The MACs officially resumed post-payment medical review of items and services with dates of service prior to March 2020, but may now officially begin conducting post-payment medical reviews for later dates of service. The Targeted Probe and Educate program will restart later per MLN Connects of June 3, 2021. As you prepare for the likely arrival of ADRs, consider these steps for managing the ADR process and reducing risk in key areas of PDPM medical review vulnerability.

Tips for Effective ADR response:

  1. Develop an ADR response process and team. Assign responsibilities for tasks such as, but not limited to: identifying ADR requests, ensuring timely response to deadlines are met, pulling together medical records and documents required to support the HIPPS code, and reviewing the packet for completeness.
  2. Organize the documentation to facilitate ease of review by the contractor. This may include inserting labeled section dividers to identify critical sections of the record (e.g., qualifying hospitalization, admission, physician orders and oversight, therapy, nursing, etc.
  3. Allow sufficient time for staff with clinical and MDS coding expertise to review the claim and documentation for accuracy and to write a defensive brief if possible.
  4. Maintain a copy of the entire packet that was provided to the review entity. This will be helpful in the event that appeals become necessary.
  5. Document and maintain records/receipts of timely submission of the ADR following contractor guidelines.
  6. Maintain an ADR log for all medical review activity. You may use this log to track “error rates” and as a central source of recordkeeping related to claims status. Understanding your own claims denial and payment error rates is important, as this information may be used to guide decisions to extend medical review probes, pull additional claims for review, and even to make decisions to apply extrapolation of error to determine repayment amounts.
  7. Track ADR resolution as either fully favorable, partially favorable or denied with dates.
  8. Follow the Appeals process as indicated. The first appeal (Redetermination) must be completed within 120 days from the date of the initial denial.

Will your coding and documentation withstand Medical Review Scrutiny? Contact Proactive for assistance in ensuring readiness for complex Medical Review, or for assistance in managing ADR response or appeals.

Watch for Part 2 of this article next week focused on Preparing for Medical Review: Overcoming PDPM Vulnerabilities:


Blog by Amie Martin OTR/L, CHC, RAC-CT, MJ, Proactive Medical Review

Learn more about Amie and the rest of the Proactive team.