July 22, 2015

Getting Ahead of ADRs: How to Work Smarter and Comply to Requests with Confidence

By Dawn Crump, MA, SSBB, CHC

Known to all who directly or indirectly deal with quality reviews, audits, and denials, additional documentation requests (ADRs) expend huge amounts of staff time, departmental resources, and audit angst. Technical denials and revenue recoupments occur if providers fail to meet ADRs in a timely fashion—or submit incomplete information. Missing documentation also leads to lost claims, and heightened risk for additional compliance reviews and audits down the road. 

Regardless of the provider’s technical capabilities, from rural paper-based practices to huge hospitals wielding state-of-the-art electronic health records, ADRs make their powerful presence known.

ADR Impact is Widespread

For provider personnel involved with the ADR process, it’s all about understanding documentation requirements and executing three main points:

  1. Determine the role of health information management and other departments in filling ADRs.
  2. Ascertain what specific documentation is required for each request.
  3. Compile a list of practical pointers on compiling documentation to avoid technical denials and mitigate future risk. 

The influence of ADRs can be felt through almost every department in a practice or hospital. Those who directly handle ADRs include HIM (health information management) directors, HIM staff, EHR managers, and RAC (recovery audit contractor) coordinators. Many more positions and teams also deal peripherally with ADR-related fallout.

In addition, there are always multiple sources of information to manage. Information that needs to be seamlessly meshed within the patient record may come from the radiology department, operating rooms, rehab facilities or units, pharmacies, and other providers of services. These are just a few possible sources of ADR documentation. 

Cross-platform and stand-alone information systems add to the frustration associated with gathering a complete set of ADR documentation. Often, an intermediary “solution” must be employed to serve as a universal translator, so communication can be achieved among myriad components that may not speak the same language.

One effective strategy is to build specific lists of practical pointers on compiling documentation based on each type of ADR. A thorough review of records prior to submitting to auditors is the best practice to ensure all information is included, and to mitigate risk of technical denial due to missing documentation. Here are four specific documentation items to consider for inclusion in ADR packets:

  • Diagnostic test results supporting medical decisions (admission, procedures, therapy)
  • Documentation that previous treatment options were considered and attempted
  • Physician orders with appropriate signatures
  • Certification statements

If providers hope to bolster defenses against the ADR onslaught, they must know what auditors are looking for now and what they are likely to seek in the future. 

Know What Auditors Want

Claims are usually placed into the “insufficient documentation” category for three reasons:

  • Medical documentation submitted is inadequate to support payment for the services billed.
  • Evidence that allowed services were actually provided, were provided at the level billed, and/or were medically necessary is missing.
  • A specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.

Remember: All requests are not the same. It’s important to know your auditors and what they are auditing. Creating checklists for high-volume/high-dollar services is imperative. To that end, use the following items to help develop your lists:

  • LCD/NCD requirements—Know the LCD (local coverage determination) and NCD (national coverage determination). Be sure to review annually for changes on high-volume procedures.
  • CERT (comprehensive error rate testing) tips guidelines.
  • Medicare billing manuals.
  • Recovery auditor websites.

Missing or insufficient documentation for ADRs is one of the top three reasons for denial. It’s an issue that must be understood and addressed effectively across every provider organization.

Costs of Missing Documentation

Let’s face the facts: Medicare auditors are after all improper payments from all providers. There’s no magic wand for providers to combat this, aside from proactive preparedness and knowledge to minimize mistakes and maximize reimbursement. Here are some facts and costs worth noting:

  • Medicare Modernization Act and Affordable Care Act have components to reduce fraud, waste, and abuse to preserve the Medicare Trust Fund.
  • Though some auditors may focus more on hospitals, the reviews can lead to physician provider reviews.
  • If the inpatient procedure was deemed medically unnecessary, then the corresponding Part B claims may also be deemed medically unnecessary.
  • CERT program cites insufficient documentation for high-percentage of errors.

Medicare fee for services estimates 12.7 percent of claims valued at $45.8 billion in improper payments for fiscal year 2014.

Moreover, when it comes to CERTs, insufficient documentation continues to have a large impact on error rates for Medicare on a national level. The health information provided must demonstrate the medical necessity of the services, support the services billed, and be legible and in proper order—all according to Medicare guidelines.

ROI Rules More Complex, Impact ADR fulfillment

The ADR issue is exacerbated by the fact that rules and regulations regarding release of information (ROI) have grown increasingly complicated over the past several years. This is in part due to the numerous forms included in medical records—from EHRs, archive systems, and paper records, or a combination of these.

It is imperative that all involved directors, managers, and staff members be able to comprehend and execute four basic ADR concepts. To wit, they should:

  • Understand the impact of missed submission of health information.
  • Research tips on how to determine what needs to be included for a request.
  • Troubleshoot missing information.
  • Understand how to create a checklist of information sources for different audit types.

At the end of the day, effectively processing ADRs is all about properly identifying missing documents, streamlining the research of missing information, and making certain the health information that is submitted supports the patient record. These are the keys to getting, and remaining, ahead of the ADR curve.

About the Author

Dawn Crump, MA, SSBB, CHC, has been in the healthcare compliance industry for more than 18 years and joined HealthPort in 2013 as vice president of audit management solutions. Prior to joining HealthPort, Crump was the network director of compliance for SSM. She has healthcare experience in education, organization development, quality improvement, and corporate compliance. She is a former board director of the Greater St. Louis Healthcare Finance Management Association chapter and currently serves as the networking chair. Crump is also a member of the Health Care Compliance Association (HCCA).

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