CMS – DCS RAC Presentation 1

DCS, a Performant Company:

Recovery Audit Contractor (RAC) Presentation 2009

CMS – DCS RAC Presentation 2

DCS Healthcare – a division of DCS, a Performant Financial Company

• DCS is a subsidiary of Performant Financial Corporation• DCS has over 33 years experience providing service to

large government agencies and private companies• Services and products include:

– Portfolio management, operational improvement, revenue optimization and risk management services supported by a highly scalable and configurable technology platform

• DCS maintains strategic relationships with various government and private agencies, and thus operates in highly regulated, security sensitive environments

CMS – DCS RAC Presentation 3

DCS’ Experience Spans CMS, Dept of Treasury, Dept of Education and various state taxing agencies

• CMS MSP RAC Demonstration (California) • CMS Recovery of Medicare Beneficiary Prescription

Drug Benefit Premium• U.S. Department of the Treasury (MSP & Non-MSP

debts)• U. S. Department of Education• State taxing authorities • Federally chartered state student loan guarantee

agencies

CMS – DCS RAC Presentation 4

DCS’ Roles and Locations

• Livermore, CA:– Outreach – Information technology and data analysis – Contract management and compliance– Program management

• San Angelo, TX:– Issue development – Auditing and quality assurance– Customer service– Medical records processing – Provider correspondence

CMS – DCS RAC Presentation 5

CMS – DCS RAC Partnership

DCS places the highest value on its client partners; that value is the heart of everything we do, and is the basis of our Mission Statement:

 "Being the leading provider of business services and solutions thatsurpass our client expectations and deliver exceptional value.“

•  Excellence: As a CMS RAC, DCS is committed to providing the highest levels of quality, accuracy, and service for CMS and the provider community.   

•  Innovation:  We are proactively working with CMS to develop cost effective products and services that address their evolving needs.

•  People:  Our employees will represent the values of our company and those of CMS; professionalism and integrity are paramount.  We cultivate open communication, adaptability, and strategic thinking to inspire each team member to excel.  

•  Service:  Our success hinges on being an indispensible partner to CMS.  That means working seamlessly with CMS and the provider community to understand and proactively respond to changes in policy, direction and the nuances of the RAC contract to deliver fair, accurate and effective results.

CMS – DCS RAC Presentation 6

PRG-Schultz Corporate Overview

• PRGX is subcontracting in Region A, supporting DCS in RAC audit operations

• PRGX has 12 years of healthcare auditing industry experience

• Healthcare clients include Medicare, Medicaid & Commercial Payors

• RAC Demonstration participation in California

CMS – DCS RAC Presentation 7

Experienced Healthcare Auditing Staff Credentials in Operations Include:

• Physicians/medical directors providing audit oversight• Registered nurses/certified coders performing all claims

& service auditing• Experienced and knowledgeable provider services call

center representatives

CMS – DCS RAC Presentation 8

RAC Medical Director Responsibilities:

• Understanding of NCD/LCD & Medicare policies – providing clinical expertise

• RAC issues recommendation• Staff training• Quality Assurance & oversight• Keeping abreast of current medical practice and

technology• Applying clinical expertise to possible effects on

improper payments• Provider outreach & discussion availability

CMS – DCS RAC Presentation 9

RAC Process for Auditing

• Complex Review – includes additional documentation request & auditor review

• Automated Review – based on payment policy & data where two conditions exist:- Certainty the service is not covered or is

incorrectly coded, AND:- A written Medicare policy, Medicare article or

Medicare sanctioned coding guideline exists (e.g., CPT, coding clinic, etc.)

CMS – DCS RAC Presentation 10

RAC Process for Auditing, Continued

• Establish a primary point of contact– Contact the RAC to update your information– Use on-line website to register and update

• Respond to medical record requests within 45 days– If you can not meet the timeline, please contact

our provider service department & request an extension

• If a findings letter is issued, utilize the “discussion period”

• Communication is key

CMS – DCS RAC Presentation 11

Key Personnel

• RAC Project Director -– Catherine Till

• Director Audit Strategy and Informatics - – Betty Blahna, MHA, BSN

• Contractor Medical Director - – Eugene J. Winter, MD

• Contractor Medical Director (PRG) -– Charles Whigham, MD

• Vice President Healthcare (PRG) - – David Wyatt

CMS – DCS RAC Presentation 12

Estimated Timetable

• CMS awards RAC contracts - completed• RAC and CMS conduct outreach sessions – completed• Develop issues – In process/continual throughout

contract • Perform automated audits - started• Perform complex reviews – December 2009

– Medical record review requests – December 2009

– Conduct complex reviews – January 2010 throughout contract

CMS – DCS RAC Presentation 13

Automated Review Process

• Review claims data• All potential issues are thoroughly vetted and approved

or rejected by CMS• Claims are screened against approved issues at the

system level based on a comprehensive library of CMS rules, regulations, guidelines, and coding policies that are regularly updated

CMS – DCS RAC Presentation 14

Complex Review Process

• All potential issues must be approved by CMS• Documentation requests are made to providers within

pre-defined limits• Medical records are reviewed by qualified personnel • Review teams:

– Coding review determinations (RN, Certified Coders, Therapists)

– Medical necessity reviews are performed by RNs who have access to Physician Reviewers as necessary

– Medical Director providers oversight of reviews• Complete documentation is maintained in DCS’ case

management system• Demand letters or underpayment letters sent to

providers

CMS – DCS RAC Presentation 15

Correspondence to Providers

• Letters providers may receive– Additional documentation request– Detailed review results letter– Demand letter

CMS – DCS RAC Presentation 16

Recommendations

• Communicate and get to know your RAC representatives– DCS is working with and communicating with

provider organizations and MACs in your area– DCS maintains an open communications policy and

welcomes provider feedback– Providers should keep contact information up-to-

date– If there are questions or additional information is

needed, contact our Outreach team • Discussion period

– Speak to the correct party – there are trained audit specialists available to address your needs

CMS – DCS RAC Presentation 17

DCS Contact Information

• Toll free number - 1-866-201-0580• Fax number - 1-325-224-6710• Website address - www.dcsrac.com • E-mail - info@dcsrac.com • Provider contact form on website to send contact

information • Hours of operation - 8:00am – 4:30pm (EST)

CMS – DCS RAC Presentation 18

PRG Sub-contractor Contact Information

• Point of contact for MAC Region J14, Home Health & Hospice– Call Center: 877-677-4281§– Email: MRASRegionA@prgx.com– Fax: 866-340-0625

§Licensed by the Georgia Public Service Commission (GPSC) to use service observing equipment.