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I Received an Audit Letter! Now What Do I Do?

Written by: Guest Author on Monday, June 29, 2015 Posted in: HME/DME


by Mary Ellen Conway

Administrative law judges reportedly receive 16,000 audit appeals weekly. Here’s how you can avoid getting caught in the backlog.

For every home care business that serves Medicare recipients, the likelihood of some type of audit is high. In the Centers for Medicare and Medicaid Services’ (CMS) quest to detect and prevent fraud and abuse, many legitimate claims are scrutinized, so rest assured that you are not alone in receiving an “additional documentation request” (ADR) letter.

In fact, during a Congressional hearing in July 2014, Chief Administrative Law Judge Nancy J. Griswold told a Subcommittee on Energy Policy, Health Care and Entitlements that administrative law judges are receiving approximately 16,000 audit appeals weekly. This has created an overwhelming backlog, which means that DMEPOS suppliers are sometimes waiting years for resolution and, in the meantime, not being paid. Rep. Tammy Duckworth (D-Ill.) noted during the hearing that more than 100 orthotics and prosthetics suppliers had gone out of business while waiting for CMS payments that had been delayed during the appeal process.

If you’ve been vigilant with your documentation, then you should be able to withstand the audit onslaught. So get started on your response right away. And use these tips for assembling your documentation and developing a complete and effective response to the dreaded ADR letter.

Double-check for errors

The ADR letter, essentially an audit notification, will specify which claims are being audited and outline the documentation you need to provide. In most cases, you only have about 30 days to respond, so make this project a priority, and start gathering and requesting documentation right away.

Before you assemble your response packet, check all your documentation, and look out for these common compliance errors and be sure you can fix them.


Assemble your response packet

Once you have collected all the paperwork needed to support your claim, make two sets of copies of everything you are sending. Keep one set for yourself, so you know exactly what each packet contained.

Follow these eight steps—supplied by Mary Ellen Conway, RN, BSN, president of Capital Healthcare Group, LLC—for assembling and submitting your responses.

  • Include a cover letter explaining that you are replying to their request. Include in the cover letter the telephone number auditors should use to contact you or your representative if any questions arise.
  • Include a copy of the ADR letter as the first sheet in each packet.
  • Write an individual summary of each record, detailing the medical issues addressed in your documents; include the patient’s name, date of birth, HIC number, medical condition, prescribers’ names, etc., and discuss what will be found in the enclosed documents.
  • If anything in the ADR is not included, mention that in the written summary. For example, if physician documentation doesn’t arrive in a timely manner, note that physician documentation is lacking but will be forwarded when it becomes available.
  • Assemble the documents in the order listed on the ADR, and put each file in the same order.
  • Pack into an appropriate box with a list of all records contained in each box.
  • Keep copies of everything sent.
  • Send via any method with return receipt that will ensure delivery at least one day prior to your deadline.

For more of Mary Ellen Conway’s audit insights, listen to our recorded webinar, Putting the Breakes on a Medicare Audit. Find out home Mediware also addresses audits, click here for more information.

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