Why Are We Getting So Many ADRs?

March 14, 2016

First of all, don’t panic. This latest round of ADRs (additional documentation requests) has been brought about by the IMPACT act. These are “probe and educate” reviews that all agencies are or will be subjected to. It does not mean that you have done anything wrong. Basically, the Fiscal Intermediaries are required to select 5 end of episode claims for pre-payment review. Their focus will be face-to-face documentation, however they will be reviewing the submitted paperwork just like any other review. There are a few things you can do to help lessen the probability of denial of your claims:

  • Make sure you respond to all ADR requests and that you do so in a timely manner. Your fiscal intermediary (FI) will be sending the request via US mail so make sure that you check your mail regularly (especially if you have a PO Box). You can be proactive and check your Florida Shared/DDE billing system for any claims that are in status SB6001. You can also check status SB6000 – this will show claims that may be subject to ADR review but a final determination has not been made. If your biller is not accessing the Florida Shared/DDE system, follow up with your FI on instructions on how to access this system.

  • Make sure you send ALL requested information. Read through each point carefully to ensure that you are providing all requested paperwork. Is this a recertification episode? Note that CMS now requires that your agency provide ALL therapy evaluations and reassessments from the start of care to the current episode.

  • Make sure your face-to-face documentation is complete. Not only should you provide any face-to-face documentation in your medical record, you should also make sure that you provide a copy of the physician’s progress note from the face-to-face visit and that the documentation in his/her progress note contains information relevant to your home health episode.

  • Make sure all signatures are legible (readable). If they are not legible, make sure that you also include a signature log. therapyBOSS provides an electronic signature compliance statement here.

  • Look at a print-out of the submitted claim and ensure that you have provided documentation for all billed visits.

  • Another tip: CMS came out with clarifications to the content in the recertification. If your patient has been recertified, it is important to make sure that your recertification includes a statement by the physician about how much longer services are to continue. To provide a frequency for your disciplines in the next certification period is no longer considered sufficient for this requirement. CMS wants to know whether there is a planned end date to the home health services and if so when that date will be. If you would like to find out more about this requirement, NAHC has a very informative article here.

  • Before submitting your ADR documentation, take a look one last time and make sure that all requested information is included in your response.

  • Send your ADR using a method which will give you a delivery receipt. If your fiscal intermediary allows faxing, make sure you receive a fax confirmation. If you opt to send your paperwork via US mail, ensure that you send the documentation via certified mail and that you confirm that it has been delivered. Note: it is recommended that you send each ADR separately to avoid the possibility of the paperwork getting mixed up when it is received.

  • The final step in submitting your ADR documentation is to check the Florida Shared/DDE system and ensure that the claim status has changed from SB6001 to SM50MR or some other code reflecting that the claim is processing.

  • If you do not agree with the determination for your claim, you can appeal. For information about agency appeal processes and contact information, please follow up with your fiscal intermediary.