DCS Healthcare

Welcome to the DCS RAC Frequently Asked Questions

FAQ Table of Contents

RAC Contacts
General Process
Timeline
Correspondence
Medical Records
Audit Review

RAC Contacts

Question:  Who are the DCS contacts for provider staff?
Answer: 

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General Process

Question:  What states are in DCS’ Region A?
Answer:  Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

Question:  What states are included in the Region A MAC Jurisdictions (J12, J13 & J14)?
Answer:  The MAC Jurisdictions are as follows: J12 - DC, MD, DE, PA, NJ; J13 - NY, CT; J14 - NH, VT, ME, MA, RI.

Question:  Where are DCS customer service staff located?
Answer:  DCS customer service staff are located in Texas.

Question:  Does DCS use a subcontractor? If so, who is the subcontractor, and does DCS or CMS have oversight of the subcontractor?
Answer:  DCS does utilize subcontractors. These subcontractors include iHealth Technologies and PRG Schultz. DCS does provide direct oversight of the subcontractors.

Question:  What procedure does DCS plan to utilize to coordinate payment take backs with the MACs? Will the take backs appear on a separate voucher that clearly identifies they are the result of a Recovery Audit Contractor (RAC) audit?
Answer:  The process will be the same as it currently is with your MAC. The MAC will notify the provider by submitting a remittance advice prior to recoupment stating that the adjustment is RAC related and will have a remittance advice code N432.

Question:  Will DCS begin with smaller batch sizes in order to acclimate both DCS and the provider to the RAC process?
Answer:  The “batch sizes” will depend on the type of the case. However, DCS will work with the providers to ensure that we do not overwhelm them.

Question:  How will DCS communicate with providers and provider associations regarding issues that have been identified?
Answer:  Once CMS approves an issue for review, DCS will place the issue on the DCS Web site. Providers should check the Web site regularly to see all issues that have been approved by CMS and are being audited by the RAC.

Question:  How often will DCS staff provide update forums either in person, via audio conference, or Web conference?
Answer:  DCS may provide periodic conference calls/webinars. However, the primary source of information should always be the DCS Web site.

Question:  Will DCS review only Medicare Fee for Service (FFS) claims or will you also review Medicare Advantage claims?
Answer:  DCS will only review Medicare FFS claims.

Question:  Will PRG Schulz be focusing on home health/hospice only, or are there other areas they will be responsible for?
Answer:  PRG Schultz will conduct Part A and Part B audits in MAC Jurisdiction 14 and home health/hospice audits in all states in Region A.

Question: Will DCS be sending correspondence to providers for all audits, or will some come from PRG Schulz?
Answer:  PRG Schultz will send some correspondence to providers but the letterhead will be DCS’ and all correspondence will be signed as DCS.

Question: How will the RAC escalate issues that customer service representatives cannot resolve?
Answer:  RAC customer service representatives have an escalation process to answer questions and address issues as efficiently as possible by the best qualified person. This will, of course, include the involvement of the Contractor Medical Director (CMD).

Question:  Does DCS have enough qualified staff (i.e.: medical director, coders, RNs, etc.)? For example, if a case pertains to hematology or pediatrics, will the individual reviewing the case have the same background?
Answer:  DCS has a pool of qualified staff with many years of experience working as auditors/medical reviewers. Our CMD will be very involved in the process including determining what issues we should review, training our staff, and overseeing reviews. Nurses will be utilized for medical necessity complex reviews. Coding reviews will be performed by certified coders that are CCS, CPC, RHIA, or RHIT certified. The CMD will be involved in QA of reviews and will have access to 35 specialty physicians.

Question:  If I am a chain provider whose FI is WPS (Wisconsin Physicians Service)(serving as the national fiscal intermediary) who will my RAC be?
Answer:  This answer assumes the hospital originally had Mutual of Omaha as the claims processing contractor and the merger of WPS and Mutual of Omaha is how WPS became the provider's claim processing contractor. WPS currently serves as a national fiscal intermediary for CMS. They service providers in the majority of the states. These providers have not yet transitioned to a MAC. WPS will work with all 4 RACs. If WPS is your claim processing contractor (as the national fiscal intermediary and not part of the local jurisdiction) your RAC is based on your physical location. For example, if you are located in Region A, but WPS is your claims processing contractor your RAC is in Region A.

Question:  During the “discussion period”, if a record is discussed and agreement is reached that the provider is correct, will the provider receive a letter to that effect?
Answer:  If and when it is decided during the discussion period that the provider is correct, then DCS will notify the MAC of the decision. If the provider requests a letter stating the new results of the review, DCS will generate a letter stating the decision.

Question: Please clarify the procedure that a provider may follow if they disagree with the DCS determination and wish to discuss the account with DCS concerning the denial? (Discussion Period)
Answer:  The RAC discussion period begins with receipt of the review results letter for complex reviews or the demand letter for automated reviews. If a provider has any questions after receiving a letter they should contact DCS immediately to ask questions. The discussion period continues until the issue is resolved or recoupment is complete. This period is for the provider to contact DCS via telephone or written inquiry using the discussion form , and provide additional information they feel may support their original claim or request clarification from DCS as to why the denial was issued.

Question:  If a provider is in the discussion period with the RAC, is the appeal still due on day 31? What are the exact details and rules we must follow in regard to rebutting a decision during the “discussion period”?
Answer:  Yes the appeal is still due on day 31. Although the discussion period falls into the time frame when the provider can file an appeal, it is distinctly separate from the appeals process. We would encourage the providers to contact DCS shortly after receiving the Review Results Letter or Demand Letter and discuss the issue/issues they may have.

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Timeline

Question:  When will DCS have their web-based status system operational for providers?
Answer:  January 2010.

Question:  What is the contract duration between DCS and CMS?
Answer:  The contract duration is five (5) years.

Question:  What period of time will the RAC work on? Will they work from 10/1/2007 forward or will they begin by reviewing current charts.
Answer:  DCS will conduct analysis on data received from CMS. Based on this analysis DCS will determine which claims to audit. DCS may “look back” up to 3 years to review claims. However, RACs may not review claims prior to October 1, 2007.

Question:  How long will the provider have the Review Results Letter before the Demand Letter will be issued?
Answer:  Several things will factor into this timetable. DCS will make every effort to forward the claim to the MAC at the same time the Review Results Letter is sent out. Once the MAC has created the appropriate Accounts Receivable, they will inform DCS and the Demand Letter will be sent as soon as possible.

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Correspondence

Question:  How will DCS obtain provider contact information? If a provider is part of a larger system of providers, and the system staff will be coordinating the RAC activities, how will DCS adapt their processes to accommodate this?
Answer:  DCS will accept customized provider contact information from the provider via our Web page, telephone, mail, email or fax. Additionally, we will accept updated contact information provided by the provider associations.

Question:  How will DCS send additional documentation requests, review results, and demand letters?
Answer:  DCS will follow CMS’ requirements to send all communication using first class mail as opposed to private carriers. DCS is prohibited from sending Protected Health Information (PHI) in an electronic format.

Question:  How many letters will the Provider receive from DCS?
Answer:  The Provider may receive three letters, 1) request for medical record, 2) review results letter, and 3) demand letter. For automated review you will receive only the demand letter. For the complex review, you may receive all three letters from DCS.

Question:  Will the providers receive individual demand letters for each account or will letters list multiple accounts for complex and automated reviews?
Answer:  DCS will issue demand letters with multiple accounts on one letter for both complex and automated reviews.

Question: Will the RAC be assigning a claim number for each review or will a unique batch ID be generated by the auditor for each request and maintained through all future correspondence?
Answer:  There is no batch ID generated by DCS on correspondence. DCS references the Medicare claim number in letters. The Demand Letter also contains a HIC number, beneficiary name, letter id, and date of service.

Question: Will there be any correspondence sent for complex review cases where the RAC auditor agrees with the original billing of the claim?
Answer:  Yes, review results letters are sent on cases that the RAC agrees with the original billing of the claim.

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Medical Records

Question:  What is the maximum number of records that DCS may request from a provider at any given time? Is the limit based on NPI or TIN?
Answer:  We realize that this issue has caused a lot of concern for providers. CMS is currently in the process of providing updated instructions/guidance on the medical records limits. Please see the CMS Web site (www.cms.hhs.gov/RAC) for medical record information.

Question:  Once a provider receives an additional documentation request from DCS, how long will they have to respond?
Answer:  A provider has 45 days (plus 10 days for mailing) to provide medical records to DCS. If you need additional time, please contact DCS customer service.

Question:  Will the RAC be allowing providers to supply electronic transmission at any point? If a provider uses an electronic medical records system, what documentation will they be required to provide to DCS?
Answer:  The same information is required to be provided as when submitting a paper record. Currently, submissions of PHI via any method except paper, fax, CD/DVD, or transmission over the MDCN are not allowed. Please contact us if you are able to send medical records through the MDCN to make arrangements.

Question:  Will DCS request complete records, specific items from records, or both?
Answer:  DCS will request both specific items and the complete record and ask the provider to submit any documentation they feel supports their claim.

Question:  Is there a process for sending a single piece of information during DCS’ review/discussion period?
Answer:  Yes, you may use the discussion period form which may be faxed or mailed to DCS, or you may contact customer service via telephone.

Question: Is the cost for medical record copies reimbursed and does that include medical records on CD/DVD? Will we need to invoice the RAC for the number of pages copied per review?
Answer:  DCS will reimburse $.12 per page plus first class postage for medical record copies for IPPS facilities and LTC facilities. This includes medical records on CD/DVD. DCS utilizes a system that tracks the number of pages of medical records scanned (paper) or imported (CD) into the system so the provider does not need to invoice the RAC.

Question: How many medical records can be on one CD/DVD?
Answer:  As many as can fit on the CD/DVD.

Question:  How will the provider be notified by the RAC of the calculated chart limit per 45 days per NPI?
Answer:  The medical record limit will be included on the medical record request form.

Question: Which imaging company is DCS affiliated with or endorse?
Answer:  DCS is not affiliated with and does not endorse any imaging company.

Question: Is there particular software that is recommended for creating CD/DVDs in Region A?
Answer:  No. The providers may use any kind of CD/DVD writing software that they choose.

Question:  Does CMS have a standard encryption process or is this the decision of each healthcare organization?
Answer:  Each healthcare provider may decide how or if they want to encrypt their medical records. CMS recommends that some sort of electronic protection is used but that is up to the provider.

Question: Instead of being dependent on United State Postal Services (USPS) and the mailrooms for delivery of the Additional Documentation Request (ADR) letters, would DCS consider emailing them or giving an electronic access to the letters on their Web site?
Answer:  Medicare requires DCS to send these letters via first class mail. Additionally, DCS cannot email them or provide Internet access to them due to CMS' security requirements.

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Audit Review

Question:  If DCS denies a hospital’s claims for services, will they also deny the physician claims for services?
Answer:  Currently, there is no such “automatic cross-over.” It is possible that referencing between hospital and physician claims may occur in the future. Any action that would involve denying physicians’ claims would have to be approved as a separate issue by CMS.

Question:  What areas does DCS intend to request CMS' approval for auditing?
Answer:  DCS will review the CERT reports, the QIOs' Pepper reports, and the OIG reports for possible issues. Additionally we will conduct data mining analysis to identify new issues.

Question:  Which utilization criteria will DCS use to review medical necessity; Interqual, Milliman or another?
Answer:  DCS will use only Medicare’s legal and regulatory documents and policies, such as National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as guidelines for decision making. We may also choose to utilize clinical support software products as screening tools. If such products are used, the information about this choice will be made available to the community.

Question:  Will providers receive a Demand Letter for both the Automated and Complex Reviews?
Answer:  Yes.

Question:  What will DCS accept from the provider when supporting a medical necessity denial? If the provider has their own algorithm for medical necessity can this be used to support the decision?
Answer:  The provider may submit their algorithms and reasoning supporting the medical necessity, and DCS will review these, but the clinical staff will base their decisions on the patient’s clinical situation against the background of Medicare’s rules and regulations.

Question:  Will DCS accept missing (additional) documents during the discussion period?
Answer:  Providers should provide all documentation to support a case when the medical record is originally sent. If a circumstance arises where all documentation is not sent with the original record, then the provider may submit this during the discussion period for review at the RACs discretion.

Question:  If we have any question regarding any aspect of the appeals process who should we contact?
Answer:  DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question:  Can multiple accounts (denied for the same reason) be appealed using one appeal letter or are individual letters required?
Answer:  DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question:  Can we send additional information at the first level of appeals/any level of appeal? If a provider appeals, and the appeal is denied, is a letter sent explaining why?
Answer:  DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question:  What is considered non-compliance by the ordering physician with regard to supplying medical documentation?
Answer:  Any failure to respond to a request from CMS for documentation that supports the charges on a claim would be considered non-compliance. §1833 (e) of the SSA, and 42 CFR 424.5(a)(6) prohibit Medicare payment for any claim that lacks the necessary information to determine whether payment is due and the amount of payment.

Question:  With regard to medical documentation, what is the provider's extent of responsibility for supplying documentation? Example – The ordering physician telephones an order for DME to the supplier and then faxes a written prescription, but neglects to supply medical records, despite numerous attempts on the part of the supplier.
Answer: The supplier who bills Medicare and receives payment is responsible for providing the documentation.

Question: Will DCS consider reviewing underpayments for DRG’s? If they are re-coded to a higher DRG than what the provider was paid, will this be sent as an underpayment?
Answer:  Yes.

Question:  Due to confusion and continually changing policies, how will the RAC auditors be aware of the dates policies were amended, as well as implementation dates of interim policies, memos and related correspondence?
Answer:  The Recovery Audit Contractor (RAC) must abide by the Medicare legal and regulatory documents that were in effect at the time when the services were provided, to include the correct version of the Local Coverage Determination (LCD) by the Medicare contractor who had jurisdiction. The RAC must diligently research this regulatory backup and cite the correct authorities. If providers feel that a document was not considered or that an incorrect policy was invoked, they should bring this to the RAC’s attention during the discussion period.

Question:  What specific documentation is the supplier required to maintain within their company files with regard to the KX modifier?
Answer:  The KX modifier states: “Specific required documentation on file.” There are numerous Local Coverage Determinations that further define this. As a general rule, the information in the medical documentation must support the medical necessity by Medicare’s criteria for the services rendered.

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