Ten Hospice Tips for Dealing with Additional Document Requests (ADRs) and Probe Edits

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The Centers for Medicare & Medicaid Services (CMS) and its contractors have broad abilities to perform prepayment and post-payment medical reviews of hospice claims. Hospices most commonly find themselves dealing with prepayment medical reviews through the Additional Document Request or Additional Development Request (ADR) process initiated by their fiscal intermediary. Typically, these ADRs relate to a particular probe or edit conducted by the intermediary. The probe or edit may be service-specific (e.g. non-cancer length of stay, general inpatient care, etc.), provider-specific or beneficiary-specific.

Regardless of the form of the probe, ADRs can create major administrative and financial problems for hospices. There are strategies that a hospice can employ to minimize the disruption created by ADRs, and put the hospice in the best position to respond effectively to the ADRs and move off the probe as soon as possible. The following are tips to help streamline a hospice's response to ADRs and increase a hospice's chances of getting its claims paid at this level.

  1. Routinely check DDE for ADRs and track ADR responses. ADR notifications are posted in the Direct Data Entry (or DDE) system at the fiscal intermediary. To ensure timely notification of ADR requests, hospices should regularly check the DDE system because they have only 30 days to respond to an ADR. The hospice should also track the ADR requests and responses on a spreadsheet or grid that includes applicable deadlines for response. This not only helps the hospice keep track of the status of ADR responses, but will be useful if the hospice chooses to appeal any claims that are denied as part of a probe.
  2. Ask to reduce the number of claims in the requested sample, if applicable. In provider-specific probes, the fiscal intermediary generally requests to review a set number of claims, often between 20 and 40. For hospices with a small census, it might take the intermediary several months to be able to gather enough claims to complete the probe, and the hospice would be faced with severe cash flow issues while the claims are caught in the probe. A hospice in this situation should ask the intermediary to reduce the number of claims pulled in the probe to a more reasonable number based on the hospice's census.
  3. Continue to bill claims while in a probe. Hospices sometimes make the mistake of ceasing billing when in a probe. However, this will simply prolong the probe because as discussed above, the intermediary will need to pull billed claims in order to complete its probe. The irregular billing patterns may also raise additional questions with the intermediary.
  4. Submit a cover letter with ADR responses. By submitting a cover letter highlighting the evidence that supports patient eligibility, the hospice stands a better chance to avoid claims denials and avoid targeted medical review. The cover letter should be written persuasively and concisely (approximately two pages) to make the hospice's case for patient eligibility during the claim period at issue and point to documentation that supports the hospice's position.
  5. Consider requesting an educational call. If the hospice receives a significant number of denials as part of a probe, the hospice may request an educational call between the intermediary and hospice staff. These calls are an opportunity for the hospice to ask questions and to hear what intermediaries look for in reviewing ADR documentation, and signals to the intermediary that the hospice is making a good faith effort to improve its performance and is taking this process seriously.
  6. Include documentation from other claim periods, if helpful. The terminal condition of a hospice patient will occasionally plateau, or even briefly improve, during a month. This does not mean that the patient is not terminally ill, however. In this case, it is often helpful to provide documentation from claim periods outside of those requested on ADR to show the trajectory of the patient's disease, along with a carefully crafted cover letter explaining the information and its relevance to the ADR period.
  7. Send each ADR response separately. When hospices package ADR responses together, the combined responses will occasionally be misplaced by the intermediary. Although it is a little more work from an administrative perspective, it is always safest to send each ADR response separately, with a separate cover letter. Hospices should also consider sending the packages via overnight delivery or other means by which timely receipt can be assured and tracked.
  8. Never send original medical records and keep a copy of the ADR response. Hospices should send copies of the medical records requested in the ADR, as well as those additional documents that the hospice believes are relevant (as discussed above). Original records should always be retained by the hospice. It is important for the hospice to retain an exact copy of the information provided to the intermediary in response to an ADR. If the claim is denied by the intermediary and the hospice decides to appeal the denial, the hospice can use the ADR response as the basis for its appeal to the intermediary.
  9. Know your intermediary and understand the probe. Each intermediary treats ADRs slightly differently. It is important to know the standards that your intermediary has set related to when a hospice is placed on targeted medical review, for example. Also, understanding the type of probe that you are in will be important as you respond to the ADRs. If you are unsure, contact your intermediary.
  10. Document! The most important strategy for successfully responding to an ADR is a proactive one–clearly and carefully document the patient's condition and the services provided so that the documentation submitted with an ADR response leaves no doubt of the patient's hospice eligibility. Local Coverage Determinations (LCDs), while not the legal standard for hospice eligibility, are strictly followed by reviewers evaluating ADR responses. As a result, a hospice should integrate the LCD into its admission, certification and IDT meeting processes; and educate nursing staff on LCD elements such that the patient's clinical record will show that the patient's condition meets the LCD whenever possible. If you are having trouble with documentation, consider hiring a hospice consultant to help staff with effective strategies to improve documentation.

If the intermediary denies a claim based on their review of the hospice's ADR response, the hospice may choose to appeal the denial through the Medicare appeals process. For more information on the Medicare appeals process, see our article on strategies for dealing with denied hospice claims.

To assist hospices in addressing ADRs and the hospice appeal process, the Hospice and Palliative Care Group at Reinhart Boerner Van Deuren, s.c. is developing a toolkit explaining the process and providing sample cover letters and other helpful information. If you are interested in more information on the upcoming toolkit or if you need help with ADRs or the hospice Medicare appeal process, please contact a member of the Reinhart Hospice and Palliative Care Group.


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