To: Board of Supervisors
From: Dr. Grant Colfax, Health Services Director
Report Title: Contract #27-791-14 with Cotiviti, Inc.
☒Recommendation of the County Administrator ☐ Recommendation of Board Committee
RECOMMENDATIONS:
APPROVE and AUTHORIZE the Health Services Director, or designee, to execute on behalf of the County Contract #27-791-14 with Cotiviti, Inc., a corporation, in an amount not to exceed $3,000,000 to provide a hosted software solution for analyzing Healthcare Effectiveness Data and Information Sets (HEDIS) for fraud, waste and abuse for Contra Costa Health Plan (CCHP) for the period November 1, 2025 through October 31, 2028.
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 CCHP Enterprise Fund II revenues.
BACKGROUND:
This Contract meets the needs of the County’s population by providing data analysis software for HEDIS projects and reports to support State and contractual requirements for 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. HEDIS Measures & NCQA Accreditation certification is a requirement of the Department of Health Care Services (DHCS), for which CCHP is assessed. HEDIS is required for NCQA Accreditation and DHCS compliance. HEDIS scores are used 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 NCQA certified software to process the data. Under this Contract, Cotiviti provides the NCQA software to process the data.
CCHP is contractually and legally required to implement and maintain 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 (FWA). Failure to meet these requirements would result 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 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.
This Contract is entered into under and subject to the following legal authorities: California Government Code §§ 26227 and 31000; Health and Safety Code § 1451. Contractor currently cooperates with and participates in CCHP’s Quality Management Program which consists of quality improvement activities to improve the quality of care and services and member experience. Cooperation includes collection and evaluation of performance measurement data and participation in the organization’s clinical and service measure Quality Improvement Programs. The nature of the electronic claims processing services needed is complex and requires seamless coordination, integration and collaboration with existing programs and systems. This Contract has been posted for continuous solicitation with the County Public Works Department’s Purchasing Division. CCHP will monitor measurable service contract deliverables regarding its access to the software maintenance and support services in compliance with Section III(B)(7) of the Purchasing Policy. Health Services Personnel approved this contract renewal to ensure no conflict with labor relations.
On November 1, 2022, the Board of Supervisors approved Contract #27-791-11 with Cotiviti, Inc., in an amount not to exceed $3,000,000, to provide a hosted solution for software services related HEDIS measures, data analysis related to fraud, waste and abuse and member outreach services for the period November 1, 2022 through October 31, 2025.
On December 12, 2023, the Board of Supervisors approved Contract Amendment #27-791-12 with Cotiviti, Inc., effective December 31, 2023 to discontinue member outreach services, with no change in the payment limit of $3,000,000 or term ending October 31, 2025.
Approval of this Contract #27-791-14 will allow the Contractor to continue to provide its hosted software solution, Quality Intelligence Application Service Provider (ASP), a HEDIS-licensed program and data analysis which aid in identifying fraud, waste, and abuse schemes affecting CCHP through October 31, 2028. Under this 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 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.
CONSEQUENCE OF NEGATIVE ACTION:
If this Contract is not approved, County will not have access to Contractor’s data analysis software solution, nor funds to reimburse providers per requirements from Department of Managed Healthcare (DMHC) and DHCS, which will negatively impact CCHP’s ability to operate and ultimately, patient care.