Reimbursement, Billing, ADRS and Claim Appeals – Additional Documentation Requests: A Checklist for Advocacy

Many hospices have experienced an increase in ADRs (additional documentation requests) and are discovering that this process can be very time consuming and costly to the organization. Whether the results of a probe edit or a beneficiary edit, sequential billing means that significant resources will be tied up in the pipeline and hospices run the risk of progressive corrective action and significant delays in payment. Some edits have been known to result in fraud investigations. In recent experience, it appears that at least some of the fiscal intermediaries are sometimes misapplying their own guidelines in terms of eligibility. However, recent experience also indicates that hospices can be more vigilant in ensuring proper documentation that truly "paints the picture" regarding eligibility. The following is a brief checklist to assist hospices in better dealing with additional documentation requests. What is most important is that hospices must understand that ADRs are part of the cost of doing business, in order to ensure that all those who need and want hospice care and are eligible for hospice, have access to hospice services. This means that hospices must be prepared to defend eligibility in cases where the fiscal intermediary does not agree with the hospice eligibility determination. The cost of advocacy can be significant in terms of staff resources and outside consultants. Nevertheless, from an ethical standpoint, it is an important part of the hospice mission. Following is a simple checklist to assist hospices in advocating for their patients with regard to additional documentation requests:

□ Understand eligibility criteria.

□ Ensure proper documentation.
A. Eligibility
B. Level of care

□ Know the difference between ADR and fraud investigations. (If it's the fraud unit, don't wait, contact legal counsel!)

□ On initial ADR, prepare a summary and highlight documentation that supports eligibility, in light of relevant LMRP/LCD or Unipolicy.

□ Request an educational conference with the RHHI.

□ Ask questions and develop rapport with the RHHI.

□ Do not discharge eligible patients and include appeals in your budget as a cost of doing business (but know when to discharge).

□ Know the appeals process and timelines for appeal. Be prepared to go to hearing.

□ When necessary hire consultants to help.