industry buzz: Additional Development Requests (ADRs) are on the rise,
especially from Palmetto GBA Medicare. We knew this was coming and as an
industry, we have been warned many times. Compliance is Beacon Healths mantra:
Do it right the first time and follow the rules. Many agencies are now reeling
from intense medical review; some have reported having to send in as many as 50
clinical records. One of your Medicare Administrative Contractors (MAC)
primary responsibilities is to identify and correct overpayments and
underpayments. What must be closely examined is why these records are being
requested, why your agencys data has triggered medical review, and what you
can do to ensure compliant billing.
take a close look at your agencys coding practices, OASIS-C data, case mix
weights (both initial and final), and your billing data and practices.
many data components that result from the OASIS alone so your agency staff must
have a comprehensive understanding of the assessment, ensure that it is
accurately completed, and comprehend how/what it contributes to your agencys
data. Diagnosis coding must be accurate and appropriate as must your case-mix
weights. Closely review your agencys service utilization patterns and clinical
documentation. Your service utilization must reflect those that are reasonable
and necessary, and your clinical documentation must support those services from
admission to discharge.
take a long, hard look at your referrals and the supporting documentation for
those referrals. Ensure that you are, in fact, obtaining appropriate
documentation and that you are admitting patients who meet Medicares
eligibility and coverage criteria.
review can turn into probe edits, ZPIC audits or OIG investigation so providers
must take notice. All MACs have resources to assist providers in responding to
ADRs, including checklists.
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