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CMS Additional Document Requests (ADRs)

Medicare Participants Must Be Extremely Careful When Responding to a CMS Additional Document Request (ADR)

Medicare-participating healthcare providers and companies are subject to the oversight of the Center for Medicare and Medicaid Services’ (CMS) fee-for-service contractors. These contractors have substantial authority to enforce the Medicare billing rules by conducting invasive prepayment and post-payment reviews, demanding recoupments, and imposing other penalties on CMS’s behalf.

When examining Medicare participants’ billing records during prepayment and post-payment reviews, contractors will often require additional information. When this is the case, they can issue CMS Additional Document Requests (ADRs). While necessary, responding to a CMS ADR can present substantial risks—and this means that targeted providers and companies must proceed cautiously.

What Is a CMS Additional Document Request (ADR)?

In today’s world, CMS’s audit contractors do much of their work remotely. They have direct access to Medicare participants’ billing data through CMS, and they rely on software to identify potential issues with providers’ and companies’ billings under Medicare Parts A, B, C, and D.

But, in some circumstances, reviewing a Medicare participant’s billing data won’t provide adequate insights to make a determination regarding compliance. When a CMS audit contractor needs to dig deeper, it can do so by issuing a CMS ADR. As CMS explains:

“An additional documentation request (ADR) is generated when documentation is necessary to support a Medicare claim. This request is for medical record documentation to support payment of an item(s) or service(s) reported on the claim to ensure compliance with Medicare’s coverage, coding, payment and billing policies.”

Since CMS’s audit contractors have financial incentives to uncover underpayments, and since issuing a CMS ADR is fairly simple, contractors do not hesitate to issue these additional document requests to Medicare participants. But, while issuing a CMS ADR may be fairly simple, responding to one is anything but—and the consequences of making mistakes when responding can be substantial. Determinations of billing fraud (both intentional and unintentional) can lead to payment denials, recoupment demands, and other penalties, and they can even trigger federal healthcare fraud investigations in some cases.

Responding to a CMS ADR During a Medical Review

With this in mind, Medicare participants that receive CMS ADRs need to be very careful. Submitting a response is mandatory; and, under the Medicare billing rules, “if a contractor gives a provider or supplier notice and time to respond to an additional documentation request and the provider or supplier does not provide the additional documentation in a timely manner, the contractor has authority to deny the claim.”

As a result, ignoring a CMS ADR is not an option. But, choosing the right way to respond to a CMS ADR requires a clear understanding not only of the relevant Medicare billing rules, but also of the circumstances at hand. Auditors can—and frequently do—overreach, and submitting documentation that your practice or company isn’t required to submit can create unnecessary risk exposure.

So, how should you respond to a CMS ADR? While circumstances vary, we generally take the following steps when advising clients that have received CMS ADRs during healthcare audits:

  • Evaluating the CMS ADR for Compliance and Assessing Its Scope – Upon receiving a CMS ADR, the first step is to evaluate the additional document request thoroughly. Does it comply with the rules and restrictions that CMS’s auditors are obliged to follow? If not, how is it deficient, and what are the implications of these deficiencies? What is the scope of the CMS ADR, and what are the risks involved with compliance?
  • Assisting with Preservation and Collection of Responsive Records – Complying with a CMS ADR can require a substantial undertaking. Upon receiving CMS ADRs, Medicare participants must promptly take the necessary steps to preserve all responsive documents, and they should take a systematic approach to collecting records for submission.
  • Providing Advice Regarding CMS’s Best Practices for Responding to an ADR (As Warranted) – While CMS does not issue ADRs directly, it has published some best practices for CMS ADR response. For example, CMS notes that providers should “submit the necessary documentation to support the services for the billing period being reviewed,” and clarifies that this “may include documentation that is prior to the review period.” We help our clients comply with CMS’s recommendations to the extent warranted.
  • Preparing and Submitting a Compliant CMS ADR Response to the Auditor – We assist our clients with preparing and submitting compliant CMS ADR responses. Depending on the circumstances, this may involve 100% compliance, or it may involve communicating with the auditor to address flaws, ambiguities, or other deficiencies in the additional document request and then complying with a revised (and more limited) request.
  • Determining Risks and Next Steps – In parallel with assisting our clients with their CMS ADR responses, we also assess our clients’ risks and advise them regarding their next steps. If the audit has the potential to result in payment denials, recoupments, or other penalties, additional steps will be necessary to mitigate the consequences of the audit to the fullest extent possible.

How We Help Medicare Participants That Are Facing CMS ADRs

At Fortis, our team members rely on extensive experience on both sides of Medicare compliance matters to help Medicare participants make informed decisions during prepayment and post-payment reviews. This includes making informed decisions about how to respond to CMS ADRs. Since many of our consultants previously served in high-ranking positions in federal healthcare fraud enforcement, we are intimately familiar with the risks that audits present. As a result, we know what you have at stake if you have received a CMS ADR, and we can do what is necessary to help you avoid costly mistakes and unnecessary consequences.

Here are just some of the ways we can help if you have received a CMS ADR:

  • Informed Decision-Making – Our former federal agents will help you make informed decisions about how to respond to your CMS ADR and how to address all other aspects of its prepayment or post-payment review.
  • Strategic Advice – We will give you strategic advice about how to respond to your CMS ADR, including advice on whether to challenge the ADR and how to implement a plan for timely compliance.
  • Proactive Response – We will assist you with responding to your CMS ADR proactively—anticipating and addressing any concerns up front so that they don’t lead to unnecessary complications.
  • Risk Mitigation – If your practice or company is at risk for payment denials, recoupments, or other penalties, we will help you take the steps necessary to mitigate the costs of the audit.
  • Forward-Thinking Approach – Throughout the process, we will advise and assist you with a focus on the future, and we will help put your practice or company in a position to avoid similar inquiries going forward.

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FAQs: Responding to an Additional Document Request from a CMS Contractor

Why Have I Received a CMS Additional Document Request (CMS ADR)?

If you have received an additional document request from a CMS audit contractor, this means that the contractor is looking into your practice’s or company’s Medicare billing history. These inquiries can present serious risks for Medicare participants, including the risk for Medicare exclusion in some cases.

Do I Have to Respond to a CMS ADR from a Medicare Audit Contractor?

Yes, responding to a CMS ADR from a Medicare audit contractor is mandatory. Failure to respond can lead to denial of pending claims—and it will raise red flags that will most likely lead to additional scrutiny. However, a cautious response is critical, as sharing records that expose Medicare violations can also be very costly.

How Long Do I Have to Respond to a CMS ADR from a Medicare Audit Contractor?

The amount of time you have to respond to a CMS ADR depends on which type of Medicare audit contractor issued the request. For example, while Medicare participants generally have 45 days to respond to CMS ADRs from Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Supplemental Medical Review Contractors (SMRCs), the deadline for responding to CMS ADRs from Unified Program Integrity Contractors (UPICs) is typically just 30 days.

Can I Get an Extension to Respond to a CMS ADR?

While Medicare audit contractors may extend response deadlines “for good cause,” you should not rely on receiving an extension to respond to your practice’s or company’s CMS ADR. Instead, you should focus on developing a strategic plan to submit a timely response; and, if you receive an extension, then you can adjust your plan accordingly.

What if the Records Requested in a CMS ADR Show that My Practice or Company Has Overbilled Medicare?

If the records requested in a CMS ADR show that your practice or company has overbilled Medicare, you will need to factor this into your response. At Fortis, we can help you make informed decisions about how best to move forward, and we can assist you with addressing any historical billing violations as necessary.

Schedule an Appointment with a CMS ADR Consultant at Fortis

If you need to know more about responding to a CMS ADR from a Medicare audit contractor, we invite you to schedule an appointment at Fortis. To speak with a senior CMS ADR consultant in confidence, please call 866-808-4160 or request a complimentary consultation online today.

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