What the buyer needs

AI summary

The West Virginia government authority in Charleston requires a vendor to provide special investigation unit services. The scope includes conducting post-payment claim reviews, performing peer comparison and data mining analytics, auditing medical records through a secure web-based portal, and executing complex investigations into suspected fraud, waste, or abuse. Only onshore United States organizations are eligible to bid. Bidders must perform the work onsite and submit responses digitally via email or online, with all questions due by October 9, 2026. The buyer is seeking proposals for the budget. The provided text does not state the evaluation criteria or the contract term.

Scope of work

Provide post-payment claim review services to flag member eligibility and provider billing abnormalities
Identify, investigate, and recover overpayments
Collaborate with Third Party Administrator on prepayment reviews for outlier providers
Collaborate with Pharmacy Benefit Manager on post-payment processes to reduce improper payments
Analyze provider billing patterns using data mining, artificial intelligence, and peer comparison
Audit medical records, employee files, and time sheets using a secure web-based portal
Conduct complex investigations including claims data analysis, interviews, interrogations, and surveillance

How proposals are evaluated

Criterion	Weight / scoring
Technical Proposal	60 Points
Cost Proposal	40 Points

Minimum qualifications

Registered with West Virginia Purchasing Division and paid $125 fee prior to award
Minimum 4 years of experience conducting healthcare fraud, waste, and abuse investigations
Minimum 5 years of experience for Lead Investigator, with at least 2 years conducting complex investigations
At least 1 assigned staff member with valid West Virginia drivers license and minimum 5 years healthcare FWA experience
Demonstrated experience coordinating with a commercial or governmental health plan
Guarantee a minimum Return On Investment (ROI) from services no less than 2:1

Documents to include with your response

Technical Proposal
Cost Proposal Workbook / Pricing Page
Title Page
Attachment 1: Intent to Bid Form
Attachment 3: Mandatory Requirements Confirmation
Attachment 6: WV-96 Form
Attachment 7: WV Data Management Addendum & Appendix
Attachment 8: State of WV Executive Branch BAA & Appendix A
Attachment 9: Litigation Waiver Form or Litigation Bond
Attachment 10: WV Redaction Attestation Form

How to submit

Method: Electronic via email, hand delivery, or delivery by courier or Postal carrier
Instructions: Requires a two-part submission with distinct Technical and Cost Proposals submitted as separate documents. One searchable electronic copy of each proposal is required.