Home Health & Hospice Week

Billing staff aren’t the only ones who should be involved in ADRs.

How you respond to Additional Development Requests may make or break your review status under the Targeted Probe & Educate program beginning this fall. With up to 40 claims chosen for review under TPE, you can’t afford to get your ADR responses wrong.

TPE review “is very serious and should be treated as such,” warns billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville.

Crucial: Failure to respond to TPE ADRs will count in your denial stats. And that was one of the

top three reasons for denials in the first two rounds of the program, the Centers for Medicare & Medicaid Services says on its Probe & Educate website.

“Agencies absolutely need to send records in when requested to avoid those automatic denials,” urges Judy Adams with Adams Home Care Consulting in Durham, North Carolina.

“It will be critical — as it always is — that providers inform their billing personnel to monitor for new ADRs and make certain those are communicated to the personnel responsible for responding,” advises M. Aaron Little with BKD in Springfield, Missouri.

Plus: “Agencies that find themselves in this probe are at risk,” Gaboury stresses. “Agencies need to make a concerted effort to ensure that the charts you are sending in for this review are meticulously reviewed by clinical staff prior to submission to the MAC,” Gaboury advises on the HPS blog.

“Agencies should review exactly why they received previous denials and ensure that the past is not repeated,” Gaboury adds.

And “make sure to use your MAC’s guidelines for submission of the ADRs,” Gaboury concludes.

Tip: In addition to non-response to ADRs, the other top two reasons for denials relate to the faceto-face requirement (including “no signature by the certifying physician and encounter notes not supporting all of the elements of eligibility”) and recertifications (“no estimate of continued need for service and initial certification was missing/incomplete or invalid”), CMS says.