Question about ADR requests

What is the best way to handle an ADR request for a pre-payment TPE audit issue?


  • Read the request to determine the issue being audited, review the records, be sure all documentation is authenticated, send the record. One common error is to not understand what they are auditing. If they are seeking medical necessity, you need to be sure the notes documenting the indications and previous treatment, if applicable, is in the chart. If it is drug admin, are the MAR and the RN notes present? 
  • I believe once a MAC has posted a TPE audit issue, if this is a service your organization performs, put all Medicare FFS accounts on a pre-billing hold - then conduct a medical record documentation and claim coding and charging detailed review - obtain any needed outside records and query to improve coding and documentation as appropriate and remember to amend records appropriately.  Ensure the entire claim is correct and that documentation proves coverage.  Then when the account(s) are billed and the ADR request comes, you have a high degree of confidence you will be paid and not denied and this also prevents any future audits once the first set of 20-40 accounts is reviewed.
  • I would also recommend bringing TPE audit issues to not only the operational leaders over the area but also their leaders. We have found that to truly make change, if change is needed due to the TPE you need to have operations at the table with you. We have created a TPE task force that has core members from facility billing, professional billing, compliance, clinical revenue integrity, HIM and informatics. We review all incoming TPE requests and identify the appropriate attendees for the new issue. I also found that education at a senior leader level (CFO, CEO) has really helped us get movement with the time sensitivity around changes in documentation or practices.
Sign In to comment.