Posted on Tuesday, September 12, 2017 4:00 PM
Medical review is the collection of information and review of medical records by MACs to ensure that payment is made only for the services that meet all Medicare coverage, coding, and medical necessity requirements. Medical review activities are directed towards areas where data analysis indicates questionable billing patterns. Validating initial findings of the medical review evaluation may require additional review and requests for information.
Service specific and provider specific probe reviews are implemented by requesting additional documentation termed Additional Development Request (ADR) from the provider billing the service. The MAC will request specific clinical and technical documents related to dates on the billed claim. This requested information must be submitted within 30 days from the date of the ADR. Failure to submit the information will result in a denial.
Not only will failure to submit the information result in a denial of the claim, failure to submit the requested information also impacts your Provider Error Rate Calculation. Why is this important? When the MAC identifies a provider-specific problem, the provider error rate is an important consideration in how to address the problem. For instance, a provider with a fairly low provider error rate with no history or patterns of errors may require a fairly minor corrective action plan. Other factors such as the total dollar amount of the problem and the past history of the provider also deserve consideration. MACs assess the nature of the problems as minor, moderate or major. The MACs will now include claims denied to no response into the provider error rate calculation.
There are two ways in which to identify an ADR:
1. When viewing the ADR screen on the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE), you may observe a claim or claims identified as requiring an ADR. Review at least every week if you are not on a probe edit and daily if you are on a probe edit.
2. Your agency may receive a notification letter stating an ADR is requested for the claim/s.
ADRs place a burden on agencies of all sizes, but are very difficult for small agencies. It is important to understand the time limitations, the requirements and how to successfully navigate through a request for ADR. Once a claim is placed in ADR status, no payment is made for services provided to the patient until the ADR is resolved. Generally, the MAC will request 20 to 40 ADRs. It may be appropriate to request to the MAC to reduce the number of claims requested in the sample if the number of ADRs requested is greater than 40 or if the agency has a small census and it will take months to accumulate enough claims to complete the probe. Not responding should not be an option! Communicate with your MAC. Do not let no response to an ADR impact your provider error rate and the MACs consideration on how to assess your agencies potential problems.
For additional information or ADR Support, please feel free to contact Corridor at 1.866.263.3795.
Click here for ADR Response Guide for Hospice.
Click here for ADR Response Guide for Home Health.
Corridor is the nation’s preferred partner and trusted business advisor to home health and hospice providers, providing quality services and impactful results for 30 years. Focusing on key operational, regulatory and financial challenges, Corridor delivering industry-unique solutions and deep expertise in coding, clinical documentation review, compliance, billing and collections , consulting and provider staff education . At Corridor, we make the business of caring for people Better! For the most important industry updates and news that impacts home health and hospice, please make sure to sign up for our weekly newsletter to receive the latest up-to-date industry information direct to your inbox!
For additional information, please contact Corridor at 1-866-263-3795.