Specifications include, but are not limited to: A. BACKGROUND: Given the highly regulated nature of medical billing, the Pinellas County Safety and Emergency Services (SES) Department has historically utilized a Medicare consultant to navigate the complexities of billing ambulance claims subject to Title XVIII of the Social Security Act, commonly known as Medicare. The Financial Service Division of SES processes approximately 185,000 ambulance claims annually with a payer mix of: 55% Medicare and Medicare Part C Plans; 8% Medicaid; 20% Commercial Insurance; 9% Facilities; and 8% Patient pay. The application of rules and regulations applicable to the predominant portion of Medicare in the payer mix is highly scrutinized at the Federal level. These services require a vendor that is highly proficient and experienced in this area of law. The continuity of contracting with a vendor to provide these services is critical to SES operations and to avoid/reduce the potential of civil or monetary penalties associated with Medicare billing. These services consist of technical guidance, claim level review, interpretation/application of new or revised regulations, post-billing audits, and keeping SES abreast of pending regulations and trends impacting the ambulance industry. B. REQUIREMENTS: 1. QUALIFICATIONS AND EXPERIENCE – Vendor must be a licensed attorney with an active fidelity fund certificate with a minimum of ten (10) years specializing in Medicare (Title XVIII of the Social Security Act) relating to the ambulance transportation industry. C. SCOPE OF WORK: 1. ANNUAL COMPLIANCE REVIEW – Vendor will conduct a compliance billing review of seventy-five (75) ambulance claims annually in the following denominations, categories, service levels, and type of transports ensuring SES’s billing practices and procedures align with the Centers for Medicare and Medicaid (CMS), and other applicable healthcare rules and regulations. # of Claims HCPCS Service Level/Type; 10 A0426 ALS, Non-Emergency; 15 A0427 ALS, Emergency; 20 A0428 BLS, Non-Emergency – to include Repetitive and Interfacility; 10 A0429 BLS, Emergency; 15 A0433 ALS 2; 5 A0434 Specialty Care (CCT/SCT); 75 Total 2. ANNUAL COMPLIANCE REVIEW DEBRIEF – Vendor must meet annually with County staff to conduct a debrief of the compliance review outcome, advising the County of areas of potential risk, best practices, and recommendations for process/operational improvements. Debrief meeting can be on-site or via meeting platforms such as Microsoft Teams or Zoom Video Communication. 3. ANNUAL COMPLIANCE REVIEW REPORT – Vendor must provide a comprehensive final written report no later than fifteen (15) business days following the debrief meeting. Report will contain at a minimum: A comprehensive opinion on the County’s billing practices alignment with applicable Medicare regulations and requirements; Claim level line-item review of specific claims and any noted issues; Recommendations for corrective actions; Recommendations for operational process or procedural improvements; and applicable best practices. 4. CONSULTATION – Vendor will be available via phone or email during regular business hours/days to respond within 2 business days to related inquiries regarding Medicare as it pertains to: Interpretation of regulations and requirements; questions of a compliance nature; billing practices; appropriate claim coding; reimbursements and refunds; and nuances of Medicare Part A responsible parties. Consultant responding to inquires must be a partner of the law firm and with at least ten (10) years of Medicare related experience. 5. DOCUMENT REVIEW – Vendor will review, at a minimum, ten (10) documents annually inclusive of contracts, agreements, and written policies/procedures associated with public and private healthcare facilities, commercial insurances, etc. This review must include an assessment of document’s compliance with CMS rules and regulations, HIPAA, and other regulation that govern healthcare. 6. PUBLICATIONS – Vendor will provide the County with a monthly publication such as a newsletter, report, or update with a focus on federal and states legislation that impact ambulance billing and operations, new or revised healthcare mandates, heath current events, and associated pending legislation that will impact the ambulance industry. 7. ANNUAL MEETING/Q&A SESSION/WEBINAR – Vendor will provide annual access, without charge, to one meeting, Q&A session, or webinar conducted by the Vendor for a minimum of two (2) County staff.
