- Received two (2) or more denials during the five (5) ADR Probe and Educate.
- Received denials, but failed to participate in the education offered.
- Responded to the ADR requests, but failed to show improvement.
- Failed to respond to the 5 ADR request (along with more than half of all agencies).
Good news! These claims are not a lost cause. If you have denials with Reason Code 56900 and you are within the 120-day response window, QIRT can help you comply with these ADR requests. No response results in a guaranteed loss, but if you respond you still have a chance of payment.
- Your MAC will send ADR requests for 20-40 charts – respond promptly.
- After each review, education will be offered – participate in the program offered.
- Agencies that fail to show improvement will be referred to CMS for additional action, which might include:
- 100% pre-pay review.
- Extrapolation of findings to all claims.
- Referral to a RAC or other auditing body.
- Prompt and proper compliance with ADR requests.
- Full and proper payment of claims.
- Minimal impact on agency productivity – QIRT has processed thousands of ADRs, we know what we’re doing.
- Expert attention to the many moving parts of ADR response.
- You continue to focus on your agency’s most important work: patient care.
QIRT’s Director of Regulatory Reimbursement and Appeals Development is Joe Osentoski, BAS, RN-BC. With 20+ years’ experience, Joe has completed thousands of ADRs/appeals and hundreds of ALJ hearings dealing with all OMHA offices.
“Mr. Osentoski was one of the first non-attorney representatives to appear before me when I was an ALJ, and he stands head and shoulders above every other non-attorney representative. Mr. Osentoski…knows home health law, and prepares thoroughly. His credibility is beyond reproach.” ISBN 978-1-4834-5221-0. From “How to Handle Your Medicare Hearing” by retired US Administrative Law Judge Robert Soltis; Chapter 39, Recommended Representatives (p.140)