Medicare Program; Criteria and Standards for Evaluating Intermediary and Carrier Performance During FY 1994

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