Eli's Hospice Insider

Who's on your hospice's ADR team?

You can head off Targeted Probe & Educate's severe consequences, in part, by getting your ADR response process on track - and fast.

Remember: If you don't perform well under TPE medical review, you can get put on indefinite medical review, targeted for payment suspension, brought to a fraud contractor's attention, or referred to the authorities.

The Centers for Medicare & Medicaid Services and its HHH Medicare Administrative Contractors will be launched the punishing Targeted Probe & Educate medical review campaign this fall, and those are the drastic consequences that will take place if you don't perform well in the program - including responding to Additional Development Requests.

Heed this expert advice to get your ADR responses where they need to be under TPE:

1. Identify your problem. You may not even realize you have a problem if your billing staff aren't monitoring DDE for ADRs. Assess your claims paid and denials to see if you have claims denying for Reason Code 56900.

"Agencies that have had a history of not responding need to identify why that is and address it before any TPE actions come up," urges billing consultant M. Aaron Little with BKD in Springfield, Missouri.

The sooner you tackle the problem, the better, stresses Lynn Olson with Corpus Christi, Texas-based billing company Astrid Medical Services.

Providers "better start addressing the issues, especially if there is a recurring problem," Olson tells Eli. Different reasons for the nonresponses will require different methods of resolution. (See story, p. 3, for some of the likely reasons.)

2. Appoint your ADR team. Whether it's one person or multiple staffers, you need to decide exactly who will be working to identify the problem and implement the resolution - including the person who is ultimately responsible. "Agencies must designate someone to monitor and respond timely," advises Cindy Krafft with Kornetti & Krafft Healthcare Solutions. "In smaller agencies with staff wearing many hats, things can get lost in the shuffle."

3. Check for ADRs. The cornerstone of avoiding non-response denials is checking the Direct Data Entry system for ADRs. In a recent article on its website, HHH MAC CGS "encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week," it says.

A step further: Billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville recommends twice-weekly checks.

Make sure the person responsible for checking knows exactly how to use the system to check for the ADRs (see story, p. X). Don't rely on getting paper notifications any longer, experts urge. Outside of FISS, "there is no other form of provider notification when claims are selected for prepayment or post-payment medical review by the MACs," stresses the National Association for Home Care & Hospice in its newsletter. "Therefore, providers must have processes in place to routinely the check the system for ADR requests and to respond timely."

4. Respond. When you identify your ADRs, just "respond as required," Krafft exhorts.

5. Track timeliness. Responding to the ADR isn't enough. The MAC must receive the response within 45 days, or the claim will be denied. Part of your resolution must be tracking the ADR responses. Following through by deadline is just as important as identifying the ADR and compiling the response, Little notes.

You can use Palmetto GBA's ADR response calculator to confirm your deadline at www.palmetto gba.com/palmetto/toolbox.nsf/ADRcalculator.xsp?LOB=HHH.

Generating a timely, successful response will depend heavily on the interaction between the clinical and billing staff in your organization. "Clean billing involves solid, unfettered communication between the clinical staff and back office," emphasizes Julianne Haydel with Haydel Consulting Services in Baton Rouge, Louisiana. "When this does not occur, ADRs and a million other things slip through the cracks."

6. Address documentation content. Eliminating non-response denials is crucial, but so is defending against denials when you do respond. CMS and the MACs have offered a variety of new tools to help agencies improve their documentation (see story, p. 3).

7. Pay attention to operational details. Be sure you are delivering your response via the method your MAC requires. For example, Palmetto GBA instructs providers to include any electronic documents as PDF or TIFF files, and gives a way to deliver passwords for files in its "Responding to a Home Health ADR Checklist" tool.

8. Leave plenty of time. If you are using snail mail, be sure to give yourself adequate time to meet the 45-day deadline for the MAC to receive it. Send the response "well in advance" of that 45-day mark, NAHC recommends.

9. Consider appeal. Claims denied for ADR non-response aren't necessarily a black mark you must live with, if you move fast, NAHC suggests. "Providers should contact the contractor and request a reopening of claims denied due to no response as soon as possible," the trade group urges. "Contractors have the discretion to reopen these claims if notified within a reasonable time frame. According to the CMS Program Integrity Manual, that time frame is generally within 15 calendar days after the denial date."

Note: CGS's ADR response page, including hospice response checklists and links to additional tools is at www.cgsmedicare.com/hhh/medreview/adr_process.html.