There are times when Medicare will need additional information in order to determine whether or not to pay for a claim. This request for information is referred to as an additional documentation request or ADR. Each request must contain certain information and provide the doctor with a minimum amount of time to respond to the request. The Medicare regulations have specific requirements that reviewers need to meet in order for an ADR to be legitimate.
Understanding Records Reviews
The first thing we need to establish is what a records review is and who, exactly, can request records from you or your office. According to the Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.1(A):
“Medical record review involves requesting, receiving, and reviewing medical documentation associated with a claim. Medical record review, for the purpose of determining medical necessity, requires a licensed medical professional to use clinical review judgment to evaluate medical record documentation.”
There are four entities within Medicare that can make an ADR:
These contractors vary in severity. A request from a CERT contractor is pure luck of the draw and has little to no risk of consequences for the doctor. A request from a MAC is what you will most commonly experience, and the risk is a denial of the claim and no payment. RAC contractors are not currently focused on chiropractic. They are paid based on a percentage of the amount they recover and, quite frankly, chiropractors do not make enough to be of interest to them.
A request from a UPIC contractor should cause alarms to go off in your head. UPICs investigate fraud allegations and if they are requesting records, then you are under investigation. You have a problem and need to get help as soon as possible.
Who Can Review Your Records?
Next, we need to look at who can review your records. Remember, “medical records review requires a licensed medical professional.” Who is included in that classification? According to the Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.1(C):
“The MACs, MRAC, and CERT shall ensure that medical record reviews for the purpose of making coverage determinations are performed by licensed nurses (RNs), therapists or physicians. UPICs, RACs and the SMRC [supplemental medical review contractor] shall ensure that the credentials of their reviewers are consistent with the requirements in their respective SOWs (Statement of Work). During a medical record review, nurse and physician reviewers may call upon other health care professionals (e.g., dieticians or physician specialists) for advice. The MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy).”
The great majority of the time, a licensed registered nurse is the one reviewing your documentation. This puts us, as chiropractors, at a disadvantage because most registered nurses do not know a lot about chiropractic.
Mandatory Elements of an ADR
When you receive a written request for additional documentation for review, it seems like there is a lot of unnecessary wording in the letter. This is because the contents of those requests are dictated by Medicare regulations. According to the Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.4, the ADR must contain the following:
Introductory Paragraph: Note CMS as the government agency making the request; the program making the request (e.g. the MAC program, SMRC program, Recovery Audit Program, or CERT program); and the regulations and/or laws that apply to the request.
The first paragraph in the ADR may identify the following: the program’s purpose; where additional information about the program and regulations can be found (for example, a website reference); and any additional program information that may be helpful to the provider or supplier.
Reason for Selection: The reason the provider or supplier was sent the ADR letter and notes about the claims under review.
Action: The action(s) the provider or supplier shall take as a result of receiving the ADR letter.
When: The date a provider / supplier shall reply to the ADR letter and submit the documentation to the contractor.
Consequences: The consequences if the provider or supplier fails to submit the requested documentation.
Instructions: Any instructions and notes that will help the provider or supplier respond to the ADR letter.
Submission Methods: The methods by which the provider or supplier can submit the requested documentation.
Questions: Contractor contact information for provider inquiries related to the ADR.
Attachments / Supplementary Information: If there are attachments or other supplementary information associated with the ADR, provide a listing of the attachment titles or provide the supplementary information.
Know Your Rights
The request for documentation is not supposed to be unnecessarily burdensome to the doctor or the office. The Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.4 notes these general considerations:
“The MAC shall use discretion to ensure that the amount of medical documentation requested does not negatively impact the provider’s ability to provide care. The MACs, CERT, SMRCs, and Recovery Auditors, shall request records related to the claim(s) being reviewed and have the discretion to collect documentation related to the beneficiary’s condition before and after a service. The MACs, Recovery Auditors, and SMRCs have the discretion to issue as many reminder notices as they deem appropriate. Reminder notices can be issued via email, letter, or phone call. The MACs, Recovery Auditors, and SMRCs shall not target their ADRs to providers based solely on the provider’s electronic health record status or chosen method of submitting records.”
If you find that the request is placing an exceptional burden on you or your office, then contact the office making the request and ask for additional time.
Editor’s Note: Dr. Short continues his discussion with pt. 2 of this article in the October issue.
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