Many Medicare overpayment determinations begin the same way: with an Additional Documentation Request (ADR). An ADR asks the provider to produce the medical records supporting specific claims that a CMS contractor has selected for review.

An ADR may come from any of several CMS contractors, including Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Unified Program Integrity Contractors (UPICs). Federal oversight bodies, including the HHS Office of Inspector General (OIG), have identified skin substitute services as a significant fraud, waste, and abuse concern, and contractors have increased their review of wound care claims as a result.

Because ADR deadlines are short, providers should act quickly. Response periods vary by contractor and review type, and many UPIC requests allow only 30 calendar days. Providers should confirm the deadline stated in the letter as soon as it arrives and, if more time is needed, request an extension in writing before the deadline passes. A late response, or no response at all, can be costly. Without the requested records, the contractor may deny every claim under review, producing a 100% error rate. If the claims were part of a statistical sample, the contractor may extrapolate that error rate across the provider's entire universe of claims. For skin substitute providers, an extrapolated overpayment determination based solely on a failure to respond to an ADR can reach millions of dollars.

Providers can, and should, use the response to anticipate the contractor's review and make a proactive showing of compliance. Although providers are not required to produce more than the ADR requests, Medicare pays only for services that meet its coverage requirements, and the reviewer will deny any claim for which the documentation does not show those requirements were met. Identifying the applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) before responding helps providers determine which records in their possession demonstrate compliance with each coverage requirement. Providers should consider including those records in the ADR response, even if they fall outside the date range the contractor requested.

Skin substitute claims illustrate how providers can make this proactive showing. A common coverage requirement is that the patient must have received at least four weeks of documented conservative care that failed to heal the wound before skin substitute treatment begins. ADRs often request records only for the dates of service under review, which may omit the earlier visits documenting that care. Without those records, the reviewer may conclude that the conservative care requirement was not met.

Providers can head off that finding by voluntarily including the conservative care records. Because wound care providers often treat patients whose wounds were first managed elsewhere, providers should obtain prior treatment records at the outset and reference them in their own pre-service documentation.

Providers should never alter existing records or create new ones when responding to an ADR. Medicare's rules permit legitimate amendments, corrections, and delayed entries only when they are clearly identified, signed, and dated, and contractors will disregard entries that do not meet those standards. More importantly, altering or backdating records after receiving an ADR can expose the provider to liability under the False Claims Act and to criminal charges for falsifying records or obstructing a federal audit or investigation.[1]

Ultimately, the ADR response is the provider's first chance to put a complete record before the reviewing contractor. A thorough response lays the groundwork for any later appeal and, in some circumstances, may prevent an overpayment finding altogether. What belongs in the response depends on the claims under review, the applicable NCDs and LCDs, and what the provider's records actually show. Because the coverage analysis and record assembly should begin as soon as the ADR arrives, providers benefit from engaging counsel at the ADR stage rather than waiting for an overpayment demand. Munsch Hardt's health care attorneys regularly advise wound care and other providers on ADR responses, Medicare audits, and overpayment appeals, and can help providers evaluate a request and assemble a response that addresses the applicable coverage requirements.

This update is for general informational purposes only and is not legal advice.