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Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
Medicare Advantage RFP Sample
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Medicare Advantage RFP Sample

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This RFP was assembled for a large plan with 4.5 stars, looking to focus on Risk Management, Care Management, Member Retention, and Star Ratings

This RFP was assembled for a large plan with 4.5 stars, looking to focus on Risk Management, Care Management, Member Retention, and Star Ratings

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  1. Request for ProposalMedicare Advantage Performance Management System January 16th, 2012
  2. Request for Proposal – Clinical and Financial Performance Management System Table of ContentsI. Project Overview – Clinical and Financial Performance Management System Evaluation ............ 3II. Contact /Timeline Information for RFP.......................................................................................... 4III. [MAPD Plan] Overview ................................................................................................................. 4IV. Vendor Instructions for RFP Response ........................................................................................ 4V. Vendor Requested Information and Questionnaire ....................................................................... 4 Page 2
  3. Request for Proposal – Clinical and Financial Performance Management SystemI. Project Overview – Clinical and Financial Performance Management System Evaluation [MAPD Plan], a 4.5-star Medicare Advantage plan, is requesting proposals from third-party vendors for a clinical and financial performance management system to support a Collaborative Care Environment (CCE). [MAPD Plan] is pursuing a CCE as a quality and performance solution, with the primary focus on improving the performance of the enterprise as a whole. The system will provide collaboration between [MAPD Plan] and a contracted network of physicians to deliver, evaluate, and modify practice patterns and reward value creation. The primary purpose of this Request for Proposal (RFP) is to seek qualified vendor technology solutions that meet the requirements of a clinical and financial performance management system. The system will be the primary method to collect, measure, report, and manage quality outcomes. Physicians will use the clinical and financial performance management system as a common platform to impact outcomes and provide cost-saving opportunities. The assessment of submitted solutions will evaluate value, ease of use, experience, approximate cost, and time to market for each vendor’s proposed system. Important capabilities of the proposed solution include: Enterprise model with access to cross-continuum patient data Population health management for comprehensive disease management and prevention Care management comparisons to evidence-based clinical practice guidelines Performance management to monitor achievement of quality, utilization, and cost measures Transparent physician reporting, including peer-group comparatives Physician pay-for-performance attribution model capabilities Vendor experience with information system interoperability and the aggregation of data from multiple sources across the Medicare Advantage continuum of care, including EMR systems. Tool sets and visual presentations intuitive for physician usage, including web-based dashboards that provide access to data anytime, from anywhere Role-based infrastructure to safeguard compliance, security, and PHI considerations Page 3
  4. Request for Proposal – Clinical and Financial Performance Management System II. Contact /Timeline Information for RFPIII. [MAPD Plan] OverviewIV. Vendor Instructions for RFP Response V. Vendor Requested Information and Questionnaire All participating third-party vendors that are a part of your solution must complete the questions in this section. A. Company Overview 1. Provide the proposing companys name and address. Describe the complete corporate structure showing all ownership and subsidiaries, including names, addresses, lines of business, and percentages of ownership. 2. Provide a brief overview and history of the company. Include the year it was founded, location of its corporate headquarters, number of employees, and biographies of its leadership team. 3. Provide the company’s mission, goals, objectives, and vision statement. Briefly describe its general scope of products and services, solution offerings, and core competencies. 4. Provide the names, titles, and contact information of the individuals responsible for the information contained in the response. Indicate the sections for which these individuals are responsible. 5. Describe all partnerships or relationships the company has with third-party vendors, service providers, consultants, or other technology suppliers that are relevant to the company’s delivery of the proposed solution. For each of these partners, include the number of engagements and the length of the relationship. Describe how these relationships could affect the company’s delivery of the proposed solution. 6. What benefits would be derived from using the proposed solution? 7. How are the companys customers integrated into the process for setting the direction of the proposed solutions design and development? 8. Provide the number of completed client implementations for the proposed solution. 9. Provide a list of implementations for clients similar in size and complexity to [MAPD Plan], including their year of implementation. B. Physician / Provider Network Engagement 1. How does the proposed solution support accountable care initiatives? Please explain in detail. Page 4
  5. Request for Proposal – Clinical and Financial Performance Management System 2. Describe the companys capabilities to support provider contract incentives. 3. How does the proposed solution assist both health plans and provider organizations with pay- for-performance initiatives? 4. How does the proposed solution foster and enable data transparency between health plans and providers? 5. Describe the proposed solutions capabilities to provide performance reporting in the following areas: a. Medical expenditures b. Pharmacy utilization and costs c. Key utilization statistics 6. How does the proposed solution allow providers to benchmark their performance? 7. How does the proposed solution allow users to identify variations and drill down into actionable, patient-level detail? 8. Is the proposed solution currently being utilized by both health plans and physicians/providers? Please provide examples.C. Risk Adjustment 1. How does the proposed solution educate providers on risk-adjustment methodology? 2. Can providers earn CME credits for utilizing the education resources provided by the proposed solution (e.g., CME credit for completion of courses)? 3. Describe the algorithms that have been developed to identify documentation and coding opportunities. 4. Describe the proposed solutions abilities to mine disparate data sources for documentation and coding opportunities. 5. What guides and tools does the proposed solution provide that assist providers with proper documentation and coding? 6. Describe how proposed solution prioritizes patient visits based on the documentation and coding opportunities that are present at the patient level. Page 5
  6. Request for Proposal – Clinical and Financial Performance Management System 7. How does the proposed solution assist provider organizations with shared savings contracts for documentation and coding issues? 8. Describe the proposed solutions patient summary and how it provides health plans and physicians with a single source of documentation and coding history. 9. Provide case studies that illustrate the proposed solutions’ role in improving documentation and coding. 10. Describe the proposed solutions’ reporting capabilities with regard to Medicare Advantage risk adjustment. 11. Describe how the proposed solution is currently being utilized by Medicare Advantage plans. 12. How does the proposed solution identify and track chart audit candidates and incorporate the audit results?D. Star Ratings and Quality Initiatives 1. Describe the algorithms that have been developed to identify and target patients with gaps in care. 2. Describe how the proposed solution provides health plans and physician users with a view of a patient summary that details a patient’s gaps in care. 3. Describe how the proposed solution allows for customization of the measures and metrics underlying star ratings and quality performance algorithms. 4. Describe your process for benchmarking the proposed solution’s star ratings and quality performance algorithms. 5. Describe the proposed solutions capabilities that allow plans to monitor and track their star rating performance. 6. Describe the proposed solution’s functionality for provider organizations that have contractual incentives on star ratings or quality performance. 7. Describe the proposed solution’s capabilities that allow plans to improve star rating performance. Provide case studies for clients who have used the proposed solution to improve star rating performance.E. Care Management 1. Describe how the proposed solution enables coordination of care in a patient population. In particular, discuss how the proposed solution integrates with, and drives care coordination through, the following: a. EMR/EHR systems Page 6
  7. Request for Proposal – Clinical and Financial Performance Management System b. Provider processes for member referrals and transitions c. Provider processes for member intake and discharge 2. How does the proposed solution integrate into the workflow of a provider network? 3. Describe the ease of use of the proposed solution by a provider network. Include a discussion of provider adoption rates. 4. Describe the proposed solution’s capabilities for analyzing a patient population. Include a sample of a report on a patient population. 5. Describe the proposed solution’s capabilities for identifying and prioritizing care for high-risk members. 6. Describe the proposed solution’s capabilities for managing the treatment of chronic disease. 7. Describe how the proposed solution identifies opportunities for the most cost-effective form of care. Provide case studies for clients who have used the proposed solution to optimize the cost effectiveness of care delivery to a patient population. 8. Describe the company’s experience working directly with providers to assist them with member engagement and care management.F. Reporting Tools and Analytics 1. Provide a list of the standard reports and dashboards contained in the proposed solution. 2. Provide examples of reports and dashboards utilized by providers (i.e., physicians, nurse practitioners, case managers, social workers). 3. Provide examples of the reports and dashboards utilized by administrators (i.e., office managers, medical group administrators, health plan medical directors). 4. Describe how various user types (i.e., physicians, medical group administrators, case managers at a health plan, health plan executives) access these reports and dashboards. 5. Describe how successive levels of analysis can be accessed from these reports and dashboards. 6. Describe the reporting tools and data architecture used to develop the standard reports and dashboards in the proposed solution. Are all standard reports and dashboards developed using the same tools? 7. What limitations exist in report development using the provided tools? Page 7
  8. Request for Proposal – Clinical and Financial Performance Management System 8. How can the user interface be modified to meet the different needs of various user types (i.e., provider, medical group administrator, health plan executive)? 9. Describe how the standard reports and dashboards can be modified by the various user types. 10. Describe how the reporting tools of the proposed solution can be used to create customized reports and dashboards. 11. Describe the tools and reports in the proposed solution that allow a user to access individual patient/member clinical data. Include in the description the steps that would be required to access this level of data, along with response time. 12. Do you have the ability to perform real-time analyses and reporting? If not, what is the time lag for analytics and reporting? If applicable, please describe the steps being taken to improve data lag. 13. Describe the use of benchmarks in the tools and reports and how they are used to analyze a particular provider’s utilization, efficiency, and quality of care. 14. Describe how the reporting tools of the proposed solution compare individual and medical group level provider practice patterns to evidence-based clinical practice guidelines. 15. Describe how the reporting tools of the proposed solution allow for provider peer comparisons across individual providers, provider groups, IPAs, etc. 16. Describe how the proposed solution generates clinically relevant actionable information (e.g., alerts generated from practice guidelines, predictive models). Describe how various user types through the proposed solution would take action on this information. 17. Describe how the proposed solution will make use of third-party reporting and analytic tools for report writing and analysis. 18. Describe the download and export capabilities of the proposed solution. 19. Describe the proposed solution’s capabilities to: a. Support predictive modeling over large sets of data b. Provide for the recognition of provider practice patterns over large sets of data c. Simulate provider outcomes over large sets of data Please provide examples of each of the above capabilities.G. Host Environment/Framework Page 8
  9. Request for Proposal – Clinical and Financial Performance Management System 1. Describe the technology and architectural framework of the proposed solution. 2. Is the proposed solution vendor-hosted (ASP or SaaS), in-house, or a combination of both? 3. What hardware and software platforms does the proposed solution support? 4. Is the proposed solution deployable on a desktop, an intranet, or the internet? 5. What hardware standards are required for end users (i.e., workstations, tablet PCs, handheld devices, etc.)? 6. Provide details of additional software required to achieve full functionality with the proposed solution (e.g., MS Office, Crystal Reports, interface software, etc.). 7. Describe the companys processes for product testing and performing software upgrades. 8. How often are upgrades released for proposed software products? 9. Describe the companys disaster recovery plan for the proposed solution. 10. How will functionality continue in the case of a catastrophic occurrence such as the destruction of facilities that house critical systems, data, or records? 11. Describe the proposed solutions capabilities to report response time averages, system availability performance, and usage statistics. 12. Describe how the company is incorporating emerging or advanced technologies into the proposed solutions. Address areas including internet, wireless technologies, handheld technologies, interactive voice response, voice recognition, robotics, telemedicine, imaging, and other relevant areas.H. Data Repository/Data Integration 1. How does the proposed solution provide data warehousing or data integration of disparate clinical data? 2. How does the proposed solution integrate disparate data from multiple sources including EMRs,, lab results, radiology, membership data, medical and pharmacy claims, case management, and post-acute care?? 3. How does the proposed solution deliver patient-specific actionable information to providers at the point of care? Page 9
  10. Request for Proposal – Clinical and Financial Performance Management System 4. Describe the proposed solutions capabilities to manage patient/member identities across multiple source systems. a. Describe the matching process and exception reporting that addresses outlier issues. b. Describe the solutions ability to query a master patient index. c. Describe demographic data bases associated with the master patient index. 5. Describe the proposed solutions bulk data loading process. 6. Describe the company’s process for ensuring the validity, accuracy, completeness, and consistency of bulk data. 7. Describe the companys experience integrating various EHR/EMR systems. 8. Describe the companys experience with Health Information Exchanges (HIEs). 9. Provide information on the companys use of interface engines and other EDI tools, and its ability to supply HL7, CCOW and/or ASCII-compliant interfaces. 10. Does the proposed solution require a common data model and/or format? If it does, describe the common data model. If it does not, list all data sources, protocols, and formats for clinical information that the proposed solution supports. What sources are required for the proposed solution to deliver maximum value? 11. For data aggregation, does the proposed solution have the ability to categorize data by line of business, provider group, disease category, disease registry, and demographics? 12. Does the proposed solution provide flexible date parameters for year, month, and prior periods? 13. What is the companys historical retention of data on line? 14. How often are stored data refreshed?I. Security/Compliance Capabilities 1. Describe the proposed solutions security model and methods for data access, role-based user access, protection of PHI data, organization and user authentication, and network security. 2. How does the proposed solution ensure privacy and that access permissions are appropriate to each user, group, or audience? Page 10
  11. Request for Proposal – Clinical and Financial Performance Management System 3. Describe the proposed solution’s approach to compliance with federal and state regulations for health care and claims data handling.J. Implementation, Training, and Support 1. Describe the companys implementation strategy. Indicate the steps required to execute the proposed solution (e.g., launch of online portal, local software installation, distribution of hard/soft report). Include average length of time to implement each of these steps. 2. Describe the company’s consulting services. Outline the consulting engagements typical for a project of similar size and complexity to [MAPD Plan]. 3. Describe the companys training program. Specify the types of support offered to ensure success with the proposed solution (e.g., technical training, user workshops, etc.). 4. Describe the companys support process. Include what media is available for support, what hours support is available, turnaround times for support requests, and the escalation process. 5. Describe technology or infrastructure requirements necessary for [MAPD Plan] staff and [MAPD Plan] providers to implement and utilize the proposed solution (e.g., data warehouse, specific software, IT infrastructure). 6. How will the company handle post-implementation services with [MAPD Plan]?K. Cost of Ownership 1. Describe pricing structures for acquisition costs, license fees and/or subscriber-based fees. 2. Describe typical implementation and start-up potential costs (i.e., your company’s consulting rates for implementation, training, and other support). 3. Describe customization fees. 4. Describe annual fee structures for maintenance and support. 5. What internal resources does [MAPD Plan] need to devote to the proposed solution (types of personnel, hours required, etc.)? 6. Describe the intellectual ownership of your clients’ data. 7. What options are available to [MAPD Plan] to safeguard [MAPD Plan]’s data assets? 8. What rights will the company have to use [MAPD Plan] data for benchmark comparatives or other uses? Page 11

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