[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