United States

Senior Living Health Care Connection: ADRs' effect on SNFs

SENIOR LIVING HEALTH CARE CONNECTION  | 

There has been a growing number of additional development requests (ADRs) for all health care providers, including skilled nursing facilities (SNFs). Many of these ADRs come from managed care insurers. The amount of information that must be gathered and submitted has added an additional burden on SNF providers. If providers do not submit information in a timely and efficient process, health care dollars will be lost.

The objectives of ADR reviews include:

  • Identification and prevention of inappropriate payments
  • Identification of potential risk to the Medicare trust fund
  • Provider education
  • Appropriate payment for covered services

When a claim is selected for review by a managed care organization or Medicare, medical documentation must be sent to the requesting agency within a specified time frame. Time frames vary between 30 days from the date of the request to 45 or 60 days from the date of the request. Steps to manage these ADRs include the following:

  • Determine who will monitor requests. Some ADRs can be viewed in the Fiscal Intermediary Standard System, some are mailed to the facility and some are posted on the insurer website.
  • Create a spreadsheet to track the ADRs, including patient name, dates of service being reviewed, date of ADR, date of the ADR submission and outcome of review.
  • Create another spreadsheet to provide the interdisciplinary team with a listing of information needed per each discipline (e.g., minimum data set (MDS), activity of daily living (ADL) scores, therapy logs and notes, nursing notes, physician certifications and medications).

The ADR reviewers are focused on items that drive reimbursement. They look specifically at ADL scores, therapy minutes and days, physician SNF certifications, and physician orders to initiate therapy services. Additionally, there is a focus on the MDSs and the accurate timing and submission of these MDSs.

We recommend submitting the document package via the insurer portal if there is one, or via a claim vendor who is set up to transmit the documents, or by downloading them to a disk and then mailing them.

For more information, contact Joan McCarthy at +1 312 634 3479.

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