[Federal Register Volume 60, Number 159 (Thursday, August 17, 1995)]
[Notices]
[Pages 42888-42899]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-20317]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Statement of Organization, Functions, and Delegations of
Authority; Substructure for the Bureau of Program Operations
Part F of the Statement of Organization, Functions, and Delegations
of Authority for the Department of Health and Human Services, Health
Care Financing Administration (HCFA), (Federal Register, Vol. 59, No.
60, pp. 14648-14654, dated Tuesday, March 29, 1994, and Federal
Register, Vol. 60, No.12, pg. 3869, dated Thursday, January 19, 1995)
is amended to reflect a change to the subordinate structure of the
Bureau of Program Operations (BPO).
BPO is streamlining their organization by eliminating one entire
organizational layer and realigning functions that supports the bureau
in moving toward and into the Medicare Transaction System.
The specific amendments to part F are described below:
Section F.10.D., Health Care Financing Administration, Associate
Administrator for Operations and Resource Management (FL)
(Organization), paragraphs 4.a. through g. and all the associated
subparagraphs are deleted and replaced with the following new
organizational structure and administrative codes:
4. Bureau of Program Operations (FLG)
a. Management & Program Support Staff (FLG-1)
b. Office of Analysis and Systems (FLG1)
(1) Analysis (FLG11)
(2) Operational Systems (FLG12)
(3) Systems Testing (FLG13)
(4) Systems Design (FLG14)
c. Office of Benefits Integrity (FLG2)
(1) Medical Review (FLG21)
(2) Program Integrity (FLG22)
(3) Audit/CMP (FLG23)
(4) Overpayment & MSP Collections (FLG24)
d. Office of Program Requirements (FLG3)
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(1) Institutional Claims Processing Requirements (FLG31)
(2) Practitioner Claims Processing Requirements (FLG32)
(3) Supplier Claims Processing Requirements (FLG33)
(4) Standards Setting (FLG34)
(5) Provider Enrollment (FLG35)
(6) Benefit Coordination (FLG36)
e. Office of Contract Administration (FLG4)
(1) Acquisitions & Contracts (FLG41)
(2) Financial Management (FLG42)
(3) Transition Management (FLG43)
(4) Contract Management (FLG44)
(5) Planning (FLG45)
f. Office of Customer Communications (FLG5)
(1) Appeals (FLG51)
(2) Entitlement & Premium Billing (FLG52)
(3) Issuances (FLG53)
(4) Medicare Customer Assistance (FLG54)
(5) Communications (FLG55)
g. Medicare Transaction System Initiative Task Force (FLG6)
(1) Medicare Transaction System Quality Assurance (FLG61)
(2) Medicare Transaction System Development (FLG62)
(3) Medicare Transaction System Program Planning & Needs Analysis
(FLG63)
Section F.20.D, Health Care Financing Administration Associate
Administrator for Operations and Resource Management (FL) (Functions),
paragraphs 4.a. through g. and all the associated subparagraphs are
deleted and replaced with the following new functional statements and
administrative codes:
a. Management & Program Support Staff (FLG-1)
Plans and directs a comprehensive bureau-wide human
resource management program including manpower selection and placement,
organizational analysis, training and employee development (including
ADP and Medicare program related training), position control, manpower
utilization, employee counseling, equal employment opportunity, and
labor relations activities.
Plans, directs, and coordinates bureau-wide employee
appraisal programs including SES performance monitoring programs and
the administration of mandatory performance award system.
Plans and manages the bureau's financial management
program, interprets administrative budgetary policies and limitations,
and issues bureau-wide guidelines and instructions for budget
formulation and execution.
Executes the budget through the issuance of staff and
dollar controls, budget allowances for administrative expenditures, and
employee ceilings to BPO sub-components.
Plans and monitors all BPO administrative contracts and
procurement and conducts management evaluations to assure the
effectiveness of the bureau's overall financial operations.
Directs the bureau's ADP activities which includes
providing technical assistance to bureau components in mainframe and
microcomputer applications, developing BPO automation strategy based on
long-term needs and new initiatives, identifying bureau ADP needs and
requirements, and coordinating with the Bureau of Data Management and
Strategy the necessary implementation activities.
Serves as a focus for information and analysis to support
both short and long-range planning for the bureau, identifying trends
in the findings of external monitoring organizations (i.e, the General
Accounting Office) as well as internal reviews. Recommends changes in
operating procedures, policies, strategies, and organizational
structure as appropriate.
Conducts studies and analyses of the bureau's work
processes and procedures, workload and production data, material and
staff resources, budgetary data and expenditures trends, and physical
layout. Recommends changes in operating procedures, policies,
strategies, and organizational structure as appropriate.
Develops and implements all bureau programs and
administrative delegations of authority and serves as a focal point for
all delegations of authority issues affecting the bureau. Serves as the
focal point in leading negotiations with other HCFA components to
resolve conflicts over central or regional office responsibilities.
Serves as the bureau's primary source for management
consultation and advice on management policies and issues including
highly sensitive and complex actions involving inter-bureau
coordination. Develops and implements bureau-wide management policies.
b. Office of Analysis and Systems (FLG1)
Provides requirements and specifications for the design,
development, and maintenance of reporting and information management
systems that generate data reflecting on Medicare program operations.
Identifies reporting and information needs for data
relating to Medicare contractor operations and initiates appropriate
action for establishing or modifying the reporting and information
systems to satisfy these needs.
Analyzes a broad range of information, including computer
stored data, on operations performed in support of the Medicare
program; prepares interpretive reports and recommendations on findings
to internal bureau components for purposes of conducting program and
performance evaluations.
Provides overall support to other staff in analyzing and
interpreting program and operational data to better understand the
program.
Provides requirements and specifications for the design,
development, and management at the national level, activities required
to enhance systems for improvement of the Medicare eligibility systems,
Part A and Part B claims processing systems, and the Medicare program
database.
Provides direction and guidance to HCFA staff (central
office and regional) on improving contractor systems.
Prepares systems plans and develops policies for the
design, implementation, and evaluation of shared systems and
standardized modules for use by Medicare carriers, intermediaries, and
hosts.
Directs the design, development testing, and
implementation of innovative system enhancements to the Common Working
File (CWF) shared claims processing systems resulting in improvements
to the national Medicare claims payment process.
Provides requirements and specifications for the
development, implementation, execution, and monitoring of a procedure
to provide ongoing testing of national claims processing and
information system to detect flaws in the operation of software,
hardware, and related operations.
Provides requirements and specifications for the
development and implementation of systems that provide for the creation
and maintenance of databases and test files that are required to
conduct comprehensive system acceptance testing of a national claims
processing and information system.
(1) Analysis (FLG11)
Provides requirements and specifications for the design,
establishment, and maintenance of reporting and information management
systems that generate data reflecting on Medicare program operations.
Reviews contractors' reporting systems for consistency and
the ability to transmit the required information and
[[Page 42890]]
prepares the appropriate reporting requirements.
Develops the specifications for an automated operational
data system for Medicare.
Prepares recurring reports on the status and trends in
program administration and operational effectiveness.
Provides technical assistance to regional offices and
contractors on reporting requirements.
Identifies reporting and information needs for data
relating to Medicare contractor operations and initiates appropriate
action for establishing or modifying the reporting and information
systems to satisfy these needs.
Analyzes a broad range of information, including computer
stored data, on operations performed in support of the Medicare
program; prepares interpretive reports and recommendations for the
findings to other bureau components for purposes of conducting program
and performance evaluations.
Provides overall support to other staff in analyzing and
interpreting program and operational data to better understand the
program.
Develops and publishes national reports on Medicare
utilization patterns by procedure, beneficiary, etc.
Analyzes patterns to determine contractor differences,
changes in patterns, relationships between procedures, etc.
Serves as the bureau focal point for support and liaison
with other HCFA and non-HCFA components involved in data and
information analyses.
Utilizes the National Claims History Database to analyze
and compare utilization patterns and to assess national trends in the
provision of care to the Medicare population.
Uses statistical databases and applications to analyze,
evaluate, and make recommendations towards improving program
operations, including operational efficiency.
Provides statistical support to program studies and to
analytical studies throughout the bureau.
Evaluates and monitors proposals for new analytic methods
to identify fraud, abuse and over utilization from claims data
(Medicare Parts A and B).
Responds to ad-hoc data requests for management
information data.
Acts as a liaison with the Bureau of Data Management and
Strategy staff to enhance data available to BPO components.
Directs workgroups to promote the continuous improvement
in the use of data to conduct effective analysis in support of BPO
component activities.
Develops procedures and requirements for data analysis in
the Medicare Transaction System environment.
(2) Operational Systems (FLG12)
Prepares systems plans and develops policies for the
design, implementation, and evaluation of shared systems and
standardized modules for use by Medicare carriers, intermediaries, and
hosts.
Directs the design, development testing and implementation
of innovative system enhancements to the Common Working File (CWF)
shared claims processing systems resulting in improvements to the
national Medicare claims payment process.
Evaluates HCFA-wide systems plans for their impact on
functions related to Part A and Part B of Medicare.
Integrates systems changes within the framework of HCFA
policies, goals, and objectives in an efficient and cost effective
manner and coordinates system changes with other HCFA components, the
Social Security Administration, HCFA regional offices, provider groups,
and other affected organizations.
Provides direction to the national CWF Maintenance
Contractor and establishes priorities and schedules for all changes to
CWF software and procedures and monitors progress in the release of
these changes to all CWF users.
Conducts and reviews national system impact analysis
assessments relating to Medicare legislative mandates and oversees
development of CWF specifications for national implementation of
mandates.
Develops and controls activities associated with the
development of standard systems and standard modules and assists other
HCFA components in preparing contract modifications associated with
standard systems activities.
Develops, monitors, and evaluates budgets and the budget
forecasts for CWF, shared systems, and other contractor based
operations including participation in long-range procurement planning
support to procurement officials.
Develops comprehensive systems security instructions in
the Medicare Intermediary and Carrier Manuals.
Provides regional offices with methods of reviews of
contractor safeguards which include providing checklists for such
initiatives as contingency planning and safeguarding the integrity of
the Internal Revenue Service data used in the Medicare Secondary Payer
data match and applying internal control sampling techniques to make
sure that reviews have been performed adequately.
Prepares quarterly listings of all significant tasks for
carriers and intermediaries with special emphasis on those involving
standard systems maintenance.
(3) Systems Testing (FLG13)
Develops, implements, executes, and monitors a procedure
to provide ongoing testing of national claims processing and
information system to detect flaws in the operation of software,
hardware, and related operations.
Develops and implements systems that provide for the
creation and maintenance of databases and test files that are required
to conduct comprehensive system acceptance testing of a national claims
processing and information system.
Develops system test designs and test requirements for
accomplishing system testing (hardware and software, etc.).
Designs, develops, and maintains system software to
accomplish testing requirements and processes.
Performs system analyses and studies to develop testing
strategies, procedures, and methodologies.
Develops requirements and monitors implementation of
corrective action plans for claims processing and information system
that have failed to meet HCFA system testing requirements.
Develops processes to monitor the implementation of new
changed hardware and software that impact HCFA's claims processing and
information system.
Provides training and technical guidance to regional
office and contractor staffs for implementing and operating national
programs for assessing system testing activities.
Consults and maintains working relations with contractors,
HCFA components, and outside organizations for effective interchange of
information and resolution of problems.
Plans, develops, tests, and maintains a system to support
Medicare claim and remittance electronic standardization enforcement
and other front-end system testing activities.
(4) Systems Design (FLG14)
Designs, develops, and manages, at the national level,
activities required to enhance systems for improvement of the Medicare
eligibility systems, Part A and Part B claims processing systems, and
the Medicare program database.
[[Page 42891]]
Provides direction and guidance to HCFA staff (central
office and regional) on improving contractor systems.
Designs, develops, and manages at the national level
activities required to support the acquisition, establishment, and
operation of the operating sites for the Medicare Transaction System
(MTS).
Coordinates and plans for the establishment of a test
facility to ensure the system fully meets expectations of customers.
Plans, develops, establishes, and maintains the processes
necessary to manage all levels of change to the MTS.
Plans, coordinates, and supports activities necessary to
support the ongoing development and maintenance of system and program
requirements for the MTS.
Plans, supports, and participates in system activities to
support transition to MTS.
Serves as a technical specialist in the data
telecommunications field and performs a broad variety of systems,
software and hardware related tasks for major networks related to HCFA/
BPO's nationwide Medicare claims processing telecommunications
networks.
Plans, designs, organizes, and leads studies to develop
long-range Medicare operational systems telecommunications strategies
and advises senior program managers on applying advances in
telecommunications technologies to the Medicare operational systems.
c. Office of Benefits Integrity (FLG2)
Oversees the administration of Medicare program audit and
payment management, benefit integrity, Medicare Secondary Payer (MSP),
other overpayment collections, and medical review.
Plans and develops methods to improve and enhance the
audit and payment management functions and makes recommendations for
improvements in the management of the audit program. Analyzes
regulations, executive orders, policies, and legislative proposals and
assesses their financial impact on the audit budget.
Develops, implements, and maintains programs and systems
to ensure that Medicare benefits are paid within the meaning of
applicable law, regulations, and program policy and to ensure that
internal or external allegations of fraudulent or abusive behavior are
promptly acknowledged, developed, and disposed of including referral to
the Office of Inspector General.
Directs the development and issuance of specifications,
requirements, procedures, forms, and instructional material to
implement and maintain operational systems for Part A and Part B
medical review and utilization analysis.
Develops the national budget for intermediary and carrier
payment safeguard activities, linking programmatic expectations with
funding requirements and available resources. Implements new
legislation impacting on payment safeguard processes and/or Medicare
covered services.
Supports MSP litigation and post pay activities.
Reviews regional office and contractor performance in
determining the correct amount of provider, physician, and supplier
overpayments and assists contractors in negotiations related to the
acceptability of techniques for determining the amount of an
overpayment and the methods of recovery.
Prepares cases when compromises are not appropriate and
overpayments are collectable and assists the HCFA Claims Collection
Officer in preparing such cases for disposition.
Prepares manual instructions concerning the procedures for
the recovery of provider, physician, and supplier overpayments.
Designs, implements, and maintains a Medicare overpayment
tracking system.
Conducts in-depth evaluations of selected programmatic
areas to determine whether established policy and operational criteria
are effectively and accurately met.
Develops and implements requirements for payment safeguard
activities in the Medicare Transaction System environment.
(1) Medical Review (FLG21)
Directs the development and issuance of specifications,
requirements, procedures, forms, and instructional material to
implement and maintain operational systems for carrier and fiscal
intermediary medical review and utilization analysis.
Reviews proposed payment and coverage policy and
legislative proposals to evaluate the operational impact on the Medical
Review and Utilization Review (MR/UR) program. Implements new
legislation affecting MR/UR and develops program safeguards for new and
revised procedures.
Oversees and evaluates contractor development and
implementation of local medical review policy and procedures. Provides
support to contractor medical directors and develop tools and
instructions that enhance the consistency local MR policy. Coordinates
and generally oversees the Carrier Advisory Committee activities.
Assists with the development of contractor performance
standards to promote improvement and assess the effectiveness of the
contractor's MR/UR program.
Provides technical support and assistance to bureau, other
HCFA, and non-HCFA components. Serves as liaison with representatives
of the health care industry to obtain expert input, promote
understanding of the MR/UR program, and to ensure that HCFA's processes
are compatible with health practices.
Recommends legislative, regulatory, and programmatic
changes to implement utilization controls in problematic areas.
Develops the national budget for intermediary and carrier
medical review activities, linking programmatic expectations with
funding requirements.
Develops and implements procedures and requirements for
medical review procedures in the Medicare Transaction System
environment.
Participates in the development of analytical studies,
tools, methodologies, etc., to assist in identifying patterns and
trends in health care utilization that indicate over utilization or
abuse.
(2) Program Integrity (FLG22)
Develops, implements, and maintains programs and systems
to ensure that Medicare benefits are paid within the meaning of
applicable law, regulations, and program policy.
Develops, implements, and maintains programs and systems
to ensure that internal or external allegations of fraudulent or
abusive behavior against the Medicare program are promptly
acknowledged, developed and corrective action taken including referral
to Office of Inspector General.
Coordinates the development, budgeting, and
institutionalization of Medicare dedicated program integrity units in
Medicare carriers and fiscal intermediaries and monitors their
activities. Develop regulations, legislative proposals, contract
amendments, and operating procedures for these units.
Plans, conducts, and evaluates studies and recommends
actions aimed at short and long-range improvements in methods and
procedures, legislative and policy proposals to prevent and detect
fraud, abuse, waste, and other violations of billing requirements of
the Medicare program.
[[Page 42892]]
Provides bureau liaison with the Office of Inspector
General, the Federal Bureau of Investigations, and the Department of
Justice on program integrity issues, particularly on fraud and abuse
issues and to improve the detection, development, and referral of fraud
cases. Prepares and assists in preparation of reports to Congress.
Develops and monitors relationships between Medicare contractors, and
the State, local and private organizations, which are responsible for
the detection and prevention of health care fraud including Medicaid
State Agencies and fraud units. Ensures sharing of fraud information.
Directs the development of analytical studies, tools, and
other methodologies, etc., to detect potential fraudulent and abusive
practices and patterns of over utilization.
Develops procedures and requirements for program integrity
activities in Medicare Transaction System environment.
Issues national Medicare fraud alerts to notify
contractors and public of fraudulent schemes. Coordinates at national
level the review of proposed settlements negotiated by Office of the
Inspector General, AUSA.
(3) Audit/CMP (FLG23)
Analyzes regulations, executive orders, policies, and
legislative proposals and assesses their financial impact on the audit
budget. Develops the plan, necessary audit programs, guidelines, and
instructions for the implementation of current and future legislation,
regulations, and court orders.
Plans and develops methods to improve and enhance the
audit function and makes recommendations for improvements in management
of the audit program. This includes the identification and
implementation of ADP programs in the desk review, audit, and
settlement activities.
Develops rationale for the audit and payment management
portion of the current and future national contractor budgets; monitors
return ratios for provider audits to assure maximum return on
investment expenditures.
Reviews and analyzes Contractor Auditing and Settlement
Reports to determine the effectiveness of contractor audit and payment
performance and compliance with established audit guidelines,
priorities, funding limitations, and workload objectives.
Researches and responds to all Office of Inspector General
and General Accounting Office reimbursement and financial audit reports
and studies. Prepares position papers and reports offering alternative
methods of resolution.
Analyzes System Tracking for Audit and Reimbursement
(STAR) data to assess effectiveness of audit policy and procedures and
contractors compliance with such policy and procedures.
Evaluates contractor requests for supplemental audit and
payment management funding at the current operating budget level and
makes recommendations based on available funding and defined program
objectives.
Develops, tests, and updates desk reviews, audit
guidelines, and audit programs for use by the intermediaries to ensure
that program objectives are achieved. Maintains contact with fiscal
intermediaries through the regional office for resolution of audit
problems.
Reviews and evaluates existing audit and payment revisions
with other components to resolve current and prevent potential
problems. Analyzes and comments on proposed policy revisions,
regulations, and legislation regarding provider payments.
Plans, monitors, reports on, and develops guidelines for
implementation of legislative special audit projects; e.g., the Wage
Data Survey mandated by Section 4004 of OBRA and the implementation of
the Capital Prospective Payment System.
Manages the successful implementation of various
negotiated agreements, court orders, special project activities, and
Blue Cross/Blue Shield Association provider audit activities.
Establishes audit protocols, priorities, and procedures
for all intermediaries to follow in utilizing their audit resources.
Assures optimum use of audit resources through the ADP
processes.
Directs the resolution of provider appeals assigned to the
bureau. Analyzes and summarizes the payment issues and recommends a
course of action.
Develops guidelines and procedures for identifying
appropriate civil monetary penalty cases under provisions for which
HCFA has authority.
Works with contractors and regional offices to document
and develop specific cases.
Oversees final adjudication of cases and collection of
penalties.
Negotiates settlement and compromises of selected penalty
cases.
Develops procedures and requirements for audit and
reimbursement activities in Medicare Transaction System environment.
(4) Overpayment & MSP Collections (FLG24)
Directs the nationwide administration of the institutional
and physician/supplier (provider) payment recovery activity.
Develops regulations, policies, procedures, guidelines,
and recommendations for regional offices and HCFA contractors to assure
timely and accurate provider overpayment identification, interest
assessment, collection, and reduction of incidences of overpayment.
Assures that the accounting practices, recovery
procedures, and collection activities of regional offices and
contractors properly and sufficiently implement (with respect to
providers) the overpayment recovery policies, procedures, and
regulations of HCFA, the Department of Health and Human Services, the
General Accounting Office, the Department of Justice, and all
applicable Federal statutes.
Directs regional offices and contractors in determining
the correct amount of provider, physician, and supplier overpayments
and assists contractors in negotiations related to the acceptability of
techniques for determining the amount of an overpayment and the methods
of recovery.
Prepares cases when compromises are not appropriate and
overpayments are collectable and assists the HCFA Claims Collection
Officer in preparing such cases for disposition.
Prepares manual instructions concerning the procedures for
the recovery of provider, physician, and supplier overpayment.
Designs, implements, and maintains a Medicare overpayment
tracking system.
Develops procedures and provides training and assistance
to regional offices for the review and evaluation of the institutional
provider, physician, supplier, and beneficiary overpayment recovery and
third party systems.
Enforces Medicare Secondary Payer (MSP) provisions and
supports MSP litigation and post pay activities. Monitors regional
office and contractor operations on negotiation, waiver, and compromise
of liability settlements where Medicare has a claim for recovery of
prior conditional payments.
Directs, oversees, and manages the contract for IRS/HCFA/
SSA data match activities. Oversees contractor activities for demands
and collection of mistaken payments identified by data match.
Oversees regional office and contractor identification of
liability
[[Page 42893]]
situations where Medicare has an interest in collection of monies paid
on behalf of a Medicare beneficiary.
Develops procedures and requirements for MSP and other
overpayment activities in Medicare Transaction System environment.
Coordinates and cooperates with medical review, audit, and
program integrity units on use of overpayment recovery as a payment
safeguard tool and to coordinate relationship between established
overpayments and fraud cases.
d. Office of Program Requirements (FLG3)
Develops, issues, and administers the specifications,
requirements, methods, standards, procedures, and budget guidelines for
Medicare claims processing related activities, including detailed
definitions of the relative responsibilities of providers, contractors,
HCFA, other third-party payers, and the beneficiaries of the Medicare
program.
Develops specifications and recommends budget necessary
for more effective methods to process Medicare claims.
Develops and maintains standards, including forms and
electronic formats, used by contractors to process claims.
Represents the Medicare program before the health care industry
with regard to standards for administrative health care transactions.
Develops and implements requirements for provider
enrollment in the Medicare program and assures the safeguard of program
payments through effective enrollment processes and procedures.
Ensures effective program compliance in areas related to
Medicare claims processing and provider enrollment. Implements and
manages requirements related to prohibited physician referrals and
provider billings resulting from prohibited referrals.
Develops and implements procedures for capturing
information related to Medicare Secondary Payer situations and Medigap
insurance to insure appropriate program payment and effective
coordination of claims information with other insurers.
Reviews and evaluates the processes and procedures used in
the receipt, review, and payment/denial of Medicare claims.
Recommends alternatives to existing processes and
procedures, as well as, methods of improvement.
Manages experiments that incorporate proposed alternatives
to existing processes and procedures.
Coordinates modifications to existing operational
procedures, contracts, reporting mechanisms, and related materials as
required.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
Conducts in-depth evaluations of selected programmatic
areas to determine whether established policy and operational criteria
are effectively and accurately met.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
(1) Institutional Claims Processing Requirements (FLG31)
Develops and issues specifications, requirements,
procedures, and instructional material to process claims from Medicare
institutional providers and defines their applications to these
providers (hospitals, skilled nursing facilities, home health agencies,
hospices, rural health clinics, comprehensive outpatient rehabilitation
facilities, End Stage Renal Disease facilities) and Medicare
contractors.
Develops and issues instructions for, as well as monitors,
implementation of institutional provider pricers.
Develops applicable bill processing edits for contractors
and the Common Working File (CWF) processing of Medicare provider
claims and works with the Office of Analysis and Systems to implement
these edits at contractor and CWF sites.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
Maintains the contractor/provider instructional manuals
including CWF interface instructions for processing claims from
Medicare institutional providers.
Implements new legislation impacting on the provider
payment process.
Reviews proposed policy, reimbursement, and legislative
proposals to evaluate the operational impact on claims processing
operations, including the development of cost estimates for the
implementation of such proposals.
Maintains liaison with representatives of the health care
industry to ensure that HCFA processes are compatible with provider
administration practices.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
(2) Practitioner Claims Processing Requirements (FLG32)
Develops and issues specifications, requirements,
procedures, and instructional material to process claims from
physicians and other independent medical professionals and defines
their application to these physicians and other independent medical
professionals (Certified Registered Nurse Anesthetists, clinical
psychologist and clinical social workers) as well as Medicare
contractors and beneficiaries.
Develops and issues instructions for, as well as monitors,
implementation of practitioner provider pricers.
Develops applicable bill processing edits for contractor
and Common Working File (CWF) processing of claims from physicians and
other independent medical professionals. Coordinates with the Office of
Analysis and Systems to implement these changes at contractors.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
Maintains the contractor/provider instructional manuals
including CWF interface instructions for processing bills from
physicians and other independent medical professionals contractor
payment program for physicians and other independent medical
professionals.
Reviews proposed changes in Medicare policy, regulations,
and law to evaluate the operational impact on practitioner claims
processing operations including the development of cost estimates for
the implementation of such proposals.
Maintains liaison with representatives of the health care
industry to ensure that HCFA processes are compatible with professional
medical field administrative practices.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
[[Page 42894]]
(3) Supplier Claims Processing Requirements (FLG33)
Develops and issues specifications, requirements,
procedures, and instructional material to process claims from Medicare
suppliers of services and defines their applications to these suppliers
(durable medical equipment, ambulance, labs, orthotics and prosthetics,
oxygen and parental and enteral nutrition), Medicare contractors, and
beneficiaries.
Develops and issues instructions for, as well as monitors,
implementation of supplier provider pricers.
Develops applicable processing edits for contractor and
Common Working File (CWF) processing of claims from physicians and
other independent medical professionals. Coordinates with the Office of
Analysis and Systems to implement these changes at contractors.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
Maintains the contractor/provider instructional manuals
including CWF interface instructions for processing bills from
physicians and other independent medical professionals.
Implements new legislation impacting on the contractor
payment program for physicians and other independent medical
professionals.
Reviews proposed policy, reimbursement, and legislative
proposals to evaluate the operational impact on supplier claims
processing operations including the development of cost estimates for
implementation of such proposals.
Maintains liaison with representatives of the health care
industry to ensure that HCFA processes are compatible with the
professional medical field administrative practices.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
(4) Standards Setting (FLG34)
Develops and issues specifications, requirements,
procedures, and instructional material related to electronic formats
for claims, electronic funds transfer, remittance advice, eligibility,
coordination of benefits, and any other claims processing items related
to electronic transactions.
Develops and maintains billing forms and formats used by
contractors including the HCFA-1450 (UB-82) and the HCFA-1500.
Develops, monitors, and approves all aspects of the notice
of utilization.
Develops programs to promote acceptance and usage of
electronic claims processing, electronic funds transfer, and electronic
remittance advice.
Coordinates with stakeholders (providers, contractors, and
HCFA components) to develop standardized data content for paper and
electronic administrative transactions, such as claims, attachments,
remittance advice, and eligibility inquiries.
Serves as BPO focal point with the American National
Standards Institute (ANSI) on electronic information formats used by
the health insurance industry.
Represents HCFA at the National Uniform Billing Committee
and other established standards organizations to ascertain that HCFA's
requirements are met.
Reviews proposed changes in Medicare policy, regulations,
and law to evaluate the operational impact on claims processing
activities, including the development of cost estimates for the
implementation of such proposals.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
(5) Provider Enrollment (FLG35)
Develops and issues specifications, requirements,
procedures, and instructional material for provider enrollment and
enumeration. Provides for the maintenance of the provider data base.
Develops and issues general provider operating policy and
procedures for the processing of Medicare claims that relate to any
facet of provider applications and enumeration of provider applicants
including standardizing the format(s), identifying data to be furnished
by providers, and contractor validation/ verification of application
data submitted by non-institutional providers.
Develops applicable bill processing edits for contractor
and Common Working File (CWF) processing of claims from Medicare
providers.
Develops budget guidelines and cost estimates for Medicare
claims processing activities.
Develops instructions and maintains the contractor and
provider instructional manuals applicable to provider enrollment,
enumeration, and requirements.
Oversees the National Supplier Clearinghouse and the
Uniform Provider Identification Number (UPIN) Registry activities which
include monitoring carrier ongoing maintenance of UPIN Registry,
managing the printing of UPIN Directory, and overseeing UPIN data
cleanup to resolve issues involving missing/discrepant UPIN data.
Works with the Bureau of Data Management and Strategy in
developing and implementing the National Provider File and enumerating
providers with the National Provider Identifier.
Reviews proposed changes in Medicare policy, regulations,
and law to evaluate the operational impact on provider qualification
and enumeration including the development of cost estimates for the
implementation of such proposals.
Maintains liaison with representatives of the health care
industry to ensure that HCFA processes are compatible with their
administrative practices.
Maintains liaison with providers, contractors, and other
partners for purposes of ensuring that continuous improvements are made
to HCFA processes and that the interests of customers and partners are
considered.
Identifies vulnerabilities in Medicare claims processing
requirements and implements instructions and guidelines for
safeguarding program expenditures (administrative and benefit).
(6) Benefit Coordination (FLG36)
Develops, implements, and administers Medicare Secondary
Payer (MSP) operational policy for coordinating Medicare benefits with
other health insurance benefits. Analyzes and evaluates specific
operating policy and procedural problems in the benefit coordination
program and initiates proposals to better achieve program objectives as
they relate to claims processing.
Develops applicable bill processing edits for contractors
and the Common Working File (CWF) for application of MSP claim
processing policy and works with the Office of Analysis and Systems to
implement these edits at contractor and CWF sites.
Develops, implements, and administers Medigap operational
policy
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(Section 1882 of the Social Security Act).
Develops and implements a unique national payer
identifier.
Maintains the contractor and provider instructional
manuals including CWF interface instructions for MSP claims processing
policy.
Implements new legislation impacting on the provider MSP
payment process.
Plans and directs operational liaison and outreach
activities including public relations, publications, conferences, and
presentations.
Participates in the design, performance, and analysis of
evaluations of contractor MSP pre-pay performance assessment.
Analyzes State laws and regulations for Medicare
supplemental health insurance to ensure compliance with Section 1882 of
the Social Security Act. Prepares recommendations regarding approval or
disapproval, or other appropriate actions, to the appropriate HCFA
official.
Develops national MSP budget and annual performance
objectives for pre-pay activities. Analyzes contractors' MSP
expenditures and goal performance.
Reviews proposed changes in Medicare policy, regulations,
and law to evaluate the operational impact on claims processing
activities related to MSP and Medigap including the development of cost
estimates for the implementation of such proposals.
Maintains liaison with representatives of the health care
industry to ensure that HCFA processes are compatible with provider
administration practices.
Maintains liaison with beneficiaries, providers,
contractors, and other partners for purposes of ensuring that
continuous improvements are made to HCFA processes and that the
interests of customers and partners are considered.
e. Office of Contract Administration (FLG4)
Administers contracts with private organizations to
perform various aspects of Medicare program operations.
Develops, negotiates, maintains, and modifies primary
contracts and agreements with intermediaries, carriers, and other
organizations authorized under Title XVIII of the Social Security Act.
Provides direction and guidance to central office and
regional office staff on Medicare intermediary and carrier contracts
and procurement activities.
Establishes policies and procedures to be used by Medicare
intermediary and carrier contractors in the procurement of personnel,
equipment, facilities management, software, and other services.
Establishes financial management policies and procedures
by which Medicare contractors prepare and submit periodic budget
estimates.
In consultation with other HCFA and bureau components,
develops and negotiates the national budget for Medicare contractors.
Controls and manages the Medicare cash flow and related
banking activities. Monitors benefit payment expenditures.
Reviews periodic contractor expenditure reports to
evaluate Medicare budget execution and determines the allowability of
costs. Prepares analysis of Medicare intermediary and carrier
expenditure trends and patterns.
Serves as bureau-wide support for participation in agency
and department strategic planning and information resource management
planning. Evaluates Medicare operational contracting arrangements,
formulates recommendations for improvements, and develops appropriate
implementation plans.
Develops plans for possible transitions between new and
current contractors and manages transition activities in coordination
with the regional offices and HCFA components. Evaluates the impact of
contractor transitions on HCFA's customers and strives for process
improvements and responsiveness to customer needs.
Plans, develops, and directs Medicare intermediary and
carrier operating contracting experiments.
Makes recommendations to agency management on proposed
contract management actions for Medicare contractors determined to have
serious performance deficiencies.
Develops, implements, and monitors national performance
evaluation programs to assess and improve overall effectiveness and
quality of Medicare contractor operations.
(1) Acquisitions and Contracts (FLG41)
Develops, maintains, negotiates, and modifies all
agreements with intermediaries and contracts with carriers, as
authorized under Title XVIII of the Social Security Act, and related
contracts necessary to the Medicare program.
Develops procedures for the award, non-renewal,
termination, extension, and amendment of Medicare contracts.
Represents the Contracting Officer in processing
contractor claims resulting from changes in contract requirements and
litigation activities related to contract disputes or protests
involving selection or non-selection of contractors.
Directs contract-related surveys requested by both the
Executive and Legislative Branches of the Federal Government.
Directs, coordinates, and serves as the HCFA resource in
regard to technical contracting and procurement issues and maintains
oversight on regional activity regarding Medicare contracting.
Reviews contractors' requests for change orders and
adjustments in price, determines where liquidated damages should be
assessed against contractor, and takes appropriate action.
Develops Medicare acquisition policy, providing technical
acquisition guidance, and maintains Medicare contractor procurement
procedures.
Serves as bureau coordinator with the Office of Research
and Demonstration on demonstration projects that impact Medicare
contractor operations.
Serves as the bureau focal point on the Small and
Disadvantaged Business Subcontracting Program (SADBUS) requirements.
Reviews and approves contractors' SADBUS plans and oversees related
regional office monitoring.
Provides liaison with contractor management.
(2) Financial Management (FLG42)
Provides leadership in developing, implementing, and
evaluating policies and procedures for the Medicare contractor budget
formulation and execution process.
Formulates and approves the national budget for Medicare
contractor administrative costs.
Develops, implements, and monitors cash management letter-
of-credit procedures for contractors and servicing banks.
Develops, implements, and monitors fund control for the
Medicare contractor administrative costs.
Sets requirements and procedures for contractors and
regional offices to prepare and submit periodic budget estimates and
reports.
Participates and/or monitors negotiations and approval of
all budgets and budget adjustments. Reviews periodic contractor
expenditure reports to evaluate budget execution and to determine the
appropriateness of costs.
Designs, maintains, and as necessary, prepares
specifications to revise the Contractor Administrative Budget and
Financial Management System.
Analyzes contractor administrative cost data and trends.
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Directs and prepares instructions to guide regional office
performance to assure consistency implementation of financial policy.
Develops procedures and monitors regional office actions
related to the contractor administrative cost settlement process,
interprets cost principles, and makes recommendations on final
determinations of allowability of costs.
Develops, implements, and monitors a process for reporting
Medicare benefit payments.
Develops and maintains policy, procedures, and systems for
contractor reporting consistent with the Chief Financial Officer's Act.
(3) Transition Management (FLG43)
Manages, monitors, and provides oversight of contractor
transition activities including replacement of departing contractors
and the resulting transfer of workload, major pre-Medicare Transaction
System (MTS) electronic data processing (EDP) systems conversions,
functional re-alignments, geographic workload carve-outs, and MTS
operating site transitions, in coordination with the regional offices.
Develops and implements contingency plans including
replacement strategies for contractors at risk of leaving the Medicare
program.
Evaluates implementation proposals associated with
contractor transitions, major pre-MTS EDP systems transitions,
functional re-alignments, geographic workload carve-outs, and MTS
operating site readiness testing and transitions.
Provides technical expertise and support to HCFA central
and regional office staffs regarding transition activities.
Evaluates the impact of transitions on HCFA's customers
and strives for continuous process improvements and responsiveness to
customer needs.
Incorporates current procurement and operating policy as
well as lessons learned from prior transitions into the Transition
Handbook.
Conducts training for central and regional office staff on
successful transition management and monitoring techniques and
strategies.
(4) Contract Management (FLG44)
Works in partnership with regional offices, central office
components, and Medicare customers in identifying and arriving at
proposed performance expectations of Medicare contractors.