So you have been asked to write an ADR letter. Don’t panic. Even if you are new at this, you can probably write a very good letter on patients whose chart contains good descriptive data. It may take some time to write the letter, but you will get faster as you go. So below are some basic tips to get you started:
1) Very carefully scan the patient’s chart for potential technical denials. A beautifully written letter does you no good if the reviewer denies the ADR because of a technical denial. Each Medicare contractor has a list of common technical denials on their website. Copy that list and use it to audit your chart.
2) Length of the letter: Shorter is better. Repeating the same information over and over weakens your stance. Long letters say “I don’t know what you are looking for, but if I give you everything I have, surely you will pay this claim.” Remember that each reviewer is reading several letters a day. Longer letters present the possibility of the reviewer noting conflicting data. Conflicting data is a red flag. Try to pare your letter down to 2- 3 pages.
3) Tone: Be collegial. I have reviewed letters that bordered on hostile. One Redetermination letter intimated that the reviewer had no right to question the hospice physician’s ability to prognosticate. Well they do and they did. Frustration, anger and blaming can occur when a company is confronted with ADRs. Stay calm, release your frustrations but don’t allow your emotions to color your argument. More importantly, don’t lose your opportunity to teach the reviewer about end of life care (see #6 below).
4) Content: Stay away from empty statements that simply re-state the free hospice care orange county content of the Local Coverage Determination (“LCD”) guidelines. For example “Ms. — met the eligibility requirements for Heart Disease with her KPS of 40%, NYHA Class IV, and having been optimally treated for heart disease. This statement simply reflects that you read the LCD. What the reviewer is looking for is how she met the criteria. Did she have chest pain or dyspnea at rest? What cardiac medications was she taking and which ones had she stopped due to side effects or renal failure? How many hours per day was she in bed and with what activities did she require assistance. Paint the picture of decline for the reviewer.
5) What if the patient improved during the dates in question? Take credit for the improvement. When patients gain weight or have less pain as a result of hospice interventions spell that out. If improvement is short-term, you won’t need to discharge the patient.
6) Make no assumptions that the reviewer knows about good end of life care. Don’t miss your golden opportunity to educate them. This is where you can improve the future for all of us who want to serve the hospice-eligible patient. For example, if the reviewer denied your ADR and stated that your “patient with dementia had no shortness of breath” take that opportunity to educate them. Tell them that “the research shows that patients with dementia do not exhibit shortness of breath except in the final days of life.” “If shortness of breath is a criterion for them to receive hospice care, then they will only receive hospice care in their final days of life.” Take the time to describe for the reviewer the natural course of dementia and how your patient’s condition mirrored that course.