Special Notice / Hearing: None__
Vote Required: Majority
To: Honorable Board of Supervisors
From: Colleen Chawla, Chief, San Mateo County Health
Chester J. Kunnappilly, MD, Chief Executive Officer, San Mateo Medical Center
Subject: Amendment to the Agreement with Recovery Audit Solutions, Inc. for Medical Chart Review Services
RECOMMENDATION:
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Adopt a resolution authorizing an amendment to the agreement with Recovery Audit Solutions, Inc. to provide medical chart review services, extending the term by two years through December 1, 2027, and increasing the amount authorized to be expended under the agreement by $390,000, to an amount not to exceed $585,000.
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BACKGROUND:
San Mateo Medical Center (SMMC) has entered into a Corporate Integrity Agreement with the Office of Inspector General of the United States Department of Health and Human Services, and part of this agreement requires SMMC to engage a third party to review our medical necessity reviews. This review will ensure SMMC is billing accounts appropriately.
SMMC completed a request for proposals (RFP) in August 2024 for medical necessity review services. Recovery Audit Solutions, Inc. (RASI) submitted a proposal for this RFP and was ultimately elevated to review SMMC’s medical charts due to their experience, knowledge, accuracy rate, and detailed review process. Due to the urgent need for these services, on November 26, 2024, the parties entered into a departmental-level agreement for the term of December 2, 2024 through December 1, 2025, in an amount not to exceed $195,000.
DISCUSSION:
SMMC continues to have a need for third-party reviews of medical charts, and SMMC now wishes to amend the agreement to provide for a three-year term. This amendment will extend the term of the existing agreement by two years and add the corresponding funding.
County Attorney has reviewed and approved the resolution and amendment as to form.
The resolution contains the County’s standard provisions allowing amendment of the County fiscal obligations by a maximum of $25,000 (in aggregate).
It is anticipated that RASI will perform initial and concurrent medical necessity reviews to validate the medical record documentation meets medical necessity and level of care within forty-eight hours (excluding weekends and holidays).
PERFORMANCE MEASURE:
|
Measure |
FY 2024-25 Estimated |
FY 2025-26 Projected |
|
Number of hours within which RASI will perform initial and concurrent medical necessity reviews to validate the medical record documentation meets medical necessity and level of care (excluding weekends and holidays) |
≤48 hours |
≤48 hours |
EQUITY IMPACT:
RASI’s medical chart review services will ensure that all reviews are accurate, unbiased, and considerate of the diverse needs of SMMC’s patients. SMMC’s patients span a wide spectrum of races, ethnicities, gender, and gender-identities. Within the past 18 months the largest cohorts of specialty care patients at SMMC were female (53%), Hispanic or Latino (57%), and primarily Spanish speaking (54%). By fostering a patient-centered approach, the medical chart review services will support fair and inclusive healthcare delivery.
FISCAL IMPACT:
The term of the amended agreement is December 2, 2024 through December 1, 2027. The amendment increases the amount payable under the agreement by $390,000, to an amount not to exceed $585,000 for the three-year term. Funds in the amount of $113,750 are included in the SMMC FY 2024-25 Adopted Budget. Funds in the amount of $195,000 are included in the SMMC FY 2025-26 Recommended Budget. Similar arrangements will be made for future years.
Expenses at SMMC are covered by fees for services or third-party payors whenever possible. The portion of expenses for services provided to the medically indigent or to those covered by programs that do not meet the full costs of care is covered by the County’s General Fund contribution to SMMC and is within the existing annual appropriation.