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Medicare Compliance & Reimbursement

Home Health Reimbursement:

Use This ADR Tool To Hang Onto Reimbursement That's Yours

Published on Mon Apr 09, 2012

Providers pass on OIG's second chance to submit medical records.

You have most likely heard the phrase "if it wasn't documented, it wasn't done" so many times that it's old hat. And yet, insufficient and missing documentation remains one of the biggest denial reasons among Medicare contractors.

The HHS Office of Inspector General tried to improve upon that denial rate by offering providers a second chance to turn in required documentation, a new OIG report says. But the majority passed on the offer, leaving contractors no choice but to request a refund of the money that providers had received for those services.

Background: When CERT (Comprehensive Error Rate Testing) reviewers find that Medicare paid for claims that are missing documentation, CERT reviewers contact providers up to three times to request complete documentation to support the claims. In cases when the documentation is not sufficient, the providers have to return the money to the Medicare program.

Following a review of the 2010 CERT results, which featured a 10.5 percent error rate (totaling $34.3 billion), the OIG offered providers yet another chance to send in required documentation to support their claims. However, only 34 percent of providers the OIG contacted submitted additional documentation that allowed the CERT contractor to overturn its claim payment denials. The remaining 66 percent of providers did not submit documentation that supported the medical necessity of their claims, which meant they forfeited the reimbursement they had received for those services.

Although the 34 percent that did resubmit documentation allowed the OIG to calculate a lower claims error rate than the original CERT report, the fact that less than half of providers submitted documentation to support their claims should be a wakeup call.

Failing to respond to additional development requests persists as a top denial reason for Home Health and Hospice Medicare Administrative Contractors. Recently it ranked as HHH MAC Palmetto GBA's number-two denial reason.

HHH MAC NHIC reports that it often gets late documentation that can't be considered for review. "In one situation, our Medical Review (MR) department is receiving ... the ADR and medical documentation together, and several days later we are receiving additional documentation for the same claim," NHIC says in a message to providers. "All supporting medical documentation should be sent at the same time with the ADR."

Bottom line: "To prevent any unnecessary denials, when responding to an ADR, submit all appropriate medical documentation along with the ADR," NHIC instructs.

Note: An NHIC tool with advice on responding correctly to ADRs is at www.medicarenhic.com/Providers/MR_Key_Points.shtml. The OIG CERT report is at http://oig.hhs.gov/oas/reports/region10/11100502.pdf.

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