EDITOR’S NOTE: This article is reprinted from the July issue of The Absolute Agency, a free monthly best practices guide for home health agencies published by Home Health Solutions. Click here if you’d like to subscribe.
You’ve read and re-read your claim before submitting it, and you have all the documentation in place – but there it is: the dreaded request for additional documentation.
First of all, don’t panic.
An ADR does not necessarily mean your agency has done anything wrong. Many things outside your agency’s control can trigger these requests, including probes or edits that are service-specific, provider-specific, beneficiary-specific or diagnosis driven. In many cases the OASIS will trigger a frequently-abused HIPPS code.
If you really have done your homework, evaluating and scoring your patients according to Medicare’s own definitions and supplementing the OASIS with high quality clinical notes and assessments, your ADR experience is likely to be much less stressful.
You may simply need to do a better job of connecting the dots for the MAC reviewer by providing information that was inadvertently omitted, or pointing out documentation the busy reviewer overlooked.
“Try to look at any ADR as a learning experience that can sharpen your documentation skills, identify weaknesses in your operation and shore up your processes to protect against future ADRs,” advises J’non Griffin, owner of Home Health Solutions.
Sometimes, of course, it’s more than the luck of the draw that attracts ADRs. Agencies make mistakes. OASIS scores aren’t well supported, or call into question the patient’s homebound status, phraseology is vague or subjective rather than clinical, and it’s difficult to tell what’s actually going on with the patient’s condition.
When the agency has not clearly documented from the beginning, attempting to sort through the confusion can turn into a time-consuming bout of evidence-collecting and careful explanation.
J’non and the HHS team have helped agencies of all sizes across the country successfully respond to ADRs, and they have identified a few of the Red Flags likely to capture the notice of MACs. The good news is that agencies can address many of these risk areas before submitting claims just by carefully reviewing documentation.
“There’s no magic deterrent to protect any agency, but you can take steps to insulate yourself by being aware of certain triggers and becoming proactive about avoiding these errors or improving documentation in these areas,” J’non says.
SOME ADR TRIGGERS
Here are some of the trouble areas that can trigger an ADR for an agency:
– Contradictory answers on the OASIS
– Inadequate Face-to-Face documentation
– Multiple re-certifications
-Recertifying when there is no new or exacerbated diagnosis in the record
– Recertifying for a “later episode”
– Minor treatment changes that do not support medical necessity
– No evidence of a continuing need for skilled care
– Multiple episodes of observation and assessment of chronic conditions.
– Repetitive education or education that does not address a knowledge deficit
– Discharges followed by re-admissions without any intervening change in the patient’s condition
– Inconsistencies in patient treatment
TIPS FOR RESPONDING TO ADRs
When your agency has received an ADR, these tips may help you complete it in a timely and thorough manner:
- Look at the ADR due date and mark it on a calendar. With a limited response time, it is imperative to complete your information gathering tasks by the deadline. We recommend setting a target date for submitting your response prior to the actual due date to ensure timeliness.
- Use a team approach to address the ADR. Nursing, therapy and medical records will likely need to work together to review and collect the data needed.
- Carefully review the ADR and note each piece of requested documentation. There’s no better way than an old-fashioned checklist to make certain that you are addressing each request.
- Additional documentation which has not been requested may be provided to support payment of the claim. Signed and dated physician certifications, for example, may not be on the list of requested documentation in an ADR, but this is a foundational piece for establishing the validity of your claim.
- On the other hand, do not make the mistake of overloading the reviewer with too much documentation. A file bulging with too much information, particularly information which was not requested, will not be happily received by an overloaded reviewer behind in his or her cases. Choose your evidence wisely, based on the strength it adds to your case.
- Resist the urge to alter or attempt to correct any original documentation. Explain and supplement to make your case stronger.
- Assemble all documents in order of request. Your goal is to make the process as easy as possible for the reviewer, and providing the information in a manner that is easy to sort through will be helpful. Some agencies use page numbers specific to the particular case. Others identify documentation pages with highlighted text, or provide an index. There is no right or wrong way — but your submission must be easy for the reviewer to figure out.
- Create a persuasive Cover Letter. This is arguably the most important part of your response. The Cover Letter will justify the care delivered by your agency and briefly tell the reviewer what supportive documentation is being submitted and how to easily find it. Don’t make the Cover Letter too long. It should briefly summarize the patient’s needs, the skilled services provided to meet those needs, and the patient’s response/progress. Make it as easy to read as possible. No one likes to read two pages of text unbroken by paragraphs! Use bulleted points, and consider adding some bold-faced titles to help the reviewer quickly scan the material. See how we have used bold-faced titles such as “Some ADR Triggers” and “Tips for Responding” here to break up the text? You may wish to do the same thing in your Cover Letter with helpful titles such as “What We’re Submitting” or “Skilled Services We Provided.”
- Keep a copy of all documents submitted to the Contractor.
NEED HELP WITH YOUR ADRs?
ADRs are intimidating and time-consuming. Sometimes, the surest way to navigate an ADR is to turn to an experienced clinical consultant who can guide you through the process, make certain that you include all the key elements needed to support your claim.
The consultant can also show you how to make process improvements to reduce the risk of future ADRs or claim denials.
Home Health Solutions can provide the support you need to take the pain out of the ADR process. If you’d like more information about our ADR services, call us at 888-418-6970 or email: