ANNOUNCER: Centers for Medicare and Medicaid Services 2019 CMS National Provider Compliance
Conference, Understanding your Additional Documentation Requests (ADRs), Stacie McMichel,
Senior Provider Relations Analyst, CGS.
STACIE McMICHEL: As I was introduced my name is Stacie McMichel.
I’ve been in the Medicare arena about 22 years.
Today I'm just going to share with you some quick tips about understanding your ADR.
Most of today’s conversations have been related to audits, how to navigate through
those audits, some of the data analysis for the audits and then I'm just going to piggyback
on that and just explain the ADR process and things that you can do to assist in making
sure that you’re responding with the appropriate information.
First off and just advising on what an ADR or Additional Documentation Request letter
is that is a system generated letter that’s associated with a claim that has been selected
for review.
All of the Medicare administrative contractors utilize this process to generate a letter
out to our providers and suppliers when the claim is under audit.
The ADR will specify the individual pieces of documentation that is required related
to the services that are being reviewed.
And the ADR may be initiated as part of a pre or post pay basis.
So pre pay meaning your claim has been submitted, there’s an edit in the system that will
stop that claim for review and it will kick out a letter to that payee address, or correspondent’s
address that’s on file.
And then post pay, same process.
It’s just that we’re looking at the claims after payment and that same letter will be
kicked out depending on the audit, the reason for the audit.
Maybe it’s a HIX PIX (ph.) code or maybe it’s general for that P10.
In preparing for an audit we always encourage our providers and suppliers to make sure that
you have a thorough intake process.
Take advantage of the time that you have that face to face time with the beneficiary or
with their representatives or with the referral source to make sure that you at minimum have
access to the information that is necessary in the event that your claim is selected for
audit.
We also remind you that there should be a designated or you should implement a process
to respond timely to those ADRs, having those established relationships with your referral
source, making sure that they understand the importance of them responding to your request
for information so that you in turn can respond to the request for additional documentation
timely.
And then lastly always be mindful of the timeframes in which to respond.
We’ll look at a few examples of the letters that our contractors are sending out to our
supplier.
But it always the timeframe in which you need to respond before the claim is deemed an error
for lack of a response.
So here’s an example of the MAC ADR letters.
And the things that we like to point out in this letter is that when you’re responding,
keep in mind that depending on the contractor they could be national or even if they’re
isolated to their territories your request for documentation is not the only one that
they’re focusing on.
So make sure that you include a copy of the ADR letter with your response to the request.
That way your documentation is paired up with the claim that’s pending for review.
Always review the beneficiary and the claim information to identify which claim is being
pulled for audit.
And then review the specifics of the claim to know how that claim was submitted to Medicare
and the information that may be attached to it.
And then in the body of the letter for the MACs we always provide an itemized listing
of the documentation that we’re requesting or expecting in event of an audit.
It’s always best to submit any documentation related to the claim that supports the payment
for medical necessity and if an ABN has been issued always include the ABN with your claim,
if you billed for a denial.
Just because a claim was pulled for prepay or post pay basis does not always indicate
that payment has been made or will be made.
So in the event that an ABN is involved always include that with your response to the ADR.
And then as far as the supplier or provider documentation that’s your proof of delivery,
your ABNs, your orders, things that don’t really tie into the clinical pieces of that,
make sure that that’s always attached to the response for the additional documentation
request.
This next slide is just an example from other contractors that may be submitting information
to you, to request additional documentation.
But it’s imperative that you are able to identify who’s requesting the additional
documentation.
That is to ensure that your response goes to the appropriate contractor.
The contractors will not transfer the documentation submitted to them in error.
They may submit it to our written core department and you’ll receive a response that way.
But that impacts your timeliness.
So again just making sure when you’re receiving those letters from the contractors that you’re
identifying which contract they came from and that their response is not only timely,
but you’re submitting it to the appropriate contractor.
They have the same elements of information within the letters, but they may not be laid
out the same.
For the MACs we itemize that list.
For others it may be within the body of the letter.
So again just reminding you to read the letter in its entirety, making sure that you identify
the beneficiary, the claim that’s on the review, the date of service, the HIX PIX code
that’s under review and all of the documentation that is required for that particular item.
And then lastly make sure that you respond timely and to the appropriate contractor.
Some common mistakes to avoid.
Always return your documentation to the Medicare contractor identified on the ADR or in the
body of the letter.
Never omit requested documentation.
It’s important that when you submit your documentation it’s everything that’s related
to this service.
Even if we’re just looking at proof of delivery or maybe the audit is on medical records,
you should still have any other pertinent documentation that’s related to the claim
that is submitted to the program.
Always send a clear and legible copy of the requested information.
Do not highlight or add Post-t notes to the documentation.
We’re all in a virtual environment, meaning that if you’re submitting hard copy documentation
to the contractors chances are that information is being scanned in and then disseminated
to the operational areas that are going to work those cases.
So when you highlight documentation or add Post-it notes to that, the documentation loses
its integrity.
When it’s highlighted that becomes a black mark on a scanned document and we cannot read
the content that’s up under it.
So make sure that you’re not doing that and if you’re wanting to add emphasis to
certain pieces of documentation you can always use a cover letter in your request to highlight
those pages or that piece of information that you’re wanting to make sure that the reviewer
hones in on.
Do not send responses to the attention of any person or department.
All of the contractors have specialized PO Box numbers or faxes that you should utilize.
And we will make sure that we disseminate that to the appropriate personnel to review
those cases.
And then never miss your deadline.
Never, never miss your deadline.
I need you all to repeat that.
Never miss your deadline.
Claims will be automatically denied if the timely response is not received.
We talked about the appeals and impacts to supplier burden.
It’s very costly for the contractors to have to process an appeal and for you to have
to navigate through that appeal.
So responding timely the first time is the most appropriate thing to do.
And then in the event of an additional denial, then you can focus on those areas that you
need to secure additional documentation for.
And that’s all I have for you today for some tips and reminders.
Thank you for your time.
(Applause)
ANNOUNCER: Centers for Medicare and Medicaid Services.