Through this Request for Proposal (RFP) the Department of Vermont Health Access (hereinafter the “State”) is seeking to establish contracts with one or more companies that can provide services to increase recoveries from Medicare to offset costs to the Medicaid Program.. Provide appropriate legal and administrative services to secure Medicare payment for services provided to dually eligible beneficiaries, billed to and paid by Medicaid as primary in error. Provide technical advice to the State on substantive legal changes to the Medicare coverage rules and beneficiary appeal rights under federal law, including, but not limited to, Medicare Part D drug coverage, when such changes impact the objectives of the resulting contract. Identify potential recoveries, initiate claims, and request reviews, appeals, and other types of legal actions with or against the Secretary of Health and Human Services and agents in the administration of the Medicare program. Take such actions as it deems appropriate and necessary to obtain payment for health care services or supplies under 42 U.S.C. §§ 1395d and 1395k and to prevent improper denials of Medicare coverage of services to individuals who are beneficiaries of both Medicare and Vermont Medicaid. Review State-provided records of claims and Medicaid payments to providers for services or supplies delivered to dual eligibles (beneficiaries with Medicare and Medicaid coverage) in order to identify cases to pursue recovery from Medicare. Exercise its professional judgment in choosing to initiate appropriate claims, requests for review, appeals – at the Administrative Law Judge (ALJ) and Federal Court levels, as applicable – and other legal actions which it deems to have merit and be of sufficient value to warrant expenditure of advocate time in pursuit of recovery. Review Medicare or Federal Court decisions and will identify any actions related to billing or Medicare coverage which are recommended or required of providers following that decision. Vendor will monitor provider practices to ensure that such recommendations or requirements are implemented.
