Home Health & Hospice Week

Beware the bright orange envelope in your in-box.

Don't overlook an intermediary's request for ADR documentation on a Medicare claim. Even if your claim is well grounded, failing to respond promptly and carefully to the request can quickly lead you down the road to denials.

Spotlight: Regional home health intermediary Palmetto GBA recently issued a bulletin coaching agencies on common mistakes made in submitting additional development request documentation. The RHHI will expect agencies to be prepared for ADRs, the bulletin suggests.

The majority of mistakes that lead to ADR-related denials are avoidable, notes M. Aaron Little of BKD in Springfield, MO. "Most of them relate to organization of records," he says. "When staff are feeling rushed, they may not remember to keep things as organized as necessary and omissions can occur."

No second chances: In the past, agencies could sometimes work their way out of a denial resulting from failure to submit complete ADR documentation on time: They'd simply refile the claim as a new claim, gaining a second chance to meet the intermediary's ADR demands. The RHHI won't allow that anymore, cautions Melinda Gaboury of Healthcare Provider Solutions in Nashville, TN.

Review it first: "We recommend that all ADR information be reviewed prior to mailing by someone in the agency other than the staff that were involved in preparing the documentation," says Little.

Another approach: If you're too short staffed to do that double-check--or even to respond initially--consider contracting with a consultant who can handle the requests.

"Surprisingly, the number-one problem is people failing to respond to the ADR at all," Gaboury says. "That's a guaranteed denial."

Tune in: To make sure you don't miss any ADR requests, check Medicare's direct data entry system daily, recommends Gaboury. That way, you'll have the maximum available time to respond.

Why? When a claim suspends for medical review, the RHHI typically mails a letter to you (look for a brightly colored orange envelope if you're served by Palmetto).

The letter will ask for documentation within 30 days of the date of the letter. Since you won't receive the letter for at least a few days, it's best to hear the news electronically: ADR requests hit the direct data entry system the day the letter is mailed.

Stay Organized--Or Lose Out

Palmetto issues these cautions:

• Be sure you don't miss an ADR when the intermediary sends multiple ADR requests.

• Organize documents carefully so it's clear which paperwork corresponds to which ADR. Palmetto reports seeing multiple records attached to a single ADR. "Some of the claims may deny for non-response to the ADR if the dates of service for each claim are not individually identified," cautions the Medicare contractor.

• Be conscious of HIPAA privacy rule compliance when sending in documentation. Palmetto reports getting packages with documentation that include records of patients not involved in the review. "In light of the Health Insurance Portability and Accountability Act (HIPAA), the provider should be careful in their responses," says Palmetto's bulletin.

Costly error: If you trip up on the privacy rule and submit the records of a patient uninvolved in the ADR, you'll wind up with a full denial.

Note: To read Palmetto's bulletin, "Are You Doing All You Can To Ensure Your Medical Records Are Submitted Accurately?" go to www.palmettogba.com and search for "Additional Development Request."