Understanding your Additional Documentation Requests – 2019 CMS National Provider Compliance Conf.

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.

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