Are you prepared for CMS’ Targeted Probe and Educate Reviews? Did you know that starting this fall you could be sent ADR requests for 20 – 40 claims?

Round two of the 5 ADR Probe and Educate reviews is winding down in September, but most agencies are not out of the woods. The MACs are gearing up for Targeted Probe and Educate.
How do you know if your agency is on the Targeted Probe and Educate list? You are if you:
  1. Received two (2) or more denials during the five (5) ADR Probe and Educate.
  2. Received denials, but failed to participate in the education offered.
  3. Responded to the ADR requests, but failed to show improvement.
  4. 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.

What will happen if your agency is targeted? What do you do?
  1. Your MAC will send ADR requests for 20-40 charts – respond promptly.
  2.  After each review, education will be offered – participate in the program offered.
  3. Agencies that fail to show improvement will be referred to CMS for additional action, which might include:
    1. 100% pre-pay review.
    2. Extrapolation of findings to all claims.ADR and QIRT (1)
    3. Referral to a RAC or other auditing body.
Good news! Low error rates or “sufficient improvement in error rates” may get your agency off the hook for future audits.
QIRT’s best advice:
Contract with experts to complete your Targeted Probe and Educate, to ensure:
  1. Prompt and proper compliance with ADR requests.
  2. Full and proper payment of claims.
  3. Minimal impact on agency productivity – QIRT has processed thousands of ADRs, we know what we’re doing.
  4. Expert attention to the many moving parts of ADR response.
  5. You continue to focus on your agency’s most important work: patient care.
Have more questions? Join us for a full day seminar on ADRs. QIRT.com/Trainings
Or call 855.485.QIRT 
October Seminar:
Prepare for CMS’s Probe and Educate:
The ADR to Appeal Primer
Review and appeal processes can be overwhelming. QIRT can help. Join QIRT’s industry-renowned expert Joe Osentoski in Oak Brook, IL, for a simplified ADR explanation.
About our expert:

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 representJoe Osentoski.jpgatives 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)

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