RFP# OMIG 26-23- Home Health Care Medicare Maximization Services (HHC MMX)

This Request for Proposal (RFP) is a solicitation issued by the New York State Office of the Medicaid Inspector General (OMIG). OMIG is seeking a qualified Contractor to perform HHC MMX under the direction of OMIG’s Bureau of Provider Audit.

The Contractor will support OMIG’s efforts to maximize Medicare coverage for dual eligible Medicare and Medicaid recipients who receive home health services paid by Medicaid. Responsibilities include data analysis/case selection, Medicare appeals processing, provider coordination, audit and recovery support, reporting, provider education, and related operational activities necessary to support the HHC MMX program.

The Contractor shall perform all operational, medical, legal, audit, reporting, recovery, provider-relations, and administrative activities necessary to support OMIG’s HHC MMX program.

The Contractor shall perform all activities necessary to support Medicare coordination-of-benefits and appeals efforts intended to maximize Medicare coverage for dual eligible recipients receiving home health services paid by Medicaid.

Responsibilities include but are not limited to:

• requesting and analyzing claims data;
• identifying and developing recipient cases for Medicare coverage determinations;
• performing medical and legal reviews and briefs to optimize Medicare coverage of denied claims for all available levels of appeal;
• filing, pursuing, and tracking appeals and recoveries through all available levels of the Medicare Administrative Appeals Process;
• providing assistance and education to providers to improve compliance with demand billing and claims submission processes;
• providing expert testimony/opinions at Medicaid and Medicare administrative hearings.

The Contractor shall support OMIG audit and recovery activities involving providers that fail to comply with Medicare demand billing requirements, fail to return amounts paid by Medicare, or otherwise fail to comply with HHC MMX program directives.

The Contractor shall utilize a comprehensive recovery and reconciliation process supporting OMIG’s recovery of funds inappropriately paid by Medicaid for Medicare-covered services previously paid by Medicaid.

The Contractor shall develop and conduct Medicare third-party liability coordination-of-benefits training programs for CHHAs and other stakeholders, as directed by OMIG.

The Contractor shall utilize record-retention practices sufficient to support audit activities, operational oversight, regulatory compliance, litigation support, and program accountability requirements throughout the term of the contract, plus an additional six (6) years thereafter.

The proposal must be submitted to procurements@omig.ny.gov with hard copies of the signature pages submitted to the address listed in the Designated Contacts listed on the cover page of this RFP.

One (1) electronic copy of the proposal with three (3) sets of original signature pages that have been signed with a wet signature and scanned (and originals mailed), including everything in the original (forms, the Financial Proposal, text and narrative sections and all attachments) is to be submitted.

The Technical Proposal and the Financial Proposal, including Financial Statements, should be sent separately with the subject “RFP# OMIG 26-23 Technical Proposal” or “RFP# OMIG 26-23 Financial Proposal”.

To be considered, proposals must be received by the date and time indicated in the RFP Schedule of Events. Proposals received after the deadline may not be opened.

The transmittal letter must include a statement to the effect that the price quoted in the Financial Proposal constitutes a firm and irrevocable offer for one hundred twenty (120) calendar days.

On the included Cost Proposal form, Offerors shall provide a contingency fee percentage of gross Medicare recoveries resulting from the Offeror’s traditional recovery activities.