RFI for Enterprise Healthcare Data Auditing Billing and Coding Optimization Software

Request for Information (RFI) Healthcare Data Auditing Billing and Coding Optimization Software - This is a Request for Information (RFI) only. Do not submit a quote. The Department of Veterans Affairs (VA), Office of Information & Technology (OIT), is conducting market research to inform a planned future acquisition. The intent is to gather information from qualified solution providers offering solutions to meet this critical business need. The Government seeks industry input on a modern, modular, cloud-based system capable of supporting the coding staff to collect health care data and accurately applying the codes to determine level of care provided to the patient population and ensure timely coding and revenue cycle activities on behalf of the Veterans Health Administration (VHA). This notice is issued solely for market research and planning purposes. It shall not be construed as an Invitation for Bid, Request for Quotation, or Request for Proposal. This RFI does not commit the Government to any acquisition or contract award. Respondents will not be compensated for costs incurred in preparing or submitting information. No funds have been authorized or obligated for this requirement. All submissions become Government property. Respondents are responsible for marking proprietary information. VA does not want this market research to assume that today's current solution should simply be carried forward. VA is specifically seeking industry's perspective on how modern technology can meet the ability to provide this auditing, billing and coding capability across VHA. VA seeks industry feedback to inform future acquisition strategies for an enterprise-wide Healthcare Data Auditing Billing and Coding Optimization Software that enhances decision making, efficiency, supports VA coding professionals the ability to accurately and consistently code health care encounters and inpatient stays. Responses may support potential socioeconomic set-aside determinations; therefore, submissions should be complete, detailed, and accurate. Desired Outcomes Improve the accuracy, timeliness, consistency, and traceability of coding and billing activities. Provide configurable workflows for coding, clinical documentation integrity, billing, utilization review, compliance, and supervisory functions. Enable secure, standards-based, near-real-time or real-time exchange with Government clinical, scheduling, billing, identity, analytics, and enterprise data services. Provide enterprise, regional, facility, workgroup, and user-level reporting with auditable metrics. Reduce avoidable manual work, duplicate data entry, proprietary dependencies, and lifecycle cost. Maintain continuity of operations, cybersecurity, privacy, accessibility, and records-management compliance. Capability Requirements Enterprise Platform and User Experience An enterprise-capable solution or interoperable suite available to authorized users across geographically distributed facilities. Role-based access, configurable menus, work queues, dashboards, alerts, and administrative controls. A coherent user experience across coding, documentation integrity, billing, compliance, workflow, and reporting functions, while allowing modular components when beneficial. Support for large user populations and workload growth without per-user barriers that discourage adoption. Accessibility consists of applicable Federal information and communication technology requirements and compatibility with common assistive technologies. Coding and Encounter Management Support identification, assignment, review, coding, recoding, completion, and tracking of inpatient, outpatient, surgical, emergency, behavioral health, long-term care, and other encounters. Support current diagnosis, inpatient procedure, professional procedure, supply, dental, and other applicable code sets, including effective-date validation and version management. Validate code relationships, age, clinical attributes, modifiers, provider data, coverage, medical necessity, payer rules, and Government-configurable edits. Support code lookup and integration with one or more coding reference or encoder products through documented interfaces. Maintain status, assignment, reassignment, comments, communications, original values, changed values, user identity, reason, and date-time audit history. Clinical Documentation Integrity Provide independent, role-appropriate work queues for concurrent and retrospective review. Identify potential documentation improvement opportunities using configurable criteria and transparent logic. Create, route, communicate, and track documentation clarification requests and responses. Capture documentation-review codes, grouping results, severity, risk, expected length of stay, quality indicators, and comparison with final coded outcomes where applicable. Provide workload, response, impact, quality, and productivity reporting for documentation integrity programs. Billing, Claim Editing, and Compliance Provide institutional and professional claim review before and, where needed, after submission. Apply national, local, payer, technical, coding, medical necessity, provider identifier, present-on-admission, grouping, sequencing, and Government-defined edits. Support individual and batch claim review, transparent edit explanations, configurable messages, and authorized maintenance of custom rules. Identify incomplete, duplicate, non-billable, held, cancelled, retrospective-insurance, and same-day related encounters and preserve supporting rationale. Provide random and targeted sampling, compliance monitoring, complete audit trails, and exportable review results. Workflow and Auditability Provide configurable work assignment, prioritization, routing, escalation, suspense, alerts, and closure across organizational levels. Enable secure communication among coding, documentation integrity, billing, clinical, utilization review, compliance, supervisory, and technical personnel. Maintain tamper-evident or otherwise trustworthy audit history for user, system, rule, integration, and administrative actions. Permit authorized users to configure workflows and rules without vendor software development when feasible. Expose workflow data through documented interfaces and export mechanisms. Integration and Data Exchange Support bidirectional integration with the VistA electronic health record, legacy clinical, scheduling, admissions/discharge/transfer, surgery, clinical documentation, imaging report, laboratory, radiology, procedure, provider, identity, billing, and enterprise data services. Use documented, standards-based interfaces where practicable, including modern application programming interfaces and recognized health data exchange standards. Describe support for synchronous, asynchronous, event-driven, batch, and secure file exchange patterns, including reconciliation and error handling. Provide interface monitoring, message traceability, retry, alerting, testing, version control, and non-production environments. Allow the Government or a designated third party to integrate, automate, and extract data through appropriately secured interfaces without unnecessary contractual restrictions. Reporting, Analytics, and Data Portability Provide configurable dashboards, recurring reports, ad hoc analysis, data mining, filtering, sorting, alerts, and exports. Support enterprise, regional, facility, service, team, role, and user-level reporting for workload, timeliness, productivity, accuracy, quality, compliance, workflow, and revenue status. Integrate with Government analytics and enterprise data platforms, including common business intelligence tools. Provide complete, documented data dictionaries, lineage, metadata, refresh frequency, retention controls, and historical access. Enable Government-controlled export of transactional, audit, configuration, rule, reference, workflow, and reporting data in open, usable formats without additional extraction fees. Cybersecurity, Privacy, Identity, and Records Comply with applicable Federal and agency cybersecurity, privacy, risk management, supply-chain, records, breach-response, encryption, and continuous-monitoring requirements. Support phishing-resistant multifactor authentication, Federal credentials, federation, role-based access, least privilege, separation of duties, automated provisioning, and deprovisioning. Encrypt sensitive data in transit and at rest using validated cryptographic modules and support secure logging and security information and event management integration. Provide software bill of materials, secure development evidence, vulnerability disclosure and remediation practices, penetration testing information, and supply-chain transparency. Support Government data ownership, records schedules, legal holds, retention, export, sanitization, incident investigation, and transition obligations. Hosting, Deployment, Performance, and Continuity Describe available VA-hosted, contractor-hosted, cloud, hybrid, and managed-service deployment models and the security authorization implications of each. Support high availability, backup, restore, disaster recovery, continuity of operations, capacity monitoring, performance monitoring, and geographically distributed use. Describe measurable service levels for availability, response time, incident triage, restoration, data recovery, and support. Provide separate development, test, training, staging, and production capabilities with controlled promotion and rollback. Support coexistence, phased deployment, pilot operations, and rollback during transition. Implementation, Training, Support, and Transition Provide program management, discovery, configuration, integration, data migration, testing, deployment, change management, adoption, and risk management services. Provide role-based product documentation, administrator guides, release notes, interface documentation, installation instructions, validation checklists, and training materials. Provide virtual and, if required, on-site training for users, administrators, support personnel, and report developers. Provide a service desk with ticket tracking, escalation, status communications, knowledge management, and performance reporting. Provide transition-in and transition-out support, including data and configuration export, interface documentation, knowledge transfer, and cooperation with successor providers. Licensing and Commercial Terms Offer clear pricing for software, subscriptions, hosting, environments, interfaces, implementation, migration, training, support, maintenance, reporting, storage, and optional services. Disclose all metrics that affect price, including users, facilities, transactions, encounters, claims, interfaces, environments, storage, processing, reports, and data egress. Describe enterprise, consumption, concurrent-user, named-user, facility, transaction, and other licensing alternatives. Identify third-party products, code sets, cloud services, and pass-through charges required for full operation. Provide terms that support Government data rights, portability, continuity, interface access, competition, and reasonable exit costs. Questions Describe your organization, relevant health care market experience, role in the proposed offering, and whether you are the software publisher, prime integrator, reseller, managed service provider, or another participant. Describe the recommended architecture and explain which capabilities are provided by a single platform versus modular or third-party components. Include major technology, data, interface, and deployment layers. Identify which capabilities are commercially available today, generally available delivery dates for planned capabilities, and any capability that would require VA funded development. Describe supported health data standards, application programming interfaces, messaging methods, integration engines, batch exchanges, and legacy integration approaches. Expla…