The Centers for Medicare

1
The Centers for Medicare Medicaid Services (CMS)

• North Carolina Transition
• September 6 7, 2001

2
BackgroundLegislative Authority - Fiscal
Intermediaries

• Section 1816 of the Social Security Act
  authorizes the use of fiscal intermediaries to
  make Medicare payments to institutional providers
  of health care services, such as hospitals and
  nursing facilities.
• This section entitles providers to nominate the
  entity to serve as their Medicare fiscal
  intermediary.
• The Secretary is not bound to accept all
  nominations, but has no authority to contract
  outside the nomination process.
• In 1966, the American Hospital Association
  nominated BCBSA to be the prime fiscal
  intermediary contractor -- an arrangement that
  continues today.

3
Selection Mechanism for Fiscal Intermediaries

• For Blue Cross Plans (Part A Fiscal
  Intermediary), Blue Cross and Blue Shield
  Association subcontracts to local Blue plan with
  HCFA approval

4
General Selection Process(For new contractor or
replacement contractor)

• Issue Request for Proposal (RFP)
• Receive Technical and Cost Proposals
• Convene Evaluation Board
• Read and evaluate proposals
• Rank offerors based on technical merit
• Recommend awardee to selecting Officer
• Select contractor

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Selection Process for North Carolina

• 2 RFPs
• 1. Program Safeguard Contractor (PSC) -
  evaluation conducted by CMS
• 2. Program Management Contractor (PM) -
  evaluation conducted by Blue Cross Association
• Both procurements ranked offerors by the
  soundness of technical proposal
• Blue Cross Association recommendation for Program
  Management Contractor approved by CMS

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Selections for North Carolina

• Process worked well
• Selectees (CBA and Palmetto GBA) very
  experienced
• in Medicare operations
• in Part A
• in transitions

7
Medicare Integrity Program (MIP) Background

• Created Under The Health Insurance Portability
  and Accountability Act of 1996 (HIPAA)
• Gives CMS Specific Contracting Authority,
  Consistent with Federal Acquisitions Regulations
  (FAR), to Enter Into Contracts with New Entities,
  not Excluding Current Fiscal Intermediaries
  Carriers, to Promote the Integrity of the
  Medicare Program.
• CMS Awarded 13 Indefinite Delivery-Indefinite
  Quantity (IDIQ) Contracts for the PSC Effort in
  May 1999.

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Opportunities...

• PSCs Bring Extensive Medicare Experience and New
  Innovative Approaches to Safeguard the Medicare
  Trust Fund.
• Partnering PSCs with Traditional Medicare
  Contractors Fosters a Commitment to Customer
  Service and Provider and Beneficiary Relations.

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PSC Background

• Under the PSC Umbrella Statement of Work (SOW),
  Specific Task Orders are Awarded by CMS or Other
  Government Agencies for Some/All of the
  Activities Identified in the Umbrella SOW.
• The Western Integrity Center (WIC) PSC the
  Region A DMERC PSC are Two Examples of Task
  Orders That Have Been Awarded Implemented
  Through Successful Workload Transitions.

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The North Carolina PSC

• Spring 2001, BCBS of North Carolina Announced
  They Were Leaving the Medicare Program
• CMS Saw This as an Opportunity to Create a New
  Innovative Relationship Between the Incoming
  Fiscal Intermediary a New PSC

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The North Carolina PSC

• This Initiative Supports CMSs Overall
  Contracting Reform Strategy Allows each
  Contractor to Focus its Strengths within its
  Current Operations.

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Current MIP Activities

• The Following MIP Functions are Currently
  Performed by BCBS of NC
• Cost Report Audit, Reimbursement, Settlement
• Prepayment Postpayment Medical Review
• Medicare Secondary Payer
• Contractor Medical Director
• Local Medical Review Policy Development
• Benefit Integrity Functions
• Provider Education Training

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What is the Relationship between Palmetto GBA
CBA?

• Palmetto GBA will be the Medicare Fiscal
  Intermediary for the State of North Carolina
• Will Perform Program Management (i.e., claims
  processing administrative functions) also
  Certain Program Integrity Activities
• As the PSC, CBA will be Responsible for the
  Remainder of Program Integrity Functions.

14
Workload Division under the NC PSC
15
Transition Cut-Over Dates

• In an effort to Mitigate the Risks of Concurrent
  Transitions, CMS has Decided to Transition the
  PSC Workload on October 1, 2001.
• The Claims Processing workload will be
  Transitioned to Palmetto on October 31, 2001.

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Provider Beneficiaries in NC

• BCBS of NC, Palmetto, CBA, CMS are Working very
  Closely to Ensure Minimal Impact on both
  Beneficiaries the Provider Community
• Under this new relationship, Palmetto will
  Maintain the Traditional Provider Relations
  Beneficiary Service Functions.
• CBA, as the new PSC, will Undertake the Remainder
  of Program Integrity Functions. CBA will contact
  Providers Directly In the Event that it Requires
  Information from You in Carrying Out its
  Activities.
• Palmetto CBA are Developing a Joint Operating
  Agreement that Defines Processes, Roles,
  Responsibilities for the New Environment.

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Transition OversightA CMS Priority

• We Are Committed to Making this a Seamless
  Successful Transition for Our North Carolina
  Providers Beneficiaries.
• 5 Central Office Several Atlanta Regional
  Office Staff Members are Dedicated to Transition
  Oversight.
• We Have Daily Weekly Calls With All Three
  Contractors Involved with this Transition are
  Ready to Handle Any Issues as They May Arise.