We are well into 2013 and moving along with the manual medical review by the RACs for claims over the $3,700 threshold.  Where do you stand?  Have you received ADRs as a result of being over the $3,700 threshold?  Did you know where to send in the documentation to? Do you know the time frame for submitting the ADR documentation packet?  Was the ADR notice confusing?  Did you get a response regarding the outcome of the ADR?  I am asking you all of these questions because that seems to be the chatter in the industry—confusing and in limbo.

Providers have reported that they are not receiving the ADR via US mail, they are finding them online in the DDE system.  Other providers report that the ADR letters are confusing because both the MAC and RAC mailing addresses are at the bottom of the ADR notice and providers don’t know where to send the ADR packet to.  When they call the MAC, the MAC is telling providers to send the ADR packet to both the MAC and to the RAC.  But when they call the RAC, the RAC is saying that they are the only ones who should be receiving the ADR packet.  In addition, providers report that the time frame in submitting the ADR packet is confusing: 14 days for a non-medical claim versus 30 days for a medical claim yet the ADR notice doesn’t inform the provider which type of claim is being reviewed (non-medical versus medical).

Some providers report that they are receiving duplicate ADRs.

Then there are providers who report that they have claims above $3,700 that are in “suspense status”…the claims are just sitting there with the MAC and haven’t been released to ADR—does this sound like a delay tactic?   So those claims that are in ‘suspense status’ haven’t been released for ADR and the provider cannot do anything until the claim goes into ADR and notice is received.  If these providers are in a demonstration pre-payment review state, this could have a negative impact on cash flow.  What does one of the MACs say about this?  Well one MAC representative states the claims are sitting in a “holding queue” for the RACs to pull for medical review.  Nationwide, there are 20,000 claims sitting in this “holding queue”.  In addition, the RACs are randomly releasing 200 claims per day to the ADR location.  And to make matters worse, there was no timeframe given with the claims will be released from the queue!

What is supposed to happen is the provider will receive an ADR notification when the claim is over $3,700 and are to send the documentation to the RAC unless otherwise specified by the MAC.  In pre-payment demonstration states, the RAC has 10 days to review and provide the MAC with a payment decision.  Then the MAC is supposed to communicate that payment decision with the provider.  For those in non-demonstration states, they will be under post-payment review and the 10 day payment decision turn around time to the MAC isn’t in effect because the provider should have been paid.

So what is a provider to do?  We recommend being proactive and not letting your guard down!  Some proactive steps to be considered:

  1. Develop a process for the business office manager to review CMS’ database and look at the status of your claims
  2. Consider a ADR/Denials team in your facility
  3. Ensure your key facility staff understand the difference between an ADR and a denial
  4. Ensure your key facility staff are aware of the time limitations for submission
  5. Thoroughly read the entire ADR notice and act quickly to any ADR notices you receive
  6. Keep a copy of what you sent in for review
  7. Make sure you send in all pertinent clinical documentation to support the claim
  8. Partner with your on-site therapy manager to assist in reviewing the therapy documentation prior to sending the ADR packet to the RAC

The nightmare we experienced in Q4 of 2012 was horrible enough and some providers are still dealing with the denials and going through the lengthy appeal process.  As 2013 continues, our industry anticipates more and more issues with the RACs being effective in managing the flow of manual medical review process.

Gina Tomcsik

Director of Compliance

Functional Pathways