1. RFI GOALS AND OBJECTIVES

This Request for Information (RFI) is seeking information that will assist the Washington State Health Care Authority (HCA) in a potential procurement and implementation of a vendor to perform a Risk Adjustment Data Validation (RADV) audit for the Public Employee Benefits Board (PEBB) and School Employee Benefits Board (SEBB) programs.

HCA’s goals and objectives for this RFI are:

1. To learn – The Health Care Authority aims to use this RFI to learn from the vendor community:

• • What type(s) of vendors or organizations conduct RADV review or evaluation audits;

• • Can RADV audits be customized and applied to claims data for state employer group medical plans that exist within the commercial market;

• • How are costs assessed for the described services and what is the potential range of annual costs for a population that exceeds 500,000 members;

• • Are there any major business and/or technical complexities that vendors anticipate for this type of audit; and

2. Inform – With this RFI, HCA hopes to inform the vendor community of:

• • The potential procurement of one (1) vendor to conduct an annual RADV audit for the PEBB and SEBB programs; and

• • The framework HCA could use for the design and implementation of this RADV audit.

2. BACKGROUND

HCA conducts an annual settlement calculation for participating carriers in the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs. Each year, carriers develop bid rates on a prospective basis using an underlying assumption for the predicted risk, or resource intensity, of the assumed non-Medicare eligible population to be enrolled in their plans. Throughout a given plan year (January through December), carriers collect a risk adjusted premium from HCA, calculated using their prediction of population risk for their plan(s).

Following the close of each plan year, HCA and HCA’s contracted actuary conduct a retrospective concurrent risk adjustment calculation. This calculation measures the actual risk of a carrier’s underlying population during the applicable plan year, compares this to the predicted risk applied during rate development, and a revenue-neutral settlement payment is calculated for each participating carrier. This concurrent risk settlement “true-up” ensures the premium dollars plans received from HCA for members enrolled in their respective plans aligns with the actual resource intensity of that population.

For HCA to effectively complete this calculation, each participating carrier submits detailed claims data to HCA’s contracted actuary throughout the plan year. This claims data serves as the basis for all risk score calculations and the underlying settlement calculations. Currently, HCA does not audit the underlying claims data submitted by the carriers. However, to ensure these calculations are conducted as accurately as possible, we are exploring the potential of enacting a risk adjustment data validation (RADV) audit in future years.

3. ADMINISTRATIVE TERMS AND CONDITIONS

The RFI Coordinator is the sole point of contact in HCA for this RFI.

Any other communication will be considered unofficial and non-binding on HCA. Please be sure to include the RFI Number (2024HCA9) in the subject line of any emails.

1. Written Response - Required

All written responses to the questions in Exhibit A should be submitted via email to the RFI Coordinator as outlined in Section 3.1 at least two (2) business days prior to the scheduled conference call.

Please do not cut and paste responses into this RFI. Instead, provide a response as a separate document using the corresponding item number listed in Exhibit A – RFI Questions.

Responses should be provided in PDF format. This will assist in HCA’s review process. You only need to provide a single copy of your response. Responses may be provided in more than one file and submitted in more than one email. HCA requires that all responses be submitted via email to the RFI Coordinator.

Please note that HCA will not accept zipped or compressed files in connection with this RFI. HCA will not open any such file. If individual files to a response are too large, please send multiple emails instead of compressing files.

2. Conference Call - Required

One (1) hour conference call with HCA staff at one of the time slots listed below. Organizations or providers interested in responding to this RFI must send a reservation request to the RFI Coordinator at least two (2) business days prior to the scheduled conference call. The reservation request must include a designated contact person and a first, second, and third choice time slot.

Time slots will be on a first come, first serve basis. Once the date and time are confirmed, the RFI Coordinator will send the conference call information to the designated contact person.

3. Cost of Response

Respondents will not be reimbursed for any costs associated with preparing or presenting any response to this RFI.

4. Response Property of HCA

All materials submitted in response to this RFI become the property of HCA. HCA has the right to use any of the ideas presented in any response to the RFI.

5. Public Records and Proprietary Information

Any information contained in the response that is proprietary or confidential must be clearly designated as such. The page and the particular exception(s) from disclosure must be identified. Each page claimed to be exempt from disclosure must be clearly identified by the word “confidential” printed on the lower right-hand corner of the page. Marking the entire response as confidential will be neither accepted nor honored and may result in disclosure of the entire response.

To the extent consistent with chapter 42.56 RCW, the Public Records Act, HCA will maintain confidentiality of your information marked confidential or proprietary. If a request is made to view your proprietary information, HCA will notify you of the request and of the date that the records will be released to the requester unless you obtain a court order enjoining that disclosure. If you fail to obtain the court order enjoining disclosure, HCA will release the requested information on the date specified in its notice to you.

HCA’s sole responsibility will be limited to maintaining the above data in a secure area and to notify you of any request(s) for disclosure for so long as HCA retains your information in HCA records. Failure to so label such materials, or failure to timely respond after notice of request for public records has been given, will be deemed a waiver by you of any claim that such materials are exempt from disclosure.

HCA reserves the right to amend this RFI at any time. In the event it becomes necessary to revise any part of this RFI, addenda will be provided via e-mail to all individuals who have made the RFI Coordinator aware of their interest. Addenda will also be published on Washington’s Electronic Bid System (WEBS). The website can be located at https://fortress.wa.gov/ga/webs/. For this purpose, the published questions and answers and any other pertinent information will be provided as an addendum to the RFI and will be placed on the website.

HCA reserves the right to cancel or reissue this RFI at any time, without obligation or liability.

HCA will not contract with any vendor as a result of this RFI. While HCA may use responses to this RFI to draft a competitive solicitation for the subject of these services, issuing this RFI does not compel HCA to do so.

Responding to this RFI will not be a requirement of future solicitations. Responses and information provided in response to this RFI will not be considered when evaluating bidders responding to any future solicitation.

If HCA does a solicitation, HCA will post it on WEBS.

Any solution HCA procures and implements will need to comply with applicable state, federal, and industry regulations, such as the following:

2. HIPAA Privacy, Security and Breach Notifications
3. WA State OCIO Security Standard, OCIO 141.10
4. 42 CFR Part 2
5. RCW 70.02
6. HCA Privacy and Security Policies, such as HCA 1-02 and HCA 6-16
7. NIST 800-53 Rev 4
8. Industry certifications

Further information about any of the above can be provided at vendor request.

4. EXHIBIT A – RFI Questions

1. How often do you recommend these audits take place (annually, etc.)?
2. Do you audit a sampling of claims or the entire scope of claims?
3. Is there a focus on a specific subset of diagnosis codes or groupings?
4. Given our population size, what is a reasonable cost range for this type of audit? Is pricing done on a lump sum basis, per claim basis?
5. How would you set up a customized process like this for an employer group plan?
6. What period of claims run out is required to do an audit like this?
7. If a RADV audit is applied voluntarily for an employer group population, would it be required to mirror Federally regulated methodology? Could customized audit parameters be put into place?