1. Macon, Jana
  2. Link, Diane MHA, RN

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Q: Our home care agency is getting many additional documentation requests. How do we deal with these?


Answer: With additional documentation requests (ADRs), organizations are required to produce documentation in a timely manner to prevent claims denials or delays. Surprisingly, more than 10% of ADRs are denied because organizations don't submit any documentation. There are other reasons why claims are denied.


Below are 11 tips for success when faced with an ADR:


Familiarize yourself with FISS-The Fiscal Intermediary Standard System (FISS) is where all ADRs, and their due dates, are listed. Pages 7 and 8 are key for finding information related to a specific ADR.


Watch the clock-You'll have 45 days for a Medicare Administrative Contractor (MAC) to receive your documentation. Regardless of the submission method you choose, be cognizant of the time it will take to arrive. Deadlines are strict and exceptions will not be made. Hang on to your proof of submission.


Log your ADRs-Keep a running tab of all the ADRs you receive; when they were received, the date you sent documentation back, date the final determination is made, and what the outcome was.


Be meticulous-Follow MAC's checklist for submission, and make it easy for the representative to review and approve your claim. Insert page numbers and include a cover sheet that highlights key points. Make sure to refer to specific pages for more detail.


Be mindful of HIPAA-If you submit documentation on a compact disc, make sure it is password protected. The last thing you need is to be hit with a Health Insurance Portability and Accountability Act (HIPAA) violation.


Pay attention to trends-Is your organization receiving the same ADR over and over? Consider this an opportunity to improve how documentation is done at the clinician level to ensure future compliance related to a specific ADR.


Know "denial" isn't final-A denied claim isn't necessarily final. You may appeal MAC's decision, but first consider whether there is other documentation you could submit to support your claim, or if there were items you submitted you feel were not considered as part of the decision.


Plan for compliance-


* Prebill reviews: These can be done both on a clinical and billing level. The clinical review seeks to find if documentation provided supports the claim, and the billing review looks to see if there is a visit that matches the dates on the claim.


* Chart audits: These are comprehensive audits that look at whether the major indicators for meeting conditions of participation or condition of payment are met.


* Peer reviews: This type of review is a great learning tool that can identify consistent documentation that concerns ongoing education.



Leverage data and technology-Use your data to identify focus areas for reviews. The goal is for your data to show that you are meeting all criteria related to a specific diagnosis. Consider where documentation is being completed; if it's postpatient visit, the quality of documentation decreases. Agencies that leverage a modern electronic medical record have a greater assurance the patient's record and the agency's record keeping is compliant with the most current regulations.


Establish SMART goals-Create goals associated with these newfound focus areas. Goals should be specific, measureable, attainable, relevant, and timely (SMART). Once you set goals, clearly communicate them with your staff as they are key stakeholders in the final outcome of your claims.


Take action-Your documentation should speak for itself. Ensure staff receives the appropriate training on how to document. Standardizing what each clinician is inputting is key to a streamlined, efficient ADR process and submission.