This year, many hospice organizations have faced an influx of ADRs, also known as an Additional Document Request, creating many administrative and financial disruptions. The Centers for Medicare and Medicaid Services (CMS) and its contractors are turning over every leaf to ensure hospice agencies are meeting regulatory compliance while providing their beneficiaries with effective palliative care.

ADRs are issued for the purpose of reviewing documentation for errors and inconsistencies in claims or when additional documentation is needed to complete the claim. These reviews focus on technical aspects of the claim such as signatures, quality of the documentation, diagnosis coding accuracy, and more. The groups that manage these reviews are called Supplemental Medical Review Contractors (SMRC). The overall goal is to determine if overpayments are happening and to protect the Medicare Trust Fund.

ADR and SMRC Process Trends

With many restrictions in place in 2020 due to the COVID-19 Public Health Emergency, SMRCs resumed a more consistent level of activities by 2021.  Since reviews have been reinstated, auditing has increased in volume both on and off-site. As hospices nationwide are seeing an increase in claims being reviewed – many questions have been raised – Is CMS and its contractors making up for lost time? We’ve outlined the top reasons for ADRs that could put hospice organizations at risk.

  • Certificate of Terminal Illness (CTI): A common trend identified recently is denial of a hospice claim based on the CTI. This is not due to untimeliness or missing components, but rather the quality and content of the narrative to provide support for the terminal illness.
  • Medical Necessity: The reviewers are now drilling down into the content of the clinical records, arguing the necessity of the care. The palliation the beneficiary receives should be medically reasonable as it relates to the patient’s condition.  Every visit performed by all disciplines must have documentation for the visit to stand alone. This means that an auditor can review a randomly chosen visit note and should be able to identify the skilled service performed, the reason the skilled service is necessary, and the patient’s response to the individualized care.
  • Care Plan: A large component of ineligible claims comes from the hospice not providing evidence of a detailed, individualized, and goal-driven care plan. It is simply not enough to state “continue care plan” in any note. Reviewers are looking for personalized, realistic interventions and goals provided to the beneficiaries.
  • Templates: With software developers being tasked with creating universal types of hospice electronic medical records programs (EMR), they are limited with how varied they can create templates. Care plans and documentation templates or checkboxes should always be utilized as guidelines only and followed by narrative notes to support selections. There is no cookie-cutter or template-based process for documenting medical necessity as each patient presents unique goals, intervention needs, and outcomes.

To date, trends this year are focused on the quality of the narratives themselves, not just the technical aspects such as a late or missing signature.  Denial reasons given may be especially geared toward a longer length of stay for specific lack of changes.  This creates an extreme challenge for hospices to face, as there are often periods of plateau during a long-term illness.

Our Approach to ADRs

McBee clinical compliance experts have crafted a diligent process of handling ADRs and SMRC appeals. With the ever-changing landscape of the health industry, keeping informed of the techniques that are most effective at mitigating loss and revenue recovery is key.

Timely and effective responses

Time can be at the top of the list of challenges for busy hospice agencies when ADRs arrive. Having the ability to allocate staff to handle such a large and important task can take away from daily operations. Also, as the clock ticks, so does the ability of CMS to charge interest over and above the claim amounts if the final finding is not favorable. Filing an effective ADR or appeal depends on the following process points:

  • Access
  • Organize
  • Analyze
  • Appeal
  • Support
  • Final Product

Create a Good Argument

Developing a strong argument is key.  Appeals that are too lengthy or contain formatting issues can affect how it may be considered. Developing work that is clear, concise, and evidence driven is highly effective.  Creating citations and adhering closely to Local Coverage Determination guidelines set by CMS gives the reviewer the knowledge that you have kept the guidelines in the forefront of your patient centered care.

Tip: Utilize the SWOT method when reviewing and developing your appeals.

Uniformity and Teamwork

Successful appeals rely on effective teamwork. In appeals, we often ask ourselves questions such as, “Does the argument fulfill all the requirements and specifically address the denial comments? Are there supporting documents present? If not, can I obtain them?” There are a lot of moving parts partnering with a consulting firm, like McBee. We help your team develop a proactive review process and strategy to ensure that all supporting clinical documentation is present prior to billing. A dynamic partnership aims to respond quickly to ADRs, craft winning appeals for denied claims, and go a step further to engrain pre-bill review best practices into the culture.

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