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Biller-clinician cooperation is key to success.

Don’t let failure to respond to ADRs rob you of money you’ve earned, and land you on the list for more medical review.

Under the Probe & Educate medical review campaign focused on face-to-face physician encounter compliance, non-response to Additional Development Requests accounts for 30 to 40 percent of denials so far (see story, this page). But agencies can beat those statistics by heeding this expert advice:

1. Appoint an ADR czar. Home health agencies “need to have someone responsible (and accountable) for dealing with ADRs,” advises nurse consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. That person should keep “a spreadsheet with the ADRs as they come in including patient name, reason codes and due dates.”

“This goes back to having a QA/QI person and team with ADR response as part of the job description,” Laff adds.

2. Monitor FISS for ADRs. “The nonresponse to ADRs historically has been an issue of the agency not realizing they have requests pending or a change in personnel who had responsibility for receiving the requests and who are no longer with the agency,” says Judy Adams with Adams Home Care Consulting in Asheville, N.C.

Make sure you have a system set up where FISS is constantly monitored, even if your ADR point person is sick or quits unexpectedly.

“Pay close attention to the mail for any requests for additional documentation,” advises a spokesperson for HHH Medicare Administrative Contractor National Government Services. “To ensure proper payment, it is critical to respond promptly to these requests with all of the materials that are requested,” the spokesperson tells Eli.

Specifics: Don’t expect to keep on top of ADRs via snail mail, though. Some MACs have discontinued paper notices altogether, and others are inconsistent with them. Instead, keep tabs on ADRs by watching for claim status/location of S B6001, instructs billing expert M. Aaron Little with BKD in Springfield, Mo.

“Providers are encouraged to use FISS Option 12 (Claim Inquiry) to check for ADRs at least once per week,” MAC CGS says in an article about the ADR process on its website. “You will not receive any other form of notification for an ADR.”

Bottom line: Agencies “need to be sure their internal system of notification is working properly to avoid missing the notices,” Adams stresses.

3. Respond on time. When you receive an ADR, you have 45 days from the request date to respond, CGS notes on its website. In order to get your response materials together, you’ll need a good communication set-up between your billing and clinical staff, Little advises.

Why? Properly educated billing personnel must identify claims that have been selected for ADR. Then, they must use “an effective process for communicating such to the appropriate individuals in the agency who are responsible for responding to the ADR,” Little says. “Typically, those responsible for responding are individuals in the clinical/operational management area, but it’s the billing personnel who are in the best position to first identify that a claim has been selected for ADR by monitoring the S B6001 claim status location.”

4. Furnish a sufficient response. It’s not enough to just throw together whatever documentation you’ve got, send it off, and hope for the best. Under the Probe & Educate campaign, medical reviewers are looking for five specific F2F elements (see Eli’s HCW, Vol. XXV, No. 11).

“Each ADR record should be reviewed by a competent manager,” Laff counsels. She should make sure it includes all required F2F elements, which must come from the physician’s record. That’s why you should start collecting the F2F information from the doc at admission and not wait until billing or when you receive an ADR, experts agree. It’s much easier to request additional information from the physician up front than after the fact.

Pitfall: If you have an administrative person collecting the physician record for F2F and not reviewing that record for adequacy, you are risking denials if an ADR should arise, experts warn.

Tip: “Providers should submit the necessary documentation to support the services for the billing period being reviewed,” CGS notes. “This may include documentation that is prior to the review period,” the MAC points out.

5. Include a cover letter. To make it easier for reviewers to recognize all the required information you are sending in, you should prepare a cover letter to accompany the ADR response, Laff offers. The cover letter should briefly explain the patient’s diagnoses, care plan and response to care (improvement or decline). “This must not be wordy and should directly relate to the reason the record is under review,” Laff tells Eli.

The cover letter “can be used by CGS Medical Review staff as a roadmap, and prove very helpful to highlight key dates or documentation that supports payment of the claim,” the MAC says.

“However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.”

6. Track your response. After you’ve detected the ADR quickly and assembled a sufficient response, your job still isn’t over. Sometimes providers submit the documentation on time but the MACs don’t show that the records were ever received, Little acknowledges. “One suggestion would be to send all documentation via some kind of expedited return receipt process so that there is proof the records were received by the MAC,” he offers.

Pointer: You can monitor FISS to verify that the MAC has received your documentation, CGS explains. “When your documentation has been received by CGS, the claim is moved from status/location S B6001 to S M50MR for review.”

MACs have 30 days from the date the documentation is received to review the documentation and make a payment determination, CGS notes.

7. Investigate denials — and respond. If you do receive a denial for non-response, check to see how the ADR slipped through the cracks, Litwin recommends. Then, fix your policies and procedures to make sure it doesn’t happen again.

If you receive a denial based on F2F or other requirements, use it as an opportunity to educate staff about the problem and how to avoid it in the future. Under the Probe & Educate initiative, the MACs are conducting one-on-one educational phone calls upon request for providers that receive any denials in the review. Take advantage of that resource to find out what you’re doing wrong and how to fix it, industry veterans urge.

8. Appeal. If you let an ADR time out or never learned about it in the first place, all is not lost. “When a claim is denied with reason code 56900 indicating that the medical documentation was not received by CGS, or was not received timely, a ‘56900 reopening’ may be requested to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process,” the MAC explains.

For denials based on F2F and other documentation requirements, “agencies may follow the appeals process when they feel they have sufficient documentation to support the coverage issue denied,” Litwin points out.

Note: CGS’s ADR process overview is at .