Reviews and audits are never easy nor fun, but they are unfortunately necessary. Such is the case for home health and hospice agencies who must undergo medical reviews and recovery audits to comply with Medicare rules. However, an important step in the review process which most agencies tend to overlook is the Additional Documentation Request or what is commonly known as an ADR. Thus, to help you gain better understanding of what ADRs are and how they affect your Medicare reimbursements, we laid out the following fast facts on this process.
What is an ADR?
An ADR is a request for medical records or documents, generated when a particular claim is selected for a medical review (e.g., Probe and Educate or Targeted Probe and Educate). It can also be raised when a requestor determines additional documentation is necessary to complete a claim. Requestors may be Recovery Audit Contractors, Supplemental Medical Review Contractors, or any other Medicare contractor.
When should an ADR be submitted?
The ADR letter reflects the deadline by which an agency must submit its response. It is important you comply with the stated timeline since not responding will result in partial or total claim denials which mean insufficient or zero reimbursements for your agency.
How often can an agency receive an ADR?
Each provider has a baseline annual limit to the ADRs they receive which is determined based on the number of claims linked to their CMS Certification Number (CCN) and National Provider Identifier (NPI) that were paid in the last twelve months. One half of one percent (0.5%) of your submitted and paid claims equates to your baseline annual ADR limit. This is then divided by eight to calculate your ADR cycle limit which refers to the maximum number of claims that can be included in a single 45-day period (usual ADR cycle). However, if your ADR cycle limit is below 1, it will be automatically rounded up to 1 ADR per 45 days up until your annual ADR limit is reached.
What type of claims are subject to an ADR?
Any claim submitted to Medicare may be subject to an ADR. However, a claim is more likely to be selected if its elements match the audit or review parameters. It should be noted that ADRs may be raised for both prepayment and post-payment reviews.
What does the ADR letter contain?
The ADR letter usually contains the list of items billed on the claim you submitted as well as the corresponding documentation necessary to validate that these items comply with Medicare regulations. The letter also reflects options on how you can submit the documents to the requestor.
Prior to responding to an ADR letter, it is critical your agency understands what documents are being requested and when they should be submitted. Make sure you submit the complete set of documents in one response to the correct requestor, as identified in the letter. For multiple claims subject to an ADR, send separate responses for each claim for proper monitoring. Make the ADR letter the cover sheet to your response and only submit clear copies of the requested documents as Medicare contractors are not obliged to return original submitted documents.
Data Soft Logic, as your Intelligent Care Partner, can help you stay ADR-ready at all times with Home Health Centre and Hospice Centre, the software solutions designed for your complete home health and hospice agency workflow. To know more about how we can support you through reviews and audits, schedule a demo with us.
