Partner Request: Defense Health Agency (DHA) TRICARE Claims Review Service (TCRS) Opportunity

A San Antonio-based 8(a) SDVOSB founded by a former Defense Health IT leader is looking for potential partners, regardless of size, with firsthand experience—either in the commercial sector or federal domain—in implementing effective strategies for creating samples aimed at detecting incorrect payments (such as categorization by care type, provider category, etc.). Partners could/should also have a background in integrating medical record examinations into payment audits and/or possess direct previous achievements and/or connections with the DHA J-1/8/Deputy Assistant Director, Financial Operations (DAD-FO) Improper Payment Evaluation Branch. 

This is in direct response to an active RFI posted to eBuy related to an 8 ½-year contract.  

Pro Tip 1 – If you are a firm with capabilities and socio-economic status that might support this or any related effort, comment below and let others know you are interested. Comments are some of the most viewed portions of any post.   

Opportunity Background 

Background: The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high quality health services for more than 9.6 million beneficiaries of the Military Health System (MHS) and is responsible for shared services, functions, and activities of the MHS and other common clinical and business processes in support of the Military Services.  

The MHS is a complex integrated healthcare system that consists of healthcare delivery, medical education, public health, private sector partnerships and innovative medical research and development. The MHS has two major care delivery systems. The direct care system provides care through military treatment facilities (MTFs). The purchased-care system, TRICARE, is comprised of two health care options, Select and Prime. TRICARE Prime is similar to a health maintenance organization (HMO) with a Point of Service Option and requires beneficiary enrollment.  All Active Duty Service Members (ADSM) are TRICARE Prime enrollees; Active Duty family members may elect to enroll in TRICARE Prime; other eligible beneficiaries pay an enrollment fee to enroll in TRICARE Prime. TRICARE Select is a fee for service type plan in which the beneficiary (non-ADSM) may choose to use a TRICARE-authorized provider without a referral or pre-authorization, in most situations. The two options of TRICARE are described fully in 32 Code of Federal Regulations (CFR) Part 199.17. TRICARE provides care through six purchased-care support contractors, including two Managed Care Support Contracts (MCSCs) (East and West Regions), TRICARE Overseas Program (TOP), TRICARE Medicare Eligible Program (TMEP), Active Duty Dental Program (ADDP) and TRICARE Pharmacy Program (TPharm) contracts. The purchased-care system has more than 400,000 network individual providers (primary care, behavioral health, and specialty care providers) and more than 3,200 TRICARE network acute care hospitals. 

The objectives of this contract are to support the missions of the MHS which enable the National Defense Strategy by providing a Medically Ready Force, a Ready Medical Force, and improving the health of all those entrusted to its care. The objectives below represent the performance outcomes for this contract and are supported by technical requirements. The acceptable performance standards are explained further in the contract. 

• Objective 1, Compliance Reviews. Provide independent, impartial reviews (manual re-adjudication) of claims to include timely and accurate evaluations of each purchased care contractor’s healthcare claims processing and payment record coding procedures. 
• Objective 2, Focused Studies. Assist the IPEB in studying areas of the TRICARE health benefits program with the potential for incurring a higher than average risk of improper payments, including claims selected for an annual Payment Integrity Information Act of 2019 (PIIA) compliance review. 
• Objective 3, Medical Record Reviews. Validate healthcare services documented in a patient’s medical record is correctly invoiced to the Government for payment. 
• Objective 4, Continuity of Review Services. Maintain effective management solutions to provide the necessary claims review services, incorporating DHA and healthcare standards and best practices. 

The purpose of this contract is to assist the Office of the Assistant Secretary of Defense for Health Affairs (OASD-HA), the Office of Management and Budget (OMB), and the DHA Improper Payment Evaluation Branch (IPEB), in identifying and reporting improper payments and discrepancies in payment record coding. This contract provides an independent, impartial review of claims processing procedures and reimbursement methodologies utilized by purchased-care contractors, assesses purchased-care contractor compliance with TRICARE policies and directives, and monitors the claims processing performance of DHA TRICARE purchased-care support contractors. The contractor shall evaluate the accuracy of claims payment and payment record coding for the six purchased-care contractors. 

This contract also supports IPEB’s requirement to assess the potential risk of improper payments, identify, and report improper payments to the Office of Management and Budget (OMB) for publication in the Department of Defense (DoD), Agency Financial Report (AFR) pursuant to Public Law (PL) 116-117 – Payment Integrity Information Act (PIIA) of 2019. 

Pro Tip 2 – Feel like you are missing out on some of the key actions? It can be hard to keep up. Make sure you are in the know by checking out the Defense Health Agency intel page, chock full of insights and intelligence.      

If you have capabilities and/or relationships that can be of value, please contact us here and let us know, with any relevant information and please reference this partner request. We are getting a lot more of these. Please keep it short.     

Note: This has been provided as an anonymous request, so OS AI will not reveal the name of the requestor. We will pass the information along, but there are no promises of a response.   

Alternatively, we always encourage interested firms to share their interest publicly in the form of a comment as there will be many other firms looking for partners. We do share posted comments in our newsletter, so it can be a great way to create awareness about your capabilities in relation to this type of need. Comment below – you must be logged in.   

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