The Genesis of Adeptly Handling ADRs and Audits

Supporting her staff is first and foremost for Ally Phillipsen at Genesis HealthCare.

EDITOR’S NOTE: RACmonitor, in association with RevKeep, is producing a three-part series on additional documentation requests (ADRs) that arise post-payment. For this, the second article in the series, Chuck Buck interviewed Ally Phillipsen, vice president of accounts receivable quality and recovery at Genesis HealthCare.

When you talk to Ally Phillipsen, you are instantly struck by how supportive she is of her people.

For one thing, she is continually seeking improvements in processes that make her employees more effective, and therefore happier in their work lives. That can be a somewhat rare quality in people who work for large corporations – at more than 1,000 medical centers, Genesis is reportedly the largest post-acute provider in the country.

Phillipsen, who has a master’s degree in health administration and management from the University of Southern California, has more than 20 years of healthcare management and supervisory experience – all of which is often particularly beneficial, as it pertains to how her department handles post-payment audits with ADRs.

But recent years have presented plenty of challenges.

“We’ve all faced staffing changes with COVID, and therefore have had to change our support process to meet the current needs,” Phillipsen said. “We routinely cross-train and monitor the volume to ensure we are not caught off guard with volume. Additionally, since we (use) an EMR (electronic medical record), we are able to gather most of the support before we work with the centers. Our goal is to provide as much support to our centers and reduce some of the burden that comes from gathering documentation. Centers still gather critical elements, such as documents with wet signatures, and work with us prior to submission to ensure completeness.”

Phillipsen added that while Genesis currently uses WayStar to receive and satisfy ADRs and denials, it also utilizes spreadsheets with queries for tracking purposes – an antiquated method, she admits, but a necessity, in light of a general dearth of software specifically tailored for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

The process is handled by the Genesis denials management department, which creates reports that allow the team to report volume, response time, and decisions to upper management. The same department handles next steps when appeals are being weighed, with denials transferred to licensed nurses or therapists to recommend a path forward.

The organized workflow has come in handy lately.

“We have seen an increase in Medicare Part A and Part B audits,” Phillipsen said. “We are seeing SMRCs (Supplemental Medical Review Contractors), RACs (Recovery Audit Contractors), TPE (Targeted Probe-and-Educate), and CERTs (Comprehensive Error Rate Testing).”

It can be a bit daunting, especially considering the resources needed to respond to even just one Medicare claim audit. Phillipsen noted that her department experienced a reduction in personnel as a consequence of the COVID-19 pandemic; like many other providers, she is tasked with doing more with less.

However, she is also proud that her “batting average” in winning appeals is higher than most. While the average rate of success is generally believed to be a win rate of 65 percent, at Genesis, under her direction, it is about 85 percent.

“Genesis is in a great position to satisfy ADR requests – we have the right staff, good software, and amazing leadership that supports our needs. We have all the ingredients to be able to overcome any increase in ADRs, if one was to happen,” she said. “However, our denial management team focuses on preventing ADR requests by identifying concerns and/or areas that trigger audits, and works proactively with the clinical department to put in place education that will benefit and make our documentation stronger, where needed.”

She concluded by saying “we do recognize gaps so we are actively working on a new software partnership to enhance our other lines of business and support the various levels of request of records and/or appeal which will benefit our clients and our company needs greatly.”