[Federal Register Volume 59, Number 171 (Tuesday, September 6, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-21870]
[[Page Unknown]]
[Federal Register: September 6, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPO-117-GN]
Medicare Program; Criteria and Standards for Evaluating
Intermediary and Carrier Performance During FY 1994
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: General notice.
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SUMMARY: In the September 30, 1993 issue of the Federal Register, we
published a general notice with comment period describing the criteria
and standards for evaluating intermediary and carrier performance in
administering the Medicare program during FY 1994. This notice amends
that document to require that contractors certify the accuracy and
completeness of the information submitted to HCFA with respect to the
evaluation process.
DATES: This notice is effective September 6, 1994 and does not alter
the criteria and standards that were effective October 1, 1993.
FOR FURTHER INFORMATION CONTACT: Larry Pratt, (410) 966-7403.
SUPPLEMENTARY INFORMATION:
I. Background
On September 30, 1993, we published in the Federal Register (58 FR
51085) the criteria and standards to be used for evaluating the
performance of fiscal intermediaries and carriers in the administration
of the Medicare program beginning October 1, 1993 under the Contractor
Performance Evaluation Program (CPEP). We publish a similar notice
annually in accordance with sections 1816(f) and 1842(b) of the Social
Security Act. CPEP measures contractor compliance with program
requirements; promotes contractor initiatives to improve administrative
processes; provides comparable data on customer satisfaction; and
serves as a basis of information for contract management activities.
The results of the CPEP are considered whenever HCFA enters into,
renews, or terminates an intermediary agreement or carrier contract or
takes other contract actions.
The 1994 CPEP was structured into three criteria, designed to meet
the above objectives. Criterion one, titled Program Requirements,
measures contractor performance against basic program requirements.
Within this criterion, we identified performance standards which, when
measured, evidence how well each contractor is performing the basic
requirements of administering the Medicare program. Criterion two,
titled Process Improvement, recognizes contractor performance
improvement (compared to the previous review period) and contractor
efforts to achieve program efficiencies by evaluating and improving the
processes with which it administers the Medicare program. Criterion
three, titled Customer Satisfaction, assesses the degree to which the
contractor's customers are satisfied with the services provided by the
contractor in its administration of the Medicare program. We also
developed separate criteria and standards that measure only the
activities of regional home health intermediaries and Common Working
File hosts.
II. Amendment to the FY 1994 CPEP Notice
The notice published on September 30, 1993 (58 FR 51085), in
addition to providing detailed descriptions of the specific CPEP
criteria, standards, and procedures, included a summary of how the
performance evaluations and assessments affect individual contract
action decisions. The summary was contained on page 50190 and was
entitled ``Action Based on Performance Evaluations.'' In our discussion
of action to be taken based on performance, we did not address a
situation that could arise if we did not receive accurate information
from our contractors.
We have discovered a number of instances where information has been
manipulated or falsified by contractor personnel in an effort to
receive a more favorable evaluation under CPEP. On October 28, 1993, we
issued notices to each of the Medicare contractors that they must
certify that all information submitted to HCFA with respect to CPEP for
fiscal year 1993 was accurate and complete to the best of their
knowledge and belief. We also informed the Medicare contractors that we
would modify the annual CPEP notice to include mention of the
requirement that they certify, under penalty of perjury, the accuracy
of the information reviewed and data submitted to HCFA with respect to
CPEP. The modification does not alter the criteria and standards that
were effective October 1, 1993.
So that our public notice relating to CPEP accurately reflects our
administration of the evaluation program, we are revising Section H.
Action Based on Performance Evaluations (page 50190 of the 1994 CPEP
notice published September 30, 1993) by adding the following:
Each contractor must certify that all information submitted to
HCFA related to CPEP, including without limitation all records,
reports, files, papers and other information, whether in written,
electronic, or other form, are accurate and complete to the best of
the contractor's knowledge and belief. A contractor will also be
required to certify that its files, records, documents, and data
have not been manipulated or falsified in an effort to receive a
more favorable performance evaluation. A contractor must further
certify that, to the best of its knowledge and belief, the
contractor has submitted, without withholding any relevant
information, all information required to be submitted with respect
to CPEP under the authority of applicable law(s), regulation(s),
contracts, or HCFA manual provision(s). Any contractor that makes a
false, fictitious, or fraudulent certification may be subject to
criminal and/or civil prosecution, as well as appropriate
administrative action. Such administrative action may include
debarment or suspension of the contractor, as well as the
termination or nonrenewal of a contract.
For the convenience of the reader, the full text of Section H is
republished below with the addition found in the first paragraph.
H. Action Based on Performance Evaluations
A contractor's performance is evaluated against each applicable
standard in the Program Requirements criterion. Each contractor must
certify that all information submitted to HCFA related to CPEP,
including without limitation all records, reports, files, papers and
other information, whether in written, electronic, or other form, are
accurate and complete to the best of the contractor's knowledge and
belief. A contractor will also be required to certify that its files,
records, documents, and data have not been manipulated or falsified in
an effort to receive a more favorable performance evaluation. A
contractor must further certify that, to the best of its knowledge and
belief, the contractor has submitted, without withholding any relevant
information, all information required to be submitted with respect to
CPEP under the authority of applicable law(s), regulation(s),
contracts, or HCFA manual provision(s). Any contractor that makes a
false, fictitious, or fraudulent certification may be subject to
criminal and/or civil prosecution, as well as appropriate
administrative action. Such administrative action may include debarment
or suspension of the contractor, as well as the termination or
nonrenewal of a contract. If a contractor meets the level of
performance required by operational instructions, it meets the
requirements of that standard. Any performance measured below basic
operational expectations constitutes a deficiency. The contractor may
be required to develop and implement a corrective action plan when
performance problems are identified. The contractor will be monitored
to assure effective and efficient compliance with the corrective action
plan and improved performance where standards are not met.
A contractor's performance is assessed under the Process
Improvement criterion to determine the success of the improvements
developed and/or implemented by the contractor during the review
period. A contractor's performance is similarly assessed under the
Customer Satisfaction criterion to determine the degree to which the
contractor has satisfied its customers.
The results of performance evaluations and assessments under all
three criteria will be used for contract management activities and will
be published in the contractor's annual performance report. We may
initiate administrative actions as a result of the evaluation of
contractor performance based on these performance criteria and
standards. Under sections 1816 and 1842 of the Act, we consider the
results of the evaluation in our determinations on:
Entering into, renewing, or terminating agreements or
contracts with contractors; and
Decisions concerning other contract actions for
intermediaries and carriers (such as deletion of an automatic renewal
clause). These decisions are made on a case-by-case basis and depend
primarily on the nature and degree of performance. More specifically,
they depend on:
--Relative overall performance compared to other contractors;
--Number of standards in which deficient performance occurs;
--Extent of each deficiency;
--Relative significance of the standards for which deficient
performance occurs within the overall CPEP; and
--Efforts to improve program quality, service, and efficiency.
Decisions concerning the assignment or reassignment of
providers and designation of regional or national intermediaries for
classes of providers.
We make individual contract action decisions after considering
these factors in terms of their relative significance and impact on the
effective and efficient administration of the Medicare program.
III. Effective Date
As stated in the September 30 notice, we make every effort to
publish the CPEP criteria and standards prior to the beginning of the
Federal fiscal year to which they will be applied, and it is not our
intention to revise the criteria and standards once this information
has been published in the Federal Register. Should changes be
necessary, we will issue a Federal Register notice prior to
implementation of the changes and specify a prospective effective date
applicable to the revised standard or criterion. In this instance, the
addition of this certification requirement to our discussion of actions
based on performance evaluations does not alter any standard or
criterion published September 30, 1993. Therefore, this notice is
effective September 6, 1994.
In accordance with the provisions of Executive Order 12866, this
notice was not reviewed by the Office of Management and Budget.
Authority: (Secs. 1102, 1816, 1842, and 1871 of the Social
Security Act (42 U.S.C. 1302, 1395h, 1395u, and 1395hh)).
(Catalog of Federal Domestic Assistance Program No. 13.773,
Medicare--Hospital Insurance Program; and No. 13.774, Medicare--
Supplementary Medical Insurance Program)
Dated: June 7, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-21870 Filed 9-2-94; 8:45 am]
BILLING CODE 4120-01-P
