Additional Documentation Requests (ADR) from Medicare and other payers are hellish and on the rise! In December 2016, SNFs saw a sharp uptick in the number of Part A Post-Pay ADRs for claims from 2015, and reviewers (like Strategic Health Solutions, SCIO, and HDI) have no intention of easing up on their scrutiny of payment accuracy for therapy services.
Why is this happening?
The short story is this – in June of 2015, the Office of the Inspector General (OIG) released findings from study that showed that SNFs were using new MDS PPS assessments (Start of Therapy, End of Therapy, and Change of Therapy Other Medicare Required Assessments) differently when decreasing versus increasing therapy levels, and this cost Medicare $143M for FY2012 and FY2013.
As a result, the OIG told CMS to instruct its contractors to monitor SNF billing for changes in therapy. Specifically, the reviewers were told to identify SNFs that rarely bill for changes in therapy or that frequently use the new therapy assessments incorrectly.
Which brings us to the influx in ADRs in 2016…
Reviewers are looking specifically at SNFs PEPPER for FY2015 to see if your facility is an outlier for the Change of Therapy Assessments (COT). If your facility’s usage of COT Assessments is significantly higher or lower than the national 80th percentile of 17.8%, it sends up a red flag and puts you at high risk for ADRs. For example, if your facility is over using the COT assessment, then it appears to the reviewers that your facility (& rehab provider) are having issues completing therapy as scheduled. If your facility infrequently uses the COT assessment, then MACs and RACs may be led to believe that you are not completing required assessments. You can review your facility SNF PEPPER data here to determine your COT OMRA rate.
Should we live in fear of ADRs?
No! In today’s climate, your facility should expect to receive them, and have a plan to efficiently deal with them and keep your hard earned revenue. Please refer to Attack of the ADRs – Part 2: Additional Documentation Requests – How can we win?! for points about responding to ADRs.
How does your current therapy provider help you anticipate and prepare for upcoming changes in post-acute care? If you are seeking a more collaborative and strategic partner, talk with the team at Therapy Management, Inc. Call us at 248-349-9595 or email carrie@therapy-management.com.
