SAM #270048

CMS Supplemental Medical Review Contractor Services for Medicare Fee-for-Service Claims

CMS is seeking a Supplemental Medical Review Contractor (SMRC) to support nationwide post-payment medical reviews for Medicare Fee-for-Service claims. - Government Buyer: - Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI) - OEMs and Vendors: - No specific OEMs or commercial vendors are named; the opportunity is open to qualified small businesses with relevant expertise - Services Requested: - Nationwide post-payment medical review of Medicare Parts A, B, and DMEPOS claims - PCG Specialty Reviews and Program Integrity Support to identify improper payments, fraud, waste, and abuse - Appeals support, provider education, document management, and call center support - Development and maintenance of a secure provider portal and public website - Data analysis, statistical extrapolation of overpayments, and evidence-based research - Participation in Administrative Law Judge (ALJ) hearings to defend medical review decisions - Contract ramp-up, close-out, and transition management - Unique/Notable Requirements: - Ability to handle up to ~500,000 claims annually across ~80-100 projects - Experience with Medicare claims, medical record management, and IT system integration - Adherence to CMS IT security and privacy policies - Provision of detailed project reports, monthly status updates, and quality control plans - Optional innovation projects and statistical recalculation tasks - Extensive collaboration with CMS and external agencies

Description

Perform post payment medical reviews (MR) and medical review related activities in support of initiatives within the Center for Program Integrity (CPI)

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