Consequences of Failure to Respond to Additional Documentation Requests

Consequences of Failure to Respond to Additional Documentation Requests

Supplier standard #28 states the following:

“Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.”

When the DME MACs send out notifications of widespread prepayment reviews, almost always includes the part where suppliers fail to respond.  Here a just a few of the examples of failure to respond to Additional Documentation Requests (ADR):

  • 30% were denied as no documentation was received for oxygen equipment
  • 18% were denied for not responding for group II pressure reducing support surfaces
  • 22% denied as no documentation was received for PAP equipment
  • 15% denied for K0823 PWC as no documentation received
  • 26% of the claims were denied for no documentation received for nebulizer machines
  • 10.08% of K0825 PWC claims received a denial as no documentation was received
  • 16% of K0004 claims received a denial no documentation was received

The only way to get these audits to stop or slow down is for you as a supplier to respond to the ADRs.   The audits will continue as long as the overall error rate is high.  The lack of responding increases the overall error rate which means audits will continue.  Suppliers need to respond even if documentation is missing or does not support the item being billed.

Here are some helpful tips for processing the ADRs:

Ø  Start a spreadsheet that includes at minimum:

§  Date request was received

§  Due date

§  Patient name

§  Reference number

§  Equipment or HCPCs codes being reviewed

§  Date ADR was sent to DME MAC

Ø  Date stamp the ADR as soon as you receive it

Ø  Put an employee or team in charge of processing requests

Ø  Make sure the manager/supervisor receives regular reporting

Ø  Use as education tool for all staff

Ø  Track the results of the requests, did the claim pass or deny, and why

Ø  Flag dates for follow up, if necessary

The supplier industry needs to work together by responding to the Additional Documentation Requests in order to lower these error rates.  You have 45 days to respond to these requests, and timely response is important to avoid delays, denials, and overpayments.  Remember by not responding to these requests could cause further action with the National Supplier Clearinghouse whom is charge of your supplier number.

Please contact US Rehab for more information.

Ronda Buhrmester at 888-665-6518                   Peggy Walker at 800-401-3643