Agenda

Return

C. 35

To:	Board of Supervisors
From:	Anna Roth, Health Services Director
Date:	November 1, 2022

Contra

Costa

County

Subject:

Contract #27-791-11 with Cotiviti, Inc.

APPROVE	OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR	RECOMMENDATION OF BOARD COMMITTEE

Action of Board On: 11/01/2022

APPROVED AS RECOMMENDED

OTHER

Clerks Notes:

VOTE OF SUPERVISORS

AYE:

John Gioia, District I Supervisor
Candace Andersen, District II Supervisor
Diane Burgis, District III Supervisor
Karen Mitchoff, District IV Supervisor
Federal D. Glover, District V Supervisor

Contact:	Sharron A. Mackey, 925-313-6104
cc:	F Carroll M Wilhelm

I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown.
ATTESTED: November 1, 2022
Monica Nino, County Administrator

BY:	, Deputy

RECOMMENDATION(S):

APPROVE and AUTHORIZE the Health Services Director, or designee, to execute on behalf of the County Contract #27-791-11 containing modified indemnification, with Cotiviti, Inc., (doing business in California as Cotiviti I, Inc,) a corporation, in an amount not to exceed $3,000,000, to provide a hosted solution for software services related to Healthcare Effectiveness Data and Information Set measures, regarding data analysis related to fraud, waste and abuse and member outreach services, for Contra Costa Health Plan, for the period from November 1, 2022, through October 31, 2025.

RECOMMENDATION(S): (CONT'D)

FISCAL IMPACT:

This contract will result in contractual service expenditures of up to $3,000,000 over a 3-year period and will be funded 100% by Enterprise II Fund. (No rate increase)

BACKGROUND:

This contract meets the needs of the County’s population by providing data analysis software for Health Plan Employer Data and Information Set (HEDIS) projects and reports to support State and contractual requirements for Contra Costa Health Plan (CCHP). Cotiviti, Inc. provides its licensed program, Quality Intelligence, used by CCHP to calculate and analyze HEDIS measures. CCHP began contracting for these services with this vendor in November 2009. CCHP believes the process to conduct a bid or Request for Proposal for an already working solution would take approximately two years to complete and another year or two to execute a contract and implement. Taking on the workload burden may require hiring additional staff. CCHP believes the burden is unnecessary and takes away resources for serving its patients and customers.

Fraud, Waste, and Abuse
CCHP is contractually and legally required to establish administrative and management arrangements or procedures, as well as a mandatory compliance plan, which are designed to guard against fraud and abuse. Among other things, CCHP is required to implement and maintain procedures that are designed to detect and prevent Fraud, Waste, and Abuse. Failure to meet these requirements would results in a breach of contract and a violation of the Knox Keene Act.

Cotiviti serves the essential purpose of detecting and preventing FWA by analyzing claims information. They have the methodologies and procedures in place, which CCHP lacks, to take otherwise convoluted claims information and crosswalk it so that CCHP can make appropriate comparisons and sound conclusions regarding the presence of FWA. Failure to contract with a vendor for this purpose would mean that CCHP is no longer in compliance with the respective provisions.

HEDIS Measures & NCQA Accreditation
NCQA certification is a requirement for DHCS under our new contract starting in 2024, for which we are currently being assessed in December 2022. HEDIS is required for NCQA Accreditation, DHCS and DMHC. HEDIS scores are used currently to determine Plan assignment, and therefore impact capitation payments from the state. HEDIS will further be used for Quality Rate Factor payments in which capitation is not only based on monthly membership numbers but also HEDIS scores in comparison to other Plans. HEDIS is a heavily structured, highly audited process and calculations will not be accepted without the use of a NCQA certified software to process the data.

Cotiviti provides said NCQA software to process the data. CCHP will be audited by NCQA in December 2022. Failure to address HEDIS measures means that CCHP cannot address the underlying requirements of NCQA accreditation moving forward, which is implicitly required for recertification. Therefore, a vendor with this capacity is essential.

ELIZA - HIF Documentation & Scoring
CCHP is required to identify newly enrolled members who may need expedited services in accordance with 42 CFR 438.208(b). This is done by analyzing data from a Health Information Form (HIF)/Member Evaluation Tool (MET). Among other things, the plan is required to make at least two (2) telephone call attempts to remind new members to return the HIF/MET and/or collect the HIF/MET information from new Members.

Cotiviti performs those calls on behalf of CCHP. CCHP anticipates adding thousands of members between January 1, 2023 and January 1, 2024 as the Long-Term Care Carve In becomes effective and CCHP transitions to a single plan model and consequently absorbs thousands of Anthem members. CCHP will require assistance to meet the demand of these calls. Failure to meet the growing demand will mean CCHP is non-compliant with its contract with DHCS and Knox Keene Act.

On October 13, 2020, the Board of Supervisors approved Contract #27-791-9 with Cotiviti Inc., in an amount not to exceed $300,000 for the provision of software and consultation services and to license software to County for the period November 1, 2020, through October 31, 2021.

On November 16, 2021, the Board of Supervisors approved Contract Amendment Agreement #27-791-10 with Cotiviti, Inc, to increase the payment limit by $320,000 to a new payment limit of $620,000 and to extend the term through October 31, 2022 for the upgrade and implementation to Cotiviti’s Quality Intelligence web-based software solution from a standalone application to a hosted solution for Contra Costa Health Plan’s HEDIS measures. Additionally, this action rescinded the action of September 1, 2021 (C.34) regarding an amendment to transfer services related to fraud, waste and abuse, and patient engagement outreach services performed by Health Management Systems, Inc. (HMS) under contract #27-799-11.

On September 21, 2021, the Board of Supervisors approved item C.34 for the transition of patient engagement outreach and data analysis services that aid in identifying fraud, waste, and abuse schemes affecting CCHP provided under contract #27-799-11 with HMS. However, due to the start of the HEDIS season looming, the parties agreed to delay the transfer of those services and focus on transitioning the delivery of Cotiviti’s HEDIS licensed program, Quality Intelligence, from a stand-alone suite of software modules to its hosted solution, Application Service Provider (ASP) +.

Under this contract renewal #27-791-11, the service model for Cotiviti’s hosted software solution, Application Service Provider (ASP), a HEDIS-licensed program, will be upgraded from ASP+ (a self-service model) to ASP, a full-service model. ASP allows more flexibility with data and measures execution runs and processing schedules. Additionally, the services performed by HMS regarding patient engagement outreach and data analysis which aid in identifying fraud, waste, and abuse schemes affecting CCHP, will be transferred to this contract and performed by Cotiviti. Under the contract, Cotiviti’s liability, including its indemnity obligations, is limited to the amount paid by County under the contract except for bodily injury, death, fraud or criminal acts by Cotiviti, which is not capped, and any claims that an unauthorized party accessed data protected health information in the Cotiviti-hosted system, which is capped at $5,000,000. The contract requires Cotiviti to maintain $5,000,000 in cyber-liability insurance.

Approval of Contract #27-791-11 will allow the contractor to continue to provide services through October 31, 2025.

CONSEQUENCE OF NEGATIVE ACTION:

If the recommendation is not approved, the department will not have authorization for the change in the software service model nor the transfer of data analysis and outreach services that aid in the identification of fraud, waste, and abuse schemes affecting the Contra Costa Health Plan, resulting in an adverse effect on patient care and revenue.