DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Med icaid Services (CMS) [CMS-2382-N] Medicaid Program; Announcement of Requireme nts and Registration for CMS Provider Screening Innovator Challenge AGENCY: Centers for Medicare & Medi caid Services (CMS), HHS.
ACTION: Notice.
SUMMARY: The Centers for Medicare & Medicaid Serv ices (CMS), is announcing the launch of the “CMS Provider Screening Innovator Challenge.” This Ch allenge is sponsored by CMS and is presented as part of the Partnership fo r Program Integrity Innovation program, and will be administered by the National Aeronautic and Sp ace Administration’s (NASA) Federal Center of Excellence for Collaborative Innova tion. This Challenge addresse s our goals of improving our abilities to streamline operations, screen providers , and reduce fraud and abuse. Specifically, the challenge is an innovation competition to develop a multi-State, multi-program provider screening software application which would be cap able of risk scoring, credentialing validation, identity authentication, and sanction checks, while lowering burden on providers and reducing administrative and infrastructure expenses for States and Federal programs. More information pertaining to the Medicaid and CHIP programs can be found at www.medicaid.gov

. DATES: Important dates concerning the Challenge include the following: Challenge Competition Begin : 6:00 pm, e.d.t., May 30, 2012. Challenge Competition End : To be determined, but expected to be completed by October/November 2012 timeframe.
FOR FURTHER INFORMATION CONTACT: John “Chip” Garner, 410-786-3012.
SUPPLEMENTARY INFORMATION:CMS-2382-N 2

Subject of Challenge Competition: Entrants are asked to develop artifacts and compon ents of software applications that can be integrated into an open source so lution that can deliver a reliab le, scalable, and cost-effective provider-screening capability for multiple States (or for the nation). We expect the winning entry to exhi bit the following characteristics: 1. Reduced processing and transaction time for submitting and receiving queries to authoritative data sources regarding provider credentials and sanctions. 2. Reductions in time needed by providers to submit information and resolve discrepancies. 3. Administrative/infrastructure savings fr om a multi-tenant provider screening solution. 4. Improved availability of key provider da ta relevant for program participation and oversight. 5. Improved timeliness and accuracy in provide r participation, oversight, and enrollment decisions. 6. Improved ability to implement sections 1902(a)(39) and 1902(a)(7 7) of the Social Security Act, as amended by the Patient Prot ection and Affordable Care Act (P.L. 111-148 and 111-152) subsections 6401(b) and (c) (Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid, and CHIP), and sect ion 6501 (Termination of Provider Participation Under Medicaid if Terminated by Me dicare or Other State Plan). 7. Assist in better driving alignment of the Medicaid Information Technology Architecture (MITA) 3.0 framework to the Information and Te chnology Architecture levels. More information pertaining to MITA can be found at the following Web site: www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Data-and-Sy stems/Medicaid-Information-TechnologyArchitecture-MITA.html

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General Eligibility Rules for Participating in the Competition: To be eligible to win a prize under this Cha llenge, an individual or entity must comply with all the requireme nts under this section. An individual or entity shall not be deemed ineligible solely because the individual or entity used Federal facilities or consulted wi th Federal employees during a competition if such facilities and employees are made available to a ll individuals and entities participating in the competition on an equitable basis. A Federal entity or Federal employee acting with in the scope of his or her employment is not eligible to participate. A Federal employee seeking to partic ipate in this co mpetition outside the scope of his/her employment should consult his/her ethics o fficial prior to developing the submission. Employees of CMS, the Challenge j udges, and employees of any other company or individual involved with the design, production, execution, or dist ribution of the Challenge, along with such employees’ or judges’ immediate famili es (spouse, parents and step-parents, siblings and step-siblings, and children and step-childre n) and household members (people who share the same residence at least three (3) months out of the year) are not eligible to participate. Regarding Registration Process for Participants, interested persons should read the Official Rules and register at the Cent er of Excellence for Collaborativ e Innovation Challenge portal: http://community.topcoder.com/coeci/ . Registration is free and can be completed at any time before an entry is submitted in resp onse to a particular competition.

Amount of the Prize: Based on our current assumptions, we estima te that the total prize amount for the competitions conducted as part of this Challenge will fall between $500,000 and $600,000.

Basis Upon Which Winner Will Be Selected: Challenge competition entries will be judged by an expert panel composed of CMSCMS-2382-N 4

program staff. Judges shall be named after commencement of the Challenge. Competitions will be judged based upon both subjective and objectiv e criteria. Should the highest-scoring submitted solution be missing requirements or otherwise need modification, it will enter a remediation/fix phase. Projects are posted a nd administered through a personalized, web-based administration tool. All projects progress, w ith some variance, thr ough a sequence of phases from Registration to Submission to Screening to Review to Final Fixes. Submissions will be screened to ensure they meet minimum re quirements for the project and do not include forbidden material. Competition submissions with subjectively-eval uated components (for example, graphical design, workflow, GUI layout , etc.) are anonymized and evaluated by the Judges. Submissions with objectively-scored co mponents, such as projects (for example, architecture, development, etc.) are scored by th e Judges by their fidelity to exact, enumerated requirements. Overall, the solution must, at a mini mum, meet the following criteria: 1. Capability to Conduct Identity Verification. a. Capability to link individuals to their organizations and vice versa. b. Capability to match on multiple variations of an individual’s or organization’s name to ensure that the correct entity is verified. c. Ability to apply a range of screening ru les to cross check data elements within the enrollment application. d. Ability to apply a range of screening ru les to cross check data elements against authoritative external sources for consistency. e. Capability to establish and employ a graded screening methodology that escalates the intensity of screening for provi ders that are flagged as highe r risk (that is, Report Card Methodology).CMS-2382-N 5

2. Capability to Build Provider Profiles a. Capability to retain screening and enro llment information and results, and compare against past and future screening results. b. Capability to create a watch list to ensure that providers that ar e suspected or known to be fraudulent are flagged at the time of screening. c. Capability to track re-enrollment attempts to ensure that slight changes to provider information are not considered a new enrollment. d. Capability to revalidate periodically to ensure that changes in provider profiles are updated on a regular basis. e. Capability to leverage public Web site s to conduct link analysis through which provider associations could be explore d, and alerts posted on similar Web sites could be considered. f. Capability to capture critical attributes

● Collection of application fees status.

● Exception waiver approved status.

● Incorporating enhanced scr eening data, including the results of site visits, criminal background checks, and finger printing.

● Capturing licensing information, financial data , and any other data attributes which could impact a risk lever.

● Other critical attributes. g. Capability to achieve real time screening, scoring, and system outputs (queries/reports). 3. Capability to Evaluate and Maintain the Integrity of the Results. a. Capability to persist data sources scores to determine the most reliable source for each data element. b. Capability to evaluate data s ources for reliability and accuracy.CMS-2382-N 6

c. Capability to create a learning system to ensure that observed nega tive trends factor back into screening rules so as to flag suspicious enro llments early in the screening process, ensuring the ability to detect and reduce/eliminate the incidence of false positives. d. Capability to create system outputs to assi gn reasons/explanations to each code or score used. e. Capability to build processes to allo w for appropriate interpretation and action on screening and scoring results. f. Capability to ensure that each rule is tested and its impact is evaluated prior to implementing. 4. Improves Efficiency. a. Capability to allow searches to find sp ecific provider information with minimal search attempts. b. Capability to identify applicants, in cluding individual providers and owners of institutional providers. c. Capability to verify identity and prio r history of problems with Medicaid/CHIP or Medicare programs. d. Capability to identify and schedule revalidation process. 5. Meets Architectural Guidelines. a. Adheres to the Architectural Guidance and meets the seven conditions and standards detailed in the Guidance for Exchange and Medicaid IT Systems, Ve rsion 2.0, located at: http://www.medicaid.gov/Medicaid-CHIP-Pr ogram-Information/By-Topics/Data-andSystems/Downloads/exchangemedicaiditguidance.pdf

. b. Integrates into the MITA Framework – Is MITA Compliant. Information regarding MITA can be found at: http: //www.cms.gov/MedicaidInfoTechArch/

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6. Accurate, Cost Effective, and Timely. a. Turnaround time for performing automate d checks typical for a web-based system. b. Comprehensive verification of all da ta fields for all providers enrolled. c. Efficiency of the Screening Solution in terms of cost and schedule to actually implement: Potential extra costs (for example, licenses, etc.) are documented. d. Effectiveness of the risk-screening model in detecting fraud based issues. e. Technical soundness of ri sk-scoring in flagging poten tial fraudulent patterns and tendencies.
Additional Information: CMS is one of the principal agencies dedica ted to protecting the health of citizens by making our world healthier, safe r, and better for all Americans. For more information, see
www.cms.gov
. General Conditions: CMS reserves the right to cancel, suspend, and/ or modify the Competition, or any part of it, for any reason, at CMS’ sole discretion.CMS-2382-N

Authority: This competition is administrated by th e Federal Center of Excellence for Collaborative Innovation through a partnership betw een CMS and NASA. The partnership is in accordance with the National Aeronautics and Space Act (51 U.S.C. 20113(e)) and The Economy Act (31 U.S.C. 1535).

Dated: May 4, 2012

_____________________________ Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services.

BILLING CODE 4120-01-P

[FR Doc. 2012-12633 Filed 05/25/2012 at 8:45

am; Publication Date: 05/29/2012]