Understanding Additional Development Requests (ADRs) and How to Respond to Them

Transcription

1 Understanding Additional Development Requests (ADRs) and How to Respond to Them May 1, 2014

2 Today s Presenter Corrinne Ball, RN, CPC, CAC Provider Outreach and Education Consultant 2

3 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at 3

4 Objective To provide information on the progressive corrective action process 4

5 Agenda What is the PCA Process? Types of Audits PCA Methodology Quality Process Q & A 5

6 PCA Process Why do contractors have a PCA process? CMS requirement To reduce payment errors 6

7 Objectives Identify and prevent inappropriate payment Identify potential risk to the Medicare trust fund Educate providers Appropriately pay for covered services 7

8 Types of Medical Review Probes Service-Specific Probes Edits select claims for specific service review Providers are notified by additional development requests (ADR) Undetermined number of claims requested Providers may not receive a results letter 8

9 Types of Medical Review Probes Provider-Specific Probes Providers will be notified when they have been selected for this review Edits select claims for specific providers flagged by data May be either post-pay or pre-pay claims Detailed provider-specific results letter Usually request claims for review 9

10 Target Medical Review Continuous ongoing review Probe results letter will identify your percentage of claims reviewed Probe denial rate determines percentage of claims reviewed Quarterly results letter Payment Error Rate 15% or less to be released 10

11 PCA Methodology Data analysis Validation Calculation Corrective actions Reevaluation 11

12 Data Analysis Trends Patterns Utilization Billing comparison to peers Billing comparison to national data 12

13 Responding to an ADR CMS requires providers to respond to an ADR within 30 days from the date the additional development request was generated 45 th day after ADR generated = full claim denial Support all services/dates requested 13

14 Validation What does Medical Review look for? Technical Physician orders Physician Certifications/Re-certifications (when applicable) Eligibility Medicare coverage guidelines Medical necessity Documentation supports the services billed 60 days to review records 14

15 Calculations Payment Error Rate Claims Error Rate Service Error Rate 15

16 Corrective Action Provider-specific results letter Providers who are on targeted medical review or providerspecific probes Web articles Results from wide-spread probes Education referral Corrective Action Plan Benefit integrity 16

17 17 Quality Processes

18 Part A Providers May Track The ADR in The FISS System SB6001 claim suspend for ADR 30 days to respond to an ADR with documentation SM5REC claim moved to a medical review location Medical review has 60 days to adjudicate the claim SM5RAC claim suspend for RA audit PB Claim paid DB Claim denied Claim denied, records requested were not received 18

19 Part B Providers Denial reason code 692- records not received Contact the Part B Provider Contact Center TTY: Submit an appeal 19

20 Quality Review Your Documentation Respond to ADRs within 30 days Documentation Legible Copy both sides Signatures and dates Electronic Health Record check the print view Do not bind records together Do not highlight records Do not attach sticky notes or tabs Attach ADR request on the top of the appropriate records 20

21 Quality Review Your Documentation Organize your records Paginate your records Quality review your documentation May send a cover letter All information in the cover letter must be substantiated in the medical records 21

22 22 Questions & Answers

23 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic = <Insert course name/delete arrows> Medicare University Credits (MUCs) = # Catalog Number = <Insert catalog number> Course Code = <Enter course code> For step-by-step instructions on self-reporting please visit > Medicare University > Accessing the Self-Reporting Tool 23

24 24 Thank You!