3 vendors asked to make oral presentations. The clarifying questions must be addressed during the oral presentations. OPERS will evaluate the oral presentations to determine, in its sole discretion, whether any Phase 3 vendors will advance to Phase 4. Phase 4 Contract Negotiations: Following evaluation of the written proposals and oral presentations, OPERS may determine a list of finalists and commence sequential negotiations as described in Section (F) (5). If a contract results from this RFP, the term will be for three (3) years. The contract will be renewable, at OPERS option, for up to three (3) one (1) year periods. C. MINIMUM REQUIREMENTS The items listed in this section of the RFP are mandatory proposal requirements ( Minimum Requirements ). Your proposal must meet all of the Minimum Requirements or it will not be considered, reviewed, or evaluated. Please include the following information in Your proposal in a list format immediately following the proposal cover page. State that Your proposal includes the two (2) audits described in this RFP, and list the page range on which each audit appears in the proposal. Confirm that Your Organization is licensed to do business in Ohio, is in good standing with the Ohio Secretary of State. Confirm that Your Organization has a minimum of five (5) years of experience in conducting audits similar in size (minimum of 100,000 participants) and scope as those described in this RFP. Confirm that all work for this project will be performed within the continental United States, and that You agree that no services for this project will be performed off-shore, including subcontracting of services to any off-shore companies or locations. D. SCOPE OF ENGAGEMENT The Selected Auditor will conduct two (2) audits and one (1) operational review of the OPERS health care vendor engagements discussed in Section B., Overview: non-medicare Administrator and Medicare Administrator. The requirements for these audits (and operational review) are further detailed in the following sections. OPERS has targeted 1 st quarter of 2016 for completion of the operational review and both audits requested in this RFP. 6/29/2015 Medical Auditor RFP Page 4

5 NON-MEDICARE AUDIT D1. The Selected Auditor will conduct an audit and operational review of the non-medicare Administrator s administration of OPERS non-medicare medical coverage. The audit will review a two year time frame. The scope of the audit and operational review are described further below. D1.1 Determine if claims are being adjudicated in accordance with the correct pricing terms for each time period of the audit, e.g., provider contracting rates and provider discounts. D1.2 Determine the accuracy of claims adjudication with respect to plan design provisions as defined in the evidence of coverage (EOC) (including by way of example only, copayments, coinsurance, reversed and reprocessed claims, and, coordination of benefits). D1.3 Evaluate that as the non-medicare Administrator receives eligibility files from OPERS, the eligibility files are processed and uploaded timely, based on the non-medicare Administrator Agreement IT SOW, and quality assurance processes are performed, including reviewing error reports and data issues. D1.4 Review and test the policies and procedures that the non-medicare Administrator has in place to implement the Financial SOW for the non-medicare Administrator Agreement. D1.5 Evaluate the non-medicare Administrator s system design and the suitability and effectiveness of internal controls to ensure processing integrity by obtaining and evaluating the Statement on Standards for Attestation Engagements No. 16 (SSAE-16) report. D1.6 Review the operations maintained by the non-medicare Administrator on behalf of OPERS from an efficiency, control and security perspective. The operations review will be conducted at the offices of the non-medicare Administrator in Ohio, and include turnaround time, appeals, and customer service. The Selected Auditor must be willing to allow OPERS staff to accompany them to the non-medicare on-site visits. D1.7 Evaluate, analyze and validate the non-medicare Administrator s records of their subcontractors and agents performance, compliance, responsibilities and their locations as defined by the non-medicare Administrator Agreement and disclosed to OPERS annually based on time period audited. D2. SPECIFIC REQUIREMENTS The non-medicare Administrator audit incorporates the six (6) categories of review outlined below. Complete descriptions of each item are further described in Sections D3-D8. D2.1 Medical Claims Pricing Accuracy Review, which requires analyzing one hundred (100) percent of the claims incurred in the time period of the audit to confirm pricing accuracy. D2.2 Non-Medicare Plan Design Accuracy Review, which requires analyzing the claims for the time period of the audit to validate application of PPO coverage. D2.3 Non-Medicare Plan Eligibility, which requires review that the eligibility files the non- Medicare Administrator receives from OPERS are processed and uploaded timely to the non-medicare Administrator s eligibility system, and reviewed for errors, omissions and data quality, including retroactive termination, additions, removals and cancellation of coverage. 6/29/2015 Medical Auditor RFP Page 5

6 D2.4 Financial Statement of Work, Review and test the policies and procedure that the non- Medicare Administrator has in place to implement the Financial SOW for the non- Medicare Administrator Agreement. D2.5 Non-Medicare Administrator Quality Assurance/Internal Controls, which requires review of the applicable Statement on Standards for Attestation Engagement No. 16 (SSAE-16) report. D2.6 Non-Medicare Administrator Operational Review, which requires the review of the operations maintained by the non-medicare Administrator on behalf of OPERS from an efficiency, control and security perspective. The operations review will be conducted at the offices of the non-medicare Administrator in Ohio, and include turn-around time, appeals, and customer service. The Selected Auditor must be willing to allow OPERS staff to accompany them to the non-medicare on-site visits. D2.7 Evaluate, analyze and validate the Non-Medicare Administrator s records of their subcontractors and agents performance, compliance, responsibilities and their locations as defined by the Non-Medicare Administrator Agreement and disclosed to OPERS annually based on time period audited. This may be a sample. D3. MEDICAL CLAIMS PRICING ACCURACY REVIEW The Selected Auditor will determine if medical claims are being adjudicated in accordance with the correct pricing terms for time period of the audit. D4. NON-MEDICARE PLAN DESIGN ACCURACY REVIEW The Selected Auditor will analyze the medical claims dataset to validate the correct application of plan design to ensure claims were processed in accordance with the medical plan description (MPD). Test subjects will include, but not be limited to, copayments, coinsurance, deductibles and exclusions. For certain edits, the Selected Auditor may test a sample of the results from the electronic analysis to validate findings. A statistically valid random, stratified sample will be required. The sampled claims should be audited in detail to determine their accuracy relative to the non-medicare coverage and to determine whether their handling is consistent with standard industry practices. D5. NON-MEDICARE PLAN ELIGIBILITY The Selected Auditor will review that the OPERS eligibility files are processed and uploaded timely to the non-medicare Administrator s eligibility system, and reviewed for errors, omissions and data quality. D6. FINANCIAL STATEMENT OF WORK Review and test the policies and procedures that the non-medicare Administrator has in place to implement the Financial SOW for the non-medicare Administrator Agreement. D7. QUALITY ASSURANCE/INTERNAL CONTROLS The Selected Auditor will evaluate the non-medicare Administrator s system design and the suitability and effectiveness of internal controls to ensure processing integrity by obtaining and evaluating the applicable Statement on Standards for Attestation Engagement No. 16 (SSAE-16) report. 6/29/2015 Medical Auditor RFP Page 6

7 D8. NON-MEDICARE ADMINISTRATOR OPERATIONAL REVIEW The Selected Auditor will review the operations maintained by the non-medicare Administrator on behalf of OPERS from an efficiency, control and security perspective, including claims handling and administrative activities. The Selected Auditor must be willing to allow OPERS staff to accompany them to the non-medicare on-site visits. MEDICARE AUDIT D9. The Selected Auditor will conduct an audit of the Medicare Administrator s administration of OPERS Medicare medical coverage. The audit will review a two year time frame. The scope of this audit is described further below. The Selected Auditor must provide information about their audit procedures which relate to the MA coverage including but not limited to: A list of documents You request and review. The time period of the transactions that You review. The sampling methodology You employ. The approach You use to manipulate data. The criteria You apply to ascertain materiality, and Your typical timelines for each step in the audit process. D10. Explain how You measure the estimated accuracy of the Medicare Administrator s claim payment processing. D11. Describe in detail how You would affirm and validate the medical expense ratio (MER) calculation as reported by the Medicare Administrator. Please provide Your understanding of how the MER calculation works and what a plan sponsor could use this information for. D12. Determine whether the Medicare Administrator s development of MA premiums as presented to OPERS for the years examined in the audit are accurate. Describe the standard rate development for the typical MA product. D13. Evaluate, analyze and validate the Medicare Administrator s records of their subcontractors and agents performance, compliance, responsibilities and their locations as defined by the Medicare Administrator Agreement and disclosed to OPERS annually based on time period. D14. Evaluate, analyze and validate the status of all Medicare Administrator Agreement deliverables including the compliance and satisfaction of the contractual terms describing performance standards and guarantees and the maintenance of documentation indicating compliance with the SSAE-16 report (formerly SAS 70), as stipulated in the Medicare Administrator Agreement. D15. Audit the Medicare Administrator s Medicare Part B and Medicare Part D coordination of benefits with the Rx Administrator. D16. Review and test the policies and procedures that the Medicare Administrator has in place to implement the Financial SOW for the Medicare Administrator Agreement. D17. Review the Medicare Administrator s handling of eligibility edits and eligibility/claims transfers between the MA and Medicare secondary coverage. 6/29/2015 Medical Auditor RFP Page 7

8 D18. SPECIFIC REQUIREMENTS The Medicare Administrator audit incorporates nine (9) categories of the review outlined below. Complete descriptions of each item are further described in Section D18.2- D18.9. D18.1 You must provide information about your audit processes, which relate to the MA coverage that support the following: A list of documents You request and review; The time period of the transactions that You review; The sampling methodology You employ; The approach You use to manipulate data; The criteria You apply to ascertain materiality; and, Your typical timelines for each step in the audit process. Your proposal should include the following to demonstrate your overall understanding of the MA product and specific expertise you have auditing MA products. D18.2 Explain how You measure the estimated accuracy of the Medicare Administrator s claim payments processing. This measure should be provided separately for Medicare claims and OPERS claims and include the Medicare secondary plan. D18.3 Describe in detail how You would affirm and validate the MER calculation as reported by the Medicare Administrator. Please provide your understanding of how the MER calculation works and what a plan sponsor could use this information for. D18.4 Determine whether the Medicare Administrator s development of MA premiums as presented to OPERS for the years examined in the audit are accurate. Describe the standard rate development for the typical MA product. D18.5 Evaluate, analyze and validate the Medicare Administrator s records of their subcontractors and agents performance, compliance, responsibilities and their locations as defined by the Medicare Administrator Agreement and disclosed to OPERS annually based on time period audited. This may be a sample. D18.6 Evaluate, analyze and validate the status of all agreement deliverables including the compliance and satisfaction of the contractual terms describing performance standards and guarantees and the maintenance of documentation indicating compliance with the SSAE - 16 report (formerly SAS 70), as stipulated in the Medicare Administrator Agreement. D18.7 Audit the Medicare Administrator s Medicare Part B and Medicare Part D coordination of benefits with the Rx Administrator. Please provide your methodology for validation. D18.8 Review and test the policies and procedures that the Medicare Administrator has in place to implement the Financial SOW for the Medicare Administrator Agreement. D18.9 Review the Medicare Administrator s handling of eligibility edits and eligibility/claims transfers between the MA and Medicare Secondary coverage. Please describe Your eligibility validation coordination between the MA and Medicare secondary coverage. Validate the process against the IT SOW in place during the time period of the audit. 6/29/2015 Medical Auditor RFP Page 8

9 GENERAL D19. You must respond to all of the items addressed in Sections D20-D26 in Your proposal. The items described in Sections D20-D26 apply to both audits described in this RFP. D20. SCHEDULE (Project Timeline) Submit a detailed timetable (work plan) that presents key activities, milestones, and timing for completion of the project. The work plan should include the preparation of a draft audit report to be reviewed by OPERS before any final audit report is delivered. The work plan should assume that the non-medicare and Medicare Administrator audits will be conducted in the same time frame. Please provide an overall project schedule for both audits. D21. AUDIT REPORT A final audit report will be required detailing the findings and recommendations for each of the audits of the two Administrators, and the operations review of the non-medicare Administrator. In addition, the final audit report will include a description of the project methodology and exhibits that provide additional details about the sample and the errors discovered. It is critical that the final audit report clearly identifies the extent of potential financial recovery for OPERS and any areas of disagreement with the particular audited Administrator. D22. PROPOSED ADDITIONAL SERVICES In addition to the services described, please include any additional services You believe are applicable, and include the itemized fees for such services. The description of these services and the associated fees should be detailed in a separate section of Your proposal. The rationale for proposing these services should be included. D23. STATUS REPORTS Provide electronic status updates weekly to the designated representatives of OPERS. Conference calls will be scheduled, at a minimum, two times a month during the project timeline. D24. FINAL DRAFT AUDIT REPORTS Submit draft final audit reports to be reviewed before any final audit report is delivered. D25. FINAL AUDIT REPORTS Submit detailed, written final audit reports with recommendations. The written recommendation/reports must include, at a minimum: Executive summary Description of the audit process/procedures, including audit milestones and key events associated with those milestones Recommendations for corrective action to ensure accurate claims handling The Administrator s action plan in response to the Selected Auditor s recommendations Statement indicating the Selected Auditor has observed all conflict of interest requirements mandated by OPERS with respect to the audit process and has not received anything of value from the audited Vendors while performing audit services. D26. FINAL PRESENTATIONS Be prepared to provide an executive level presentation for OPERS Board based on the results of each audit and recommendation in the final reports. 6/29/2015 Medical Auditor RFP Page 9

10 E. PROPOSAL CONTENT At a minimum, the proposal must include the following information defined in Sections E1- E10. For ease of review, each requirement should be addressed in a separate section preceded by an index tab to identify the subject of the section. The proposal should be formatted on consecutively numbered pages and include a table of contents. You must provide an answer to each question in the order asked in the RFP, and must propose for both audits in this RFP. E1. COVER LETTER You must include a cover letter, which will be considered an integral part of the proposal, in the form of a standard business letter, and must be signed by an individual who is authorized to bind You contractually. The cover letter must include: E1.1 A statement regarding Your Organization s legal structure, e.g., an Ohio corporation, Federal tax identification number, and principal place of business. E1.2 Your primary contact on this RFP, who has authority to answer questions regarding the proposal: Organization Name Contact s Name Additional Contacts Contact s Address Contact s Phone Number Contact s Address E1.3 A statement that Your proposal meets all the requirements of this RFP. E1.4 A statement that Your Organization has not submitted its proposal with the assumption that there will be an opportunity to negotiate any aspect of the proposal. E1.5 A statement that You acknowledge that all documents submitted pursuant to this request may be subject to disclosure under Ohio s Public Records Act, see Section G of this RFP. E1.6 A statement that You acknowledge and agree that the contract provisions contained in Attachment A shall be included in any contract with OPERS that may result from this RFP, and such contract provisions shall control in the event of any conflict. E2. QUESTIONNAIRE E2.1 Your Organization s domestic office locations, identifying which location will be assigned this project. Please provide the following information: The full legal name of Your Organization; The address and telephone number of Your corporate office; and The current ownership of Your Organization, along with the name of any individual holding 10% or more of the stock or value of Your Organization, if applicable. E2.2 Your Organization s organizational structure, including subsidiary and affiliated companies, and joint venture relationships. E2.3 How many years has Your Organization been in business? 6/29/2015 Medical Auditor RFP Page 10

11 E2.4 Yes/No: Has Your Organization undergone any material change in its structure or ownership within the last 18 months? If yes, please describe. E2.5 Yes/No: Is any material change in ownership or structure currently under review or being contemplated? If yes, please describe. E2.6 If available, please provide a report, study, or assessment of Your Organization, prepared by an unbiased independent third-party source, concerning client satisfaction and measures of Your Organization s strengths and weaknesses vis-à-vis your key competitors. E2.7 Please provide Your most recent financial statements including a statement of financial position, an annual income statement and balance sheet. E2.8 Please describe any material litigation to which Your Organization is currently a party. In addition, please describe any material litigation that Your Organization has been involved in over the last three (3) years. E2.9 Please provide a list and describe litigation brought or threatened against Your Organization by existing or former clients over the past five (5) years. E2.10 Please describe any relationships that Your Organization has with potential vendors to OPERS, including any potential fees or other remuneration Your Organization may receive for recommending their products or services. E2.11 Does Your Organization have experience in performing Medicare Part B recovery audits? Describe how Your Organization would test for Medicare Part B expenses. E2.12 Does Your Organization have experience in auditing electronic eligibility timing, system processing and error testing? Describe how Your Organization would test for eligibility issues/errors. E2.13 Provide a copy of a final audit report presented to a client of similar size operationally to OPERS and similar in scope for whom You have performed an audit within the last year, redacted to the extent necessary. E2.14 Describe Your internal quality assurance process for the auditing process. E2.15 Does Your Organization have a firm written code of conduct or set of standards for professional behavior? If so, attach a copy and state how the code or standards are monitored and enforced. E2.16 How does Your Organization identify and manage conflicts of interest? E2.17 Are there any potential conflicts of interest that Your Organization would have in providing the requested services to OPERS? If yes, explain. E2.18 List and describe any relationships and/or contacts Your Organization or its officers or employees has had with any OPERS Board member and/or staff member within the last twelve (12) months. E2.19 Has Your Organization or any officer or employee given any remuneration or anything of value directly or indirectly to any OPERS Board members, officers, or employees? If yes, identify the recipient and remuneration or thing of value. Additional information on the relevant Ohio ethics law may be found at: 6/29/2015 Medical Auditor RFP Page 11

12 E2.20 Has Your Organization or any officer or employee given any remuneration or anything of value as a finder s fee, cash solicitation fee, or fee for consulting, lobbying or otherwise, in connection with this RFP? If yes, identify the recipient and remuneration or thing of value. E2.21 Complete the following table, indicating the number of clients for whom Your Organization has provided services similar to those outlined in this RFP within the last three (3) years: Annual Medical Spend (Allowed Charges) $9.99 million $10 - $49.99 million $50 - $99.99 million $100 million - $ million $150 million No. of Clients E2.22 Does Your Organization have experience in performing medical claims pricing accuracy review audits? How many years has Your Organization been conducting medical claims pricing accuracy review audits? How many medical claims pricing accuracy review audits has Your Organization conducted in the past three (3) years for clients with 75,000 or more participants? What percentage of these were MMO audits? Describe typical obstacles involved in conducting these medical claims pricing accuracy review audits and Your corresponding remediation efforts and results. Is there a typical PMPY dollar discrepancy that Your Organization expects to uncover in an audit such as this one? If so, what would You expect the PMPY discrepancy to be? Fully describe how the random sample would be selected for performing the services described in Section (D) (15), including the size of the sample. E2.23 Does Your Organization have experience in performing medical plan design accuracy review audits? How many years has Your Organization been conducting medical plan design accuracy review audits? How many medical plans design accuracy review audits has Your Organization conducted in the past three (3) years for clients with 75,000 or more participants? What percentage of these were MMO medical plan design accuracy review audits? Describe typical obstacles involved in conducting these medical plan design accuracy review audits and Your corresponding remediation efforts and results. Is there a typical PMPY dollar discrepancy that Your Organization expects to uncover in an audit such as this one? If so, what would You expect the PMPY discrepancy to be? As outlined in Section (D) (16), fully describe which types of edits may require sample testing and how the sample would be selected, including the sample size. E2.24 Please confirm that Your Organization will execute a confidentiality agreement for purposes of conducting this audit. E2.25 Indicate Your Organization s specific, relevant experience, with auditing non-medicare Administrator. 6/29/2015 Medical Auditor RFP Page 12

13 E2.26 Describe how You conduct a medical claims audit and operations review. Be specific about on-site activities, review criteria, review methods and process, required documentation, and the degree of involvement of medical plan administrator personnel. E2.27 Provide real-life examples of specific recommendations for corrective action You have provided to a client as a result of a recent medical audit. Please include specific examples of recommendations that You feel were the most effective and produced the most tangible results for the client, redacted as necessary. E2.28 Describe any aspects of Your audit process that are unique to Your Organization and that distinguish You from your competitors. E2.29 Describe and explain Your sampling methodology in detail. Please include a description of the calculation/presentation of results. E2.30 For the Medicare Administrator audit related to the MA coverage, provide a list of the documents that You would review given the scope provided. E2.31 For the Medicare Administrator audit related to the MA coverage, detail the sampling methodology you would use if you do not audit the entire population of data. E2.32 For the Medicare Administrator audit related to the MA coverage, detail the course of action You will take to manage the data to reach the deadline established for the completion of the audit, including producing deliverables in final form. E2.33 For the Medicare Administrator audit related to the MA coverage, provide Your qualified practice of determining levels of materiality, knowing this is a matter of professional judgment. E2.34 For the Medicare Administrator audit related to the MA coverage, provide specific detail on the work plan addressing each step of the audit process and the timeline the steps are associated with. E2.35 For the Medicare Administrator audit related to the MA coverage, describe how you would determine the accuracy of the Medicare Administrator s MA coverage payment of claims including payment of claims based upon OPERS plan design structure. E2.36 Describe in detail how You would check and validate the MER calculation as reported by the Medicare Administrator. This would include all necessary data sets and validation points. E2.37 Describe in detail how You would determine whether the development of premiums by the Medicare Administrator that were presented to OPERS for the years examined in the audit are consistent with prior claim experience, reasonable projection, assumptions, changes anticipated in CMS revenue, reasonable administrative cost projections and industry- acceptable methodologies for premiums rate projections. E2.38 Discuss how You would evaluate the Medicare Administrator s SSAE-16 report (formerly the SAS 70), as described in the Medicare Administrator Agreement. E2.39 Provide the action steps You would use to verify the coordination of benefits between Medicare Part B and Medicare Part D drugs as it pertains to Medicare Administrator and Rx Administrator. E2.40 Describe how You would analyze eligibility edits that are in place for OPERS incoming eligibility files to the Medicare Administrator and the updating of eligibility and claims 6/29/2015 Medical Auditor RFP Page 13

14 between the Medicare secondary coverage and the MA coverage as Participants move between the two coverages. E3. UNDERSTANDING OF ENGAGEMENT E3.1 Please describe in detail Your Organization s understanding of the services requested in Sections D2, D18 and D20-D26. E3.2 Please describe topics or processes not included in this RFP that Your Organization may examine in order to provide more complete services. E3.3 Please provide a narrative that supports why Your Organization believes that it is qualified to undertake the proposed engagement. E4. WORK PLAN (including timeline with details of hours) The proposal should set forth a work plan including: E4.1 A description of how You will consult with and make presentations to OPERS staff during the engagement. E4.2 A description of the service management and quality control procedures You will use. These should identify and describe any anticipated potential problems, the Your approach to resolving these problems, and any special assistance that will be requested from OPERS. E4.3 A tentative schedule for performing each of the audits for OPERS including estimated hours by major task and staffing plan to include both Selected Auditor s and OPERS resources. E5. DELIVERABLES E5.1 OPERS shall have full ownership of the deliverables, including documentation and other related work projects, as applicable. E5.2 The Selected Auditor will ensure that its subcontractors shall be obligated to assign to OPERS their ownership rights in any deliverables. E6. AUDITOR PERSONNEL E6.1 Provide an organizational chart of Your Organization. Highlight the names/positions and office location of all persons who will work on the engagement. E6.2 Provide the name and a brief biographical sketch of the lead auditor who will have overall responsibility for this project. For this individual, provide the following: Description of experience (a) Plan design considerations (b) Eligibility processes (c) Claims processing (capabilities, accuracy, speed, staffing and infrastructure) (d) Audit rights/procedures (e) Coordination of benefits/recovery of over-payments (f) Claims subrogation activities (g) Claims reconciliation Education Length of employment at Your Organization 6/29/2015 Medical Auditor RFP Page 14

15 Length of experience auditing Professional credentials and affiliations Description of this individual s specific responsibilities and duties under a contract that may result from this RFP. E6.3 List your five (5) largest clients (by number of participants) for which the lead auditor has performed a substantial auditing function. E6.4 Provide the names, title, contact information and a brief biographical sketch of each of the individuals who will be performing the services outlined in this RFP. For each individual, provide the following: Description of experience, i.e. work history Education Length of employment at the organization Length of experience auditing Professional credentials and affiliations Description of each individual s specific responsibilities and duties under a contract that may result from this RFP E6.5 Provide samples of work that relate to the scope of services You feel demonstrate the skill and talent of the audit team that would be assigned to this engagement. E6.6 You are requested to perform all services and may not subcontract without the written consent of OPERS. For each of Your potential subcontractors, please provide a narrative with the following information: The subcontractor s name and address. A brief description of the work said subcontractor might perform. A brief description of the subcontractor s capabilities and Describe Your oversight of the subcontractor and controls in place to ensure that expected performance levels are maintained. E6.7 Please describe Your Organization s procedures in the event that a contact person assigned to this engagement leaves Your Organization during the term of the engagement. E7. REFERENCES E7.1 The names, addresses and telephone numbers of a contact person for three (3) current clients. E7.2 The name and telephone number of a responsible official who may be contacted as a reference at each of three (3) current clients. E7.3 Provide a summary description of the scope of work performed for each of the three (3) current clients listed. E8. COST E8.1 Please provide a not-to-exceed, fixed fee price quote for this project showing the fee for the project in total to include any and all reimbursable expenses including travel costs. OPERS expects all travel costs to be included in the costs provided in Exhibit A. OPERS 6/29/2015 Medical Auditor RFP Page 15

16 will not accept proposals that include separate charges for the upkeep and/or updating of Auditor s information technology hardware or software. E8.2 Provide cost per hour for additional service work or if hourly costs are not applicable, the deliverables that You intend to provide, and the cost associated with each deliverable. E8.3 State whether You will negotiate Your proposed fee if OPERS decides negotiation is appropriate as to any aspect of the proposal, including the fee, with the finalist(s). In no case, however, will the negotiated fee be higher than the fee submitted in the proposal. E9. SAMPLE CONTRACT Please provide a sample contract with Your proposal along with a copy of Your certificate of insurance. The contract should reflect the specific scope and deliverables of this engagement as well as hourly fees for any potential work outside the scope of this engagement and response times. Notwithstanding the foregoing, any contract that may result from this RFP must include the contract provisions included in Attachment A, which provisions shall control in the event of any conflict. E10. ADDITIONAL INFORMATION You should provide any other information You believe is relevant to the engagement. 6/29/2015 Medical Auditor RFP Page 16

17 F. SELECTION CRITERIA F1. Proposals will be evaluated, and OPERS will make any final decision to award the contract. F2. During the evaluation process, OPERS management may, at its discretion, request that You or any or all responding vendors make oral presentations. Such presentations will provide responding vendors with an opportunity to answer questions regarding their proposals. Not all responding vendors may be asked to make such oral presentations. (See Section B, Overview, RFP phase 3.) F3. Any pricing information submitted by You must be disclosed on the pricing pages as designated in this RFP. (See Section B, Overview, and Exhibit A.) OPERS will not consider any pricing information which appears elsewhere in Your proposal. F4. Proposals will be evaluated based on the following criteria, each criteria may be weighted, if desired: Questionnaire. Understanding of Engagement. Soundness of the approach and quality of the work plan. Proposed deliverables. Individual qualifications of the assigned staff. Sample Contract. Cost. F5. After evaluation of the proposals, OPERS may determine a list of finalists not to exceed three (3) and may commence sequential negotiations on any aspects of the proposals OPERS deems appropriate beginning with the highest scoring finalist. If OPERS does not reach agreement with the highest scoring finalist within seven (7) calendar days, or if in the opinion of OPERS negotiations reach an impasse, OPERS may decide not to award the contract or may begin negotiations with the second highest scoring finalist. OPERS may choose to continue such negotiation schedule with subsequent finalists on the same basis until a contract is negotiated, no other finalists remain, or OPERS decides not to award the contract. 6/29/2015 Medical Auditor RFP Page 17

18 G. GENERAL TERMS AND CONDITIONS FOR SUBMITTING PROPOSALS G1. You understand that OPERS is subject to the Ohio Public Records Act, and the documents submitted in response to this RFP may be subject to a public records request. You must identify and clearly mark the documents and materials that are confidential at the time You submit Your proposal. If OPERS receives a public records request for records related to this RFP, OPERS will reasonably attempt to contact You in sufficient time to allow You to take the legal steps You deem necessary to protect the confidential information from disclosure. You shall indemnify OPERS if OPERS is assessed any damages or fees as a result of the position You assert regarding the confidentiality or public disclosure of the records. If no documents or materials are clearly identified and marked as confidential, You will be deemed to have consented to the disclosure of the documents or materials, and to have waived any cause of action against OPERS resulting from the disclosure of the documents or materials. G2. Regardless of cause, late proposals, in whole or in part, will not be accepted and will automatically be disqualified from further consideration. It shall be the Your sole risk to ensure delivery at the designated office by the designated time. Late proposals will not be opened and may be returned to the You at Your expense, or destroyed if so requested. G3. OPERS reserves the right, in its sole discretion, to reject any or all proposals submitted, and to waive as to any or all responding vendors, any informality or irregularity in a proposal or proposals or any failure to conform to the instructions in this RFP. G4. This RFP is not a contract, not meant to serve as a contract, and does not constitute a promise to enter into a contract. G5. All documents, proposals and other materials submitted in response to this RFP will become the property of OPERS and will not be returned to You. G6. You agree to comply with all terms, conditions and requirements described in the RFP. Any failure by any responding vendor to so comply shall be grounds for rejection of that vendor s proposal, as determined by OPERS in its sole discretion. G7. If a contract results from this RFP, neither the Selected Auditor, nor anyone on its behalf (including any or all of its agents, affiliates, subcontractors or vendors), shall publish, distribute or otherwise disseminate any press release, advertising or publicity matter of any type or kind (collectively Advertising Material ) having any reference to OPERS, this RFP or the resulting contract, unless and until the Advertising Material is first submitted to and approved in writing by OPERS. 6/29/2015 Medical Auditor RFP Page 18

19 H. INSTRUCTIONS FOR SUBMITTING PROPOSALS Proposed Schedule of Events 1. RFP Release Date... June 30, Questions due from potential responding vendors by (1:00 p.m. ET). July 16, OPERS response to responding vendors questions posted on website... July 24, Proposals due to OPERS (1:00 p.m. ET)... July 31, Finalist presentations and interviews... Sept 2-3, Effective date of contract... Upon Signature H1. Please provide five (5) hard copies, one redacted copy for public record requests and an electronic copy of Your proposal by 1:00 Eastern Time, on July 31, 2015, to: Jay Yoho Supervisor Purchasing Ohio Public Employees Retirement System 277 East Town Street Columbus, OH H2. Questions concerning this RFP must be submitted in writing or via to The question and answer period will be from June 30 to July 16, Questions and answers will be posted on the OPERS website. H3. No responding vendor shall attempt to communicate with OPERS concerning this RFP in any manner or at any time other than during the question and answer period (see H2) or the finalist presentations, if held (see Section F2 and corresponding date above). Communication with OPERS, other than as previously described, will result in immediate disqualification. H4. This RFP is issued on June 30, OPERS reserves the right, in its sole discretion, to amend or cancel this RFP. 6/29/2015 Medical Auditor RFP Page 19

20 ATTACHMENT A 1. CONTRACTOR S REPRESENTATIONS, WARRANTIES AND COVENANTS: Contractor represents, warrants and covenants that: it has the authority to enter into the Agreement and perform the services provided under the Agreement; it shall comply with all applicable federal, state and local laws in providing services under the Agreement, including, but not limited to, the reporting requirements contained in Sections et seq. of the Ohio Revised Code (Joint Legislative Ethics Commission), and the laws contained in Chapter 102 of the Ohio Revised Code (Ohio Ethics Commission) governing ethical behavior that apply to persons doing or seeking to do business with OPERS; and, it has not paid and will not pay, has not given and will not give, any remuneration or thing of value directly or indirectly to OPERS or to any of its board members, officers, employees, or agents, or any other third party related to Contractor s engagement under the Agreement, including a finder s fee, cash solicitation fee, or a fee for consulting, lobbying or similar services that could influence OPERS decision to enter into the Agreement. 2. DISCLOSURE AND USE OF RECORDS: Contractor shall not disclose or use any information concerning OPERS members or retirees, or any other confidential information obtained in providing services under the Agreement, without OPERS prior written consent. Contractor understands that OPERS is subject to the Ohio Public Records Act. If OPERS receives a public records request for records related to the Agreement, OPERS will reasonably attempt to contact Contractor in sufficient time to allow Contractor to take the legal steps it deems necessary to protect the confidential information from disclosure. Contractor shall indemnify OPERS if OPERS is assessed any damages or fees as a result of the position Contractor asserts regarding the confidentiality or public disclosure of the records. 3. ADVERTISING AND PUBLICITY: Neither Contractor, nor anyone on Contractor s behalf (including any or all of its agents, affiliates, subcontractors or vendors), shall publish, distribute or otherwise disseminate any press release, advertising or publicity matter of any type or kind (collectively Advertising Material ) having any reference to OPERS or this Agreement, unless and until the Advertising Material is first submitted to and approved in writing by OPERS. 4. INDEMNIFICATION AND LEGAL ACTION: Contractor shall indemnify OPERS, its board members, officers, and employees against any claims, damages, costs or losses resulting from Contractor s negligent or intentional acts, or those of its officers, employees or agents, under the Agreement 6/29/2015 Medical Auditor RFP Page 20

21 ( Indemnity Claims ). Contractor shall defend OPERS, its board members, officers and employees against Indemnity Claims, if OPERS requests that Contractor do so. OPERS will not be required to file a lawsuit to obtain reimbursement for the Indemnity Claims. OPERS shall not indemnify Contractor for claims, damages, costs or losses of any nature that arise under the Agreement ( Contractor s Claims ). Contractor may seek recovery of Contractor s Claims through legal action against OPERS, if appropriate. 5. GOVERNING LAW AND FORUM: Despite anything to the contrary in the Agreement, issues concerning the Agreement will be governed by, construed and enforced according to Ohio law, exclusive of Ohio s conflict of laws principles. Any litigation concerning the Agreement must be brought only in courts of competent jurisdiction located in Franklin County, Ohio, and Contractor irrevocably consents to this venue and jurisdiction. OPERS shall not waive its right to trial by jury in any action, proceeding or counterclaim concerning the Agreement or the actions of either party regarding any aspect of the Agreement, regardless of the legal theory, unless the Ohio Attorney General consents to this waiver. 6/29/2015 Medical Auditor RFP Page 21

22 EXHIBIT A PRICING DELIVERABLES OPERS Service Audit Cost Est. Hours TOTAL COST OPERS expects all travel costs to be included in the costs quoted in Exhibit A. 6/29/2015 Medical Auditor RFP Page 22