The recent 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 Health’s 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 Contractor’s (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 agency’s data has triggered medical review, and what you can do to ensure compliant billing.

 

Initially, take a close look at your agency’s coding practices, OASIS-C data, case mix weights (both initial and final), and your billing data and practices.

 

There are 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 agency’s data. Diagnosis coding must be accurate and appropriate as must your case-mix weights. Closely review your agency’s 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.

 

Finally, 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 Medicare’s eligibility and coverage criteria.

 

Medical 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.