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11 Tips for success when faced with an ADR

With increasing numbers of Additional Documentation Requests (ADRs), home health agencies and hospice organizations are required to produce documentation in a timely manner to prevent claims denials or payment delays. Did you know that more than 10% of ADRs are denied because organizations don’t submit any documentation at all? There are many other reasons why claims are denied, so having a solid understanding of what needs to be done and how to implement best practices in your organization can make all the difference between payment and denial.

Below are 11 tips for success when faced with an ADR:

  1. Become familiar with FISS The Fiscal Intermediary Standard System (FISS) is a biller’s best friend. FISS is where all ADRs, and their due dates, are listed. Pages 7 and 8 will be key for finding information related to a specific ADR.
  2. Track your ADRs Keep a running document with all ADRs listed; when they were received, the date you sent documentation back, date the final determination is made, and what the outcome was. With so many specifics around each individual ADR, keeping track is a must.
  3. Mind the clock You’ll have 45 days for a Medicare Administrative Contractor (MAC) to receive your documentation. Plan ahead and regardless of your preferred submission method, be cognizant of the time it will take to arrive as exceptions will not be made. Make sure to keep proof of submission, too.
  4. Pay attention to detail Follow MAC’s checklist for submission, and make it easy for the representative to review and approve your claim. Insert page numbers and include a cover sheet that highlights key points. Make sure to refer to specific pages for more detail.
  5. Comply with HIPAA While submitting anything electronically these days seems more efficient than mailing, be mindful of HIPAA rules. If you submit documentation on a CD, make sure it is password protected. The last thing you need is to be hit with a HIPAA violation.
  6. Know ‘denial’ isn’t final You may appeal MAC’s decision, but first consider whether there is other documentation that you could submit to support your claim, or if there were items that you submitted that you feel were not considered as part of the final decision. Appealing without solid backup or rationale will probably result in denial of your claim.
  7. Look for trends Is your organization being hit with the same ADR over and over? Consider this an opportunity to improve how documentation is done at the clinician level to ensure future compliance related to this ADR.
  8. Plan for compliance Proactively reviewing claims prior to submission will help achieve positive results when responding to an ADR. Consider some of these strategies:Pre-bill reviews: These can be done both on a clinical and billing level. The clinical review seeks to find if the notes and documentation provided support the claim, and the billing review looks to see if there is a visit that matches the dates on the claim.Chart audits: These are comprehensive audits that look at whether the major indicators for meeting conditions of participation or condition of payment are being met.Peer reviews: This type of review gets clinicians involved with assisting quality assurance in chart reviews. This is a great learning tool that can identify consistent documentation concerns, and opportunities for ongoing education.
  9. Use data Subscribe to this philosophy: if it went in as a data point, it can come out in a report. Leverage your data to pinpoint focus areas for reviews. The goal is for your data to show that you are meeting all criteria related to a specific diagnosis. Something important to consider here is where your staff is documenting. If it’s post-patient visit, the quality of documentation decreases.
  10. Develop SMART goals Once you identify areas for improvement, create goals associated with these focus areas. SMART goals are specific, measureable, attainable, relevant and timely. Once you set the goals, clearly communicate them with your staff as they are key stakeholders in whether your claims are approved or denied.
  11. Take action Ensure staff receive the appropriate training on how to document during orientation. Standardizing what each clinician is inputting is key to a streamlined, efficient ADR process and submission. The documentation should speak for itself.

Organizations that rely on paper-based documentation or have to search for information on disparate clinical and financial systems experience a dramatic increase in staff time, productivity loss and potential for penalties or take-backs. On the other hand, organizations that leverage a modern EMR solution have a greater assurance that patient records and the organization’s record-keeping are compliant with the most current regulations.

keep calm and prepare for ICD-10

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