Navigating Hospice ADRs

Medicare’s Additional Documentation Requests (ADRs) may seem scary and can be a hassle to navigate, but they’re also a great opportunity to ensure and showcase your hospice agency’s awesome care and compliance. By staying organized and with a few simple tips, your agency can easily handle ADRs.

What are ADRs?

Medicare uses ADRs to double-check that your hospice services meet their standards. An ADR is simply a request for additional documents to support a claim you’ve submitted. An ADR is usually not a reflection on your agency and receiving an ADR is a matter of when, not if.

Why ADRs Happen

Medicare uses ADRs to:

A. Confirm that your documentation matches the care provided.

B. Ensure compliance with hospice policies and billing guidelines.

Two Types of ADRs

ADRs can occur in two situations:

1. Pre-Payment ADRs: These happen before Medicare processes your claim for payment.
2. Post-Payment ADRs: These occur after your claim has been paid, as part of a routine review.

In both cases, a timely and accurate response is key to successfully navigating the ADR.

Steps to Take When You Receive an ADR

1. Review the Request Thoroughly:
   • Understand what documents Medicare is requesting.
   • Identify the claim details and dates of service dates under review.
2. Organize the Required Documentation:
   • Gather the necessary documents, such as physician certifications, admission assessments, and plans of care.
   • Ensure documents are legible, signed, and dated appropriately.
3. Check the Submission Deadline:
   • Medicare typically allows 30 days to respond, but some contractors may permit up to 45 days.
   • Set reminders to track the submission timeline.
4. Double-Check for Completeness:
   • Verify that all requested documentation is included.
   • Do not submit the entire chart. To prevent delays, send only the documents listed in the ADR.
5. Submission Methods:
   • If possible, submit documents electronically (e.g., using systems like NGSConnex or FISS/DDE).
   • If mailing, make sure the package is trackable and certified and that your documents are securely packaged and clearly labeled.
6. Track Your Submission:
   • Monitor claim status using Medicare systems to ensure your documentation has been received and is under review.
   • Common statuses include:
     • SB6001: ADR generated; claim under review.
     • SM5REC: Records received; claim being processed.
     • PB9997: Claim approved.
     • DB9997: Claim denied due to missing or incomplete documents.
7. Follow Up:
   • Contact your Medicare Administrative Contractor (MAC) for follow-ups and assistance.
8. Maintain Documentation Records:
   • Keep a copy of all submitted documents for your records in case of follow-up inquiries.

Commonly Requested Documents

Here are some examples of documentation that Medicare commonly requests:

• Physician Certifications: Include initial and recertifications, narratives, and face-to-face visit notes.
• Admission Assessments: Documentation from the patient’s initial evaluation.
• Plans of Care: Clearly outline goals and the interdisciplinary team’s care plan.
• Progress Notes and Orders: Ensure all notes and orders are signed and up-to-date.
• Service Records: Include nursing, therapy, and social work documentation.
• Medication Logs: Provide detailed administration records.
• Discharge or Transfer Records: If applicable, include revocation or transfer documentation.

Tips for Making ADR Responses Easy

1. Get Organized:
   • Keep records organized and in logical order.
   • Double-check that signatures and dates are complete and legible.
2. Be Proactive:
   • Regularly review your claims for potential ADRs.
   • Check PECOS and make sure the information is accurate. If needed, update your correspondence details in PECOS to avoid missing requests.
3. Use Technology to Your Advantage:
   • Your EMR should have an intuitive and logically organized chart storage system.
   • Your EMR should have a robust export feature that allows you to easily export documentation in bulk.
   • Submit documents electronically when possible.

What to Do If a Claim Is Denied

Here’s how to address a denial:

• Double-Check Your Submission: Ensure all requested documents were included and accurately completed.
• Follow Up: Contact your Medicare Administrative Contractor (MAC) if you believe there was an error.

Handling ADRs doesn’t have to be a burden. With a positive attitude, a little preparation, and a focus on organization, your hospice can turn these requests into an opportunity to shine. Stay proactive, keep your team informed, and continue providing the outstanding care your patients deserve.

For more info on ADRs, check out the links below:

• CMS ADR Info
• NGS ADR Info
• NGS ADR Timeline Calculator

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