CMS ADR (Additional Documentation Request)
Responding to a CMS ADR (Additional Documentation Request) Requires Experienced Legal Representation
CMS ADR Team Lead
Former DOJ Attorney
CMS ADR Team Lead
Medicare Audit & Appeals Consultant
Former HHS-OIG Assistant Special Agent-in-Charge
Audit contractors working with the Centers for Medicare and Medicaid Services (CMS) have substantial authority to request documentation from participating providers. Along with requesting access to providers’ files and records during the audit process, these audit contractors can also request documents during prepayment and post-payment reviews by issuing a CMS ADR (Additional Documentation Request).
If you have received a CMS ADR from a Medicare audit contractor, it is important to understand what this means. Fundamentally, it means that your healthcare practice’s or business’s program billings are under review. More importantly, it means that your practice or business may be at risk for significant recoupment liability and/or other billing-related penalties, and this means that you need to engage experienced defense counsel promptly.
What Is a CMS ADR (Additional Documentation Request)?
A CMS ADR is a request for documentation supporting a Medicare-participating provider’s program billings. 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.”
As CMS also explains, ADRs come not from CMS itself, but instead from its Medicare contractors during medical reviews: “Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements. . . [and are performed] by our Medicare medical review contactors through an Additional Documentation Request (ADR).” These contractors are financially incentivized to impose recoupment liability on participating providers under CMS’s fee-for-service program; and, as a result, they will use all of the tools they have at their disposal to uncover alleged overpayments and other Medicare billing violations.
Responding to an Additional Documentation Request from a CMS Contractor
While responding to a CMS ADR can be frustrating and time-consuming, not responding is not an option. Under the Medicare billing regulations, “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, providers need to respond in a timely manner; and, in doing so, they need to ensure that they adequately comply with the ADR while also protecting themselves to the fullest extent possible.
CMS provides some basic guidance for responding to ADRs. For example, CMS advises that it is “best practice” to attach a copy of the ADR to the response to ensure that the audit contractor handles the response appropriately. CMS also 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.”
But, before providers submit documentation to CMS audit contractors in response to ADRs, they must take several steps to protect themselves. These steps include (among others):
- Determine if the CMS ADR complies with all pertinent Medicare regulations;
- Assess all viable grounds for challenging the validity of the ADR;
- Ensure that they have a clear understanding of what additional documentation is (and isn’t) required;
- Understand the risks (if any) of providing the requested documentation; and,
- Carefully evaluate their next steps in light of the risks (if any) presented.
We help our clients take all necessary steps to protect themselves when responding to CMS ADRs, and we communicate with CMS audit contractors on behalf of our clients as well. In many cases, this communication can be critical. Audit contractors will not hesitate to impose recoupment liability and other billing-related penalties if there are any questions regarding a provider’s services and billings—and a proactive approach to dealing with auditors can be crucial for avoiding unnecessary liability (and the need to file a CMS appeal).
What are the risks of complying with a CMS ADR? As noted above, CMS’s audit contractors have substantial authority, and they also have substantial incentives to impose billing-related penalties. If an audit contractor has issued an ADR, this means that the contractor has already identified potential concerns with a provider’s billings. Providing documentation that substantiates these concerns could lead directly to recoupments and other penalties—if the provider does not take adequate steps to protect itself.
Put our highly experienced team on your side
Dr. Nick Oberheiden
Founder
Attorney-at-Law
Lynette S. Byrd
Former DOJ Trial Attorney
Partner
Brian J. Kuester
Former U.S. Attorney
Hon. Kevin McCarthy
55th Speaker, U.S. House of Representatives (ret.)
Government Consultant
Mike Pompeo
Of Counsel
Former U.S. Secretary of State
John W. Sellers
Former Senior DOJ Trial Attorney
Linda Julin McNamara
Federal Appeals Attorney
Nicholas B. Johnson
Former Prosecutor
Roger Bach
Former Special Agent (DOJ)
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Ray Yuen
Former Supervisory Special Agent (FBI)
How We Help Healthcare Providers with CMS ADR Response
We help providers protect themselves when responding to CMS Additional Documentation Requests. While responding may be necessary, providers do not have to (and should not) simply hand over a trove of documents for auditors to sift through and identify purported Medicare billing violations.
We use several means to help our clients avoid unnecessary consequences. Along with guiding our clients through the steps listed above, we also deal with CMS’s audit contractors on each client’s behalf. When our clients’ documentation reflects billing violations, we work to make clear that these violations were inadvertent and isolated, and we work with our clients to proactively update their Medicare compliance policies and procedures to prevent similar violations in the future. When our clients’ documentation demonstrates strict compliance, we make sure that auditors acknowledge this fact, and we oversee the review process to make sure that our clients are not punished without justification.
While many of our clients are able to use their documentation to demonstrate compliance with the Medicare billing rules and regulations, some must confront oversights and mistakes when responding to their CMS ADRs. Crucially, this does not mean simply accepting the consequences an audit contractor chooses to impose. Providers can—and should—play an active role in the review process; and, as counsel for healthcare providers facing prepayment and post-payment reviews, we have had significant success mitigating our clients’ liability while also protecting them against the risk of facing civil or criminal enforcement action.
FAQs: What Do Healthcare Providers Need to Know About CMS ADRs?
Why Did I Receive a CMS ADR (Additional Documentation Request)?
You received a CMS ADR because one of CMS’s audit contractors is looking into your practice’s Medicare billings. More specifically, the audit contractor is seeking additional information to confirm whether one or more of your practice’s billings violate the Medicare billing guidelines. These contractors get paid to hold participating providers accountable for billing fraud, and they often take an aggressive approach to doing so.
The CMS ADR is one of the most powerful tools Medicare auditors have at their disposal. Providers must respond to these requests; and, if they don’t, auditors can deny all claims under investigation. As a result, providers cannot ignore ADRs; and, when responding to these requests, they must be very careful to avoid exposing themselves to unnecessary consequences.
Do I Have to Respond to an Additional Documentation Request from a Medicare Audit Contractor?
Yes, healthcare providers must respond to Additional Documentation Requests from Medicare audit contractors. If they don’t, audit contractors have the authority to deny payment (or seek recoupment liability) for the claims they are scrutinizing. While disclosing documentation that confirms a Medicare billing violation can lead to liability as well, providers can (and should) engage counsel to help them deal with this situation effectively. With a strategic approach, it will be possible to significantly mitigate the consequences of Medicare billing errors in many cases.
How Long Do I Have to Respond to a CMS ADR?
The number of days you have to respond to a CMS ADR depends on two factors: (i) the CMS audit contractor that issued the ADR; and, (ii) whether the contractor is conducting a prepayment or post-payment review. The potential deadlines are as follows:
- Prepayment Reviews By Medicare Administrative Contractors (MACs) – 45 calendar days
- Prepayment Reviews By Unified Program Integrity Contractors (UPICs) – 30 calendar days
- Post-Payment Reviews By MACs, Supplemental Medical Review Contractors (SMRCs), and Recovery Audit Contractors (RACs) – 45 calendar days
- Post-Payment Reviews By UPICs – 30 calendar days
What if I Can’t Meet the Deadline to Respond to a CMS ADR?
Under the federal Medicare regulations, CMS audit contractors can agree to accept late ADR responses “for good cause.” If you are unable to meet your practice’s or business’s ADR response deadline, you should engage counsel promptly to discuss the situation with the audit contractor on your behalf.
What If the Requested Documentation Shows that My Practice or Business Has Overbilled Medicare?
This situation is not uncommon. If your practice or business has inadvertently overbilled Medicare, you are not alone. But, you must handle your situation very carefully. When you contact us, our lawyers can assess your risk, discuss potential strategies and next steps, and represent your practice or business in working toward a favorable resolution.
Discuss Your CMS ADR with a Senior Healthcare Lawyer at Oberheiden P.C.
Have you received a CMS ADR (Additional Documentation Request)? If so, we encourage you to contact us promptly. To speak with a senior healthcare lawyer at Oberheiden P.C. in confidence, call 888-680-1745 or tell us how we can help online today.
