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Question VA Response The SOW states that PCT must, "ingest data from various sources such as, but not limited to, CMS Physician Specialty Code Set, NPPES/PECOS specialty files, OIG LEIE list, CMS Freq... Question VA Response The SOW states that PCT must, "ingest data from various sources such as, but not limited to, CMS Physician Specialty Code Set, NPPES/PECOS specialty files, OIG LEIE list, CMS Frequency/utilization reports, Prospective Payment Systems (PPS). Are these data sources publicly available or is the PCT required to be integrated with external systems? VA will consider providing additional details in the RFP. Which existing VA systems must the solution integrate with initially (e.g., eligibility, referral/authorization, financial, provider master files), and what interface mechanisms are available (APIs, file feeds, messaging)? VA will consider providing additional details in the RFP. Is FedRAMP authorization required for this engagement? If so, at what impact level (Low, Moderate, High), and would you accept a roadmap to authorization if not yet authorized? VA will consider providing additional details in the RFP. Would VA consider a Vendor-hosted SaaS with VA integrations for the chosen Payer Compliance Tool (PCT)? VA will consider providing additional details in the RFP. What is VA's anticipated timeline from RFI to RFP release, and what is the target go-live date for the PCT solution VA's anticipated timeline from the Request for Information (RFI) to the Request for Proposal (RFP) release is yet to be determined. The target go-live date for the PCT solution should be proposed by vendors in their submissions, including detailed implementation plans and recommended go-live dates. What is the anticipated award date and go-live date? Are there hard deadlines or phased rollouts? See response to Question 6 What is the expected annual claims volume? VA will consider providing additional details in the RFP. If you are able, could you let us know how many users would need access to the application? At this stage, VA anticipates a core group of users initially with the potential to scale access as operational needs evolve. VA prefers to maintain flexibility. The exact number will be determined as part of the implementation process. Additional information on role-based permissioning can be found in the "Security and Access Control" section of the SOW. Home/Community Care Coverage: Does the scope of the PCT include non-medical home and community-based care services, or is it limited to institutional and professional claims? The scope of the PCT includes the ability to ingest 837I, 837P, and 837D claims. Yes, VA intends to include claims for non-medical home health care, geriatrics and extended care, and personal care services, based on VA-specific rules. The VA will provide further clarity during the implementation phase. Claims Processing Scope: Will the PCT need to analyze 100% of adjudicated claims, or will VA pre-filter a subset of claims (e.g., high-dollar, specific procedure codes, certain providers) for analysis? Yes, VA expects the PCT to analyze 100% of adjudicated claims. However, VA anticipates a phased implementation approach. Additional information is available in the "Rules Engine" section. Contract Award Structure: Does VA intend to award to a single vendor for all healthcare sectors (institutional, professional, dental), or will there be multiple awards based on specific sectors or service types? VA intends to award to a single vendor encompassing all healthcare sectors, including institutional, professional, and dental services. Geographic Division: Will the procurement be structured as a single national solution, or does VA anticipate regional implementations aligned with VISN boundaries? VA anticipates the procurement will be structured as a single national solution. VAMC Integration: How will the enterprise PCT solution integrate with or replace existing FWA processes at individual VA Medical Centers? Will there be a mandate for VAMCs to adopt the central tool, or will it supplement local efforts? The enterprise PCT solution is not intended to replace any existing FWA systems at individual VA Medical Centers. Timeline and Implementation: What is VA's anticipated timeline from RFI to RFP release, and what is the target go-live date for the PCT solution? See response to Question 6 This section states "The purpose of this Statement of Work (SOW) is to outline the requirements for procuring a VA Community Care Payer Compliance Tool (PCT)." Since the VA has enterprise-wide FWA efforts in progress, can the VA confirm the rules and payment integrity analytics will only be used for Community Care claims? The rules and payment integrity analytics will be used for 837P, 837I, and 837D healthcare claims. VA will ensure alignment of this information on the RFP. The following metrics will be critical for determining size, scope and savings estimates for the proposed tool. Can the Government provide estimated metrics such as the following: Claim volume Amount of paid dollars List of applicable CCN regions Claim types (pharm, medical, dental) Membership/veteran volume Historical claims data requirements (# years) User count and types requiring tool access VA will provide this information in the RFP. The SOW states, "The system must support integration with other tools and systems within the VA via APIs or other secure connection methods, enabling seamless data sharing and interoperability." Can the Government confirm which VA systems are required for integration? The system must support integration with existing and future systems including but not limited to, EDI pipelines, data warehouses, referral systems, and financial systems. The VA will provide further clarity regarding specific systems during the implementation phase. The SOW states, "The system must integrate with a comprehensive set of compliance rules to ensure alignment with VA, CMS, and contractual reimbursement policies and guidelines. This includes, but is not limited to, CMS compliance edits such as NCCI, MUE, MPPR, global surgical package rules, etc.; VA-specific policies including VA Payment Policies, Clinical Determinations and Indications guidelines, and other VA reimbursement guidelines." Does the VA anticipate this rules check to be exclusively post-payment, or does this include pre-payment checks? VA will provide further clarification during the implementation phase. The RFI questionnaire asks, "How does your tool support both pre-payment and post-payment integrity checks?" However, the SOW does not include requirements related to accessing pre-payment claims data or pre-pay analytics and detection. Can the VA confirm if pre-payment integration and analytics are required? VA will consider providing additional details in the RFP. The SOW states, "These modules must include, at a minimum, IPPS, OPPS, SNF PPS, IRF PPS, and ESRD PPS. The system must utilize these modules to price claims accurately according to the respective payment system guidelines. Additionally, the system must check pricing against CMS, CMS Medicare Administrative Contractor (MAC), CMS/MAC Critical Access Hospital rates, VA Fee Schedules, and CHAMPUS Maximum Allowable Charge (CMAC), including any necessary geographic adjustments." Does the VA anticipate requiring the PCT to integrate with external (non-VA systems) to access this data or will VA make these guidelines and fee schedules available to the PCT contractor? VA-specific data, such as VA Fee Schedules, Policies, and specific VA business rules, will be provided by the VA. However, it is expected that the PCT contractor will maintain current reimbursement rates, policies, and guidelines from external sources, such as CMS, MAC, and CMAC, as indicated in the "Rule Engine" section of the SOW. The SOW requires alignment to specific CMS and VA payment guidelines and fee schedules such as IPPS, OPPS, SNF PPS, IRF PPS, and ESRD PPS. and CMS, CMS Medicare Administrative Contractor (MAC), CMS/MAC Critical Access Hospital rates, VA Fee Schedules, and CHAMPUS Maximum Allowable Charge (CMAC). Given the unique VA community care guidelines included in SEOC and referral information, how does the VA expect the PCT to align these CMS standards for CCN? While the PCT must align with specific CMS and VA payment guidelines and fee schedules, it will also require integration of VA-specific business rules, as indicated in the "Rule Engine" section of SOW. Does the PCT need to sync recoupment data back to a VA system? If so, which system(s)? The system must support integration with existing and future systems including but not limited to, EDI pipelines, data warehouses, referral systems, and financial systems. The VA will provide further clarification in the RFP and during the implementation phase. Does VA anticipate that PCT analytics and models will only run on the latest version of a claim or all versions of a claim for expanded FWA pattern detection? The PCT should be able to analyze the full lineage of a claim for its rules engine and analytics, enabling expanded FWA pattern detection across all versions of a claim. What is VA s internal staffing capabilities? Is the desired payment integrity solution a software for their internal team or an outsourced full service? The desired payment integrity solution is a software as a service (SaaS) to be used by VA's payment integrity teams, as outlined in the 'Background' section of the SOW. What claims and reference systems/data feeds are currently in use (e.g., internal VA claims system, 837P/I/D feeds, OIG LEIE, CMS fee schedules)? VA will provide further clarification during the implementation phase. Which of the listed inputs are already ingested today versus expected to be newly onboarded, and what is the desired ingestion cadence (real-time, hourly, daily)? VA will consider providing additional details in the RFP. How should discrepancies betVAen VA-provided data and external authoritative sources (e.g., CMS, OIG) be resolved, do you have a source-of-truth hierarchy or reconciliation process? VA will provide further clarification during the implementation phase. What access will the vendor have to real-time and historical VA claims data? The vendor will have access to both real-time and historical VA claims data. Will the VA need the ability to author, edit, and deploy business rules internally, or must all changes go through the vendor? VA expects a limited number of internal users to have the ability to author, edit, and deploy business rules. The vendor will work closely with VA stakeholders to tailor and update the system, as specified in the SOW. What is the formal approval workflow for introducing, updating, or retiring rules (e.g., staging, sign-off authority, version control)? VA will provide further clarification during the implementation phase. Are rules primarily based on CMS/standard guidance, or are there VA-specific policies that must be encoded? If VA-specific, is there a maintained repository of those rules/policies? While rules are primarily based on CMS guidance, there will also be VA-specific policies that must be incorporated, as indicated in the SOW. These VA-specific rules are expected to continuously mature throughout the life of the contract as new statutes, regulations, and policies are enacted (e.g., services covered by VA's health benefits package, but not covered by CMS). Who will consume and act on flagged patterns does the VA have internal investigative staff, or is there interest in embedded SIU/augmentation services? Flagged patterns will be consumed and acted upon by VA staff. The vendor will provide support in instances where additional clarity is needed, such as, but not limited to understanding false positives, rule exceptions, and interpreting predictive analytics trends. What are the expectations around model retraining and feedback: frequency of retraining and the process for validating human-in-the-loop labels? VA is committed to being flexible and collaborative in providing the necessary input for model training. Our goal is to support the development and refinement of the tool to ensure accuracy, usability, and alignment with our compliance objectives. The system shall support a feedback loop where human reviewers can confirm or dismiss AI-generated flags, with outcomes logged and used to retrain and improve model performance as indicated in the SOW. VA will provide further clarification during the implementation phase. Are there defined bias/fairness guardrails (e.g., by geography, specialty), and how should anomaly scores be contextualized to minimize false positives? At this time the VA does not have defined fairness guardrails in place but recognize their importance. VA expects the PCT to provide transparency around anomaly scoring logic and support context-driven thresholds to help minimize false positives. VA will provide further clarification during the implementation phase. What performance SLAs or benchmarks will be part of acceptance criteria (e.g., claim validation latency, throughput, dashboard responsiveness)? VA will consider providing additional details in the RFP. Who are the primary user personas (auditors, investigators, finance, operations), and what level of self-service customization is expected for dashboards and alerts? VA will consider providing additional details in the RFP. What notification channels and escalation rules are required for new flags, stale cases, or critical conditions? VA will consider providing additional details in the RFP. What is the expected depth of investigative drilldown from summary metrics to underlying claim, rule logic, model explanation, and user annotations in a single workflow? VA expects the ability to drill down within a single streamlined workflow. This includes access to summary metrics, underlying claim details, rule logic, model explanations, and user annotations. For example, it is crucial to identify the specific version, year, quarter, and month of a fee schedule applied to determine an error, as well as the relevant policy, regulation, and payment methodology used. The goal is to ensure transparency, which is critical for validating findings, informing decisions, and supporting audit readiness. Which financial KPIs are most important (e.g., recovery velocity, cost avoidance, yield per investigation), and at what cadence do you expect reporting? VA's primary focus is on prevention and addressing FboNotice cause issues of improper payments, with cost avoidance and the integration of lessons learned into business rules being the most important KPIs. Regular reporting cadences are expected, with flexibility to support continuous improvement and oversight. What are your success criteria for user onboarding (e.g., time-to-proficiency, role-based certification), and do you expect a train-the-trainer model? As indicated in the SOW, VA's success criteria for user onboarding include comprehensive training programs that ensure user proficiency. These programs encompass initial onboarding, role-specific training, and ongoing education. The vendor will need to provide detailed training materials, such as user manuals, video tutorials, and quick reference guides. A train-the-trainer model is anticipated to ensure effective and widespread user training. VA will provide additional information in the RFP. What support coverage model is required (hours, severity levels, escalation path) and what are the desired response/resolution SLAs? VA will consider providing additional details in the RFP. How should training materials be maintained and versioned, and are there preferred delivery formats (live, recorded, in-app)? The vendor is encouraged to propose their approach to meet the requirements as outlined in the SOW in their proposal. Is the PCT intended solely as a technology purchase for use by existing contractors, or will this acquisition also include contracting for: a) Implementation and platform stand-up within the VA environment? b) Ongoing operations and maintenance (O&M)? c) Receiving, reviewing, translating, and working PCT results on VA s behalf? VA will consider providing additional details in the RFP. Will the contractor be expected to integrate PCT output into VA s broader payment review and compliance processes? VA will consider providing additional details in the RFP. Is there an expectation for the tool to replace existing manual reviews entirely, or simply reduce the volume and scope of manual work? The desired payment integrity solution is a SaaS tool as outlined in the 'Background' section of the SOW, designed to streamline workflows and maximize payment oversight. VA does not expect the PCT to comprehensively replace manual reviews. Does VA already have a preferred hosting environment (e.g., Azure Government, AWS GovCloud) for the PCT? VA will consider providing additional details in the RFP. Will the PCT be positioned inside the VA s secure environment, or can it be hosted externally with secure integrations? VA will consider providing additional details in the RFP. If hosted externally, what cybersecurity and FedRAMP compliance requirements will apply? VA will consider providing additional details in the RFP. Does VA require a fully developed, production-ready tool, or will it consider a phased approach such as a proof of concept (PoC) folloVAd by full implementation? The vendor is encouraged to propose their approach to meet the requirements as outlined in the SOW in their proposal. If VA is open to a PoC, what timeframe is anticipated for evaluation before full rollout? The vendor is encouraged to propose their approach to meet the requirements as outlined in the SOW in their proposal. Will VA provide historical payment data for testing and refining the PoC? VA will consider providing additional details in the RFP. What evaluation criteria will be used to compare potential PCT solutions? VA will provide this information in the RFP. Will the contractor be responsible for configuration, customization, and training of VA staff on the PCT? Yes, as indicated in the SOW, the contractor will be responsible for the configuration, customization, and training of VA staff on the PCT. This will be done in close coordination with VA to ensure alignment with operational needs and user expectations. VA will provide further clarification during the implementation phase. What level of post-implementation support and performance monitoring does VA expect from the contractor? VA expects ongoing post-implementation support, including timely issue resolution, user assistance, rule maintenance and updates, and regular performance monitoring to ensure the tool meets accuracy, efficiency, and compliance goals. This includes scheduled check-ins, reporting on key metrics, and the ability to make iterative improvements. VA will provide additional information in the RFP. Does VA require integration of the PCT with existing VA systems (e.g., payment processing, claims adjudication, or fraud detection platforms)? The system must support integration with existing and future systems including but not limited to, EDI pipelines, data warehouses, referral systems, and financial systems. VA will provide further clarification regarding specific systems during the implementation phase. How will VA measure the success of the PCT in improving payment integrity? VA will measure the success by evaluating the PCT's accuracy in distinguishing legitimate claims from problematic ones, the reduction in manual claim reviews, and increased cost avoidance. Additional metrics may include improved identification of improper payments and high-risk invoices, integration of findings into business rules, enhanced efficiency, consistency of human-in-the-loop feedback, and measurable ROI in terms of cost avoidance and recoupment. VA will provide additional information in the RFP. Is VA s goal to eliminate most manual reviews or to supplement them with automated detection and analysis? VA's goal is to reduce reliance on manual reviews by supplementing them with automated detection and analysis. However, VA recognizes that human intervention will remain necessary, particularly during the initial implementation phase and in complex cases where judgment is required. How will findings from the PCT be actioned, and by whom? Findings from the PCT will primarily be actioned by VA's payment integrity teams, who will review, validate, and determine appropriate next steps. How many total payments per year are expected to be processed through the PCT? VA will provide this information in the RFP. What is the current estimated volume and dollar value of improper payments identified annually? VA will provide this information in the RFP. What payment types, programs, or VA service areas will be included in the PCT scope? The PCT will be used for VA community care 837P, 837I, and 837D healthcare claims as outlined in the "Functionality and Feature Requirements" section in the SOW. VA will ensure alignment of this information in the RFP. What is VA s anticipated timeline for contract award, tool deployment, and go-live? See response to Question 6 What are VA s data retention and archival requirements for PCT outputs? VA will provide this information in the RFP. Will the PCT be required to produce auditable reports for oversight bodies (e.g., OIG, GAO)? Yes, VA requires the PCT to produce auditable documentation and reports for oversight bodies. VA will provide additional information in the RFP. What security and privacy frameworks must the tool comply with (e.g., HIPAA, FISMA, NIST standards)? VA will provide this information in the RFP. The background section in the draft SOW indicates that this effort includes the universe of community care claims, without identifying them by type. Does VA intend to include claims for all the types of services paid for from the Medical Community Care (0140) fund? If not, can VA clarify what services will be included? See response to Question 62 Will the tool be expected to perform payer compliance for all the identified claim types on day 1? VA anticipates a phased implementation approach. Will IVC staff be the user of the PCT? Who and how large is the community that must be trained? See response to Question 9 What is the timeframe for initiating recoupments of overpayments? VA will consider providing additional details in the RFP. Can VA provide technical schema for the Consolidated Data Sets (CDS) tool environment, specifically workflows, API into data flows, collection activities. Third party application, messaging layers would greatly assist in defining approach to integrating our software solution. VA will consider providing additional details in the RFP. Would the Technology Acquisition Center (TAC) consider allowing oral presentations or solution demonstrations in lieu of, or in support of, a streamlined written technical volume as part of any future solicitation? Not relevant to RFI purposes. TPA Integration: Given that this RFI focuses on CCN claims, how do you envision the PCT interacting / integrating with the TPAs? Not relevant to RFI purposes. FWA Baseline and Targets: What is VA's current estimated improper payment rate (as a percentage of total Community Care spend), and what is the target reduction percentage the PCT should achieve? Are there specific categories of improper payments VA is most concerned about? Not relevant to RFI purposes. Confidential Information Marking Requirements: Please provide written guidance addressing: Not relevant to RFI purposes. Specific format and language required to mark proprietary/confidential portions of our RFI response Not relevant to RFI purposes. Evaluation criteria VA will use to determine whether to honor confidentiality designations Not relevant to RFI purposes. VA's policy on potential FOIA disclosure of information marked as proprietary, including applicable exemptions and circumstances under which disclosure might occur Not relevant to RFI purposes. Whether confidentiality markings will be honored during the evaluation process and in any subsequent procurement Not relevant to RFI purposes. How much money (or what percentage of total payments) does the VA currently pay "improperly" per year? Not relevant to RFI purposes. Would it be easy for you to break this down by payer type within the CCN (i.e. homecare, dentistry, physical therapy, etc) Not relevant to RFI purposes. What is the target reduction in dollars (or in percentage) the PCT should achieve? Are there specific categories of improper payments VA is most concerned about? Not relevant to RFI purposes. Since FWA in the Community Care space is currently handled by multiple vendors, who does VA consider the incumbent? Not relevant to RFI purposes. How will the PCT integrate with community care TPA claims processing systems? Not relevant to RFI purposes. How does the Government envision the Payer Compliance Contractor working with the Community Care Network TPAs regarding existing FWA and payment integrity efforts? Not relevant to RFI purposes. The RFI includes a series of questions about Utilization Management (UM), but the SOW doesn't reference UM. Can VA clarify if UM is required or included in the scope? Not relevant to RFI purposes. What is the preferred pricing model (e.g., subscription, per-claim, contingency/recovery share, hybrid)? Not relevant to RFI purposes. What are the evaluation milestones, decision criteria, and timeline for vendor selection and contract award? Not relevant to RFI purposes. Will the VA provide electronic access to provider-specific contract rates and terms (e.g., negotiated fee schedules, bundled rates, exclusions)?  Not relevant to RFI purposes. How frequently do provider contract terms change, and will VA supply deltas or full refreshes? Not relevant to RFI purposes. What are the expectations for subcontractors must they individually meet the same compliance/certification requirements, and is there an approval or flow-down process VA needs to follow? Not relevant to RFI purposes. What security documentation or evidence is expected during proposal and onboarding (e.g., current authorization packages, penetration test reports, System Security Plan, encryption/key management design)? Not relevant to RFI purposes. Would there be a need to demo the tool for the bidding process or just the presentation of sufficient documentation? Not relevant to RFI purposes. Who is the existing contractor(s) currently supporting Payment Integrity manual reviews? Not relevant to RFI purposes. What is the scope of responsibilities for the current contractor(s) in relation to Payment Integrity? Not relevant to RFI purposes. Will the existing contractors have continued involvement if the Payer Compliance Tool (PCT) is acquired? Not relevant to RFI purposes. Has VA already identified or predetermined a specific PCT vendor or product? Not relevant to RFI purposes. Is VA aware of other PCT solutions currently available in the market? If so, can VA share examples of tools under consideration? Not relevant to RFI purposes. Are there any anticipated budget constraints that would influence a phased or scaled deployment approach? Not relevant to RFI purposes. Will VA accept prototype demonstrations as part of the proposal evaluation process? Not relevant to RFI purposes. Would VA please consider the release of the RFP as a Service-Disabled Veteran-Owned Small Business (SDVOSB) set aside under NAICS 541611 given that there are contractors who specialize in payments and payment integrity within this population? Not relevant to RFI purposes. Is there an incumbent performing payment integrity work for community care? Not relevant to RFI purposes. Will VA provide the contractor access to the payer contract documents, blanket purchase agreements, Veterans Care Agreements (VCAs) and any other type of document that may contain the payment terms for community care claims? Not relevant to RFI purposes. Will contractors performing work in IVC related to operations manuals, standard operating procedures, support to claims processing, or project management for the community care programs or claims systems be conflicted from this potential procurement? Not relevant to RFI purposes.