When a Skilled Nursing Facility receives a post-payment Additional Documentation Request (ADR) from WPS, the issue is no longer a routine billing review. A postpayment ADR means claims have already been paid and are now subject to medical review for potential recoupment. These audits often focus on medical necessity, skilled level-of-care criteria, therapy intensity, certification compliance, and length of stay appropriateness.
WPS, as a Medicare Administrative Contractor (MAC), conducts these reviews under authority from the Centers for Medicare & Medicaid Services. Understanding how WPS evaluates SNF claims and how to respond strategically can prevent avoidable recoupments and further audit exposure.
Understanding WPS Postpayment ADR Reviews
A postpayment ADR differs from prepayment review. The claim has already been paid. WPS is now evaluating whether:
The services met Medicare Part A SNF coverage criteria
Documentation supports daily skilled need
Physician certifications were timely and valid
Therapy services were reasonable and necessary
The length of stay was clinically justified
If documentation does not support coverage requirements, WPS can deny the claim and initiate recoupment.
Common Triggers for WPS SNF Postpayment Review
WPS analytics often target:
Extended length of stay outliers
High therapy intensity patterns
High RUG or PDPM reimbursement categories
High-volume use of certain ICD-10 codes
Frequent hospital readmissions
Claims inconsistent with peer benchmarking
Facilities that are statistical outliers are more likely to receive ADR sampling.
What WPS Reviewers Evaluate in SNF Claims
Qualifying Hospital Stay
WPS verifies:
Three consecutive inpatient hospital days
Proper inpatient status documentation
Admission timing compliance
Failure at this step invalidates the entire SNF stay.
Daily Skilled Need
Medicare Part A requires daily skilled nursing or therapy services that can only be provided by professional staff.
WPS reviews:
Nursing progress notes
Therapy daily notes
Physician orders
Care plans
Clinical monitoring documentation
Documentation must demonstrate why services required professional skill and could not be delivered at a lower level of care.
Medical Necessity
Medical necessity must be supported daily. WPS frequently denies claims when:
Notes reflect maintenance rather than skilled intervention
Progress notes are repetitive or templated
Clinical instability is not demonstrated
Goals are not measurable
There is no evidence of improvement or need for skilled monitoring
Generic phrases such as “continue skilled services” are insufficient.
Therapy Documentation
WPS evaluates:
Initial evaluations
Objective functional measures
Frequency and duration justification
Progress toward goals
Discharge planning notes
Therapy intensity without measurable improvement or reassessment often results in partial denial.
Physician Certification and Recertification
Medicare requires timely certification and recertification for SNF Part A stays.
WPS will deny claims if:
Certifications are missing
Certifications are untimely
Signatures are absent
Documentation does not support physician affirmation
Certification compliance is a common technical denial reason.
Length of Stay Justification
WPS compares clinical documentation against the duration of stay.
Red flags include:
Extended stays without change in condition
Minimal therapy progression
Stable vital signs with no skilled adjustments
Discharge delays without documentation
If documentation does not justify continued skilled need, days may be denied.
How to Assemble an ADR Response Packet
A strong ADR response must be organized and complete.
Step 1: Build a Claim-Specific Checklist
Include:
Hospital discharge summary
Admission orders
Physician certifications
Nursing notes
Therapy notes
Care plans
Medication records
Lab results if relevant
Discharge summary
Step 2: Create an Indexed, Paginated Packet
Use:
Table of contents
Sequential numbering
Clear section dividers
Reviewers are more likely to approve well-organized documentation.
Step 3: Include a Clinical Summary Narrative
Provide a concise explanation of:
Qualifying hospital stay
Skilled services provided
Medical complexity
Ongoing instability
Therapy rationale
Length-of-stay justification
The narrative should reference supporting pages.
Common Documentation Weaknesses That Lead to Denials
Copy-and-paste daily notes
Inconsistent documentation between disciplines
Therapy notes lacking objective metrics
Missing physician recertifications
Poor documentation of discharge readiness
Failure to document skilled nursing judgment
WPS reviewers compare nursing and therapy notes for consistency.
Financial and Operational Risks
Postpayment ADR denials may result in:
Recoupment of paid claims
Interest accrual
Increased future medical review
Targeted Probe and Educate escalation
Referral to additional program integrity contractors
Repeated high denial rates can trigger broader scrutiny.
Appeal Rights
If WPS denies a claim, SNFs may pursue:
Redetermination
Reconsideration
Administrative Law Judge hearing
Medicare Appeals Council review
Federal court review
Appeals must clearly demonstrate skilled level-of-care and medical necessity criteria were met.
Heightened Compliance Mode During ADR Review
While responding, facilities should:
Implement pre-bill skilled review audits
Validate physician certification timelines
Re-train nursing and therapy staff on documentation specificity
Audit length-of-stay justifications
Review hospital qualification documentation processes
Preventing future ADRs requires systemic improvement, not isolated corrections.
Five Critical Survival Principles
Organize records thoroughly before submission
Demonstrate daily skilled needs clearly
Ensure physician certifications are timely and complete
Avoid generic documentation language
Conduct internal claim audits to identify similar vulnerabilities
How HealthBridge Assists SNFs Facing WPS ADR
HealthBridge provides:
ADR packet assembly and indexing
Medical necessity narrative drafting support
Internal mock medical review
Physician certification compliance audit
Therapy documentation training
Appeal strategy support
Length-of-stay risk analysis
PDPM documentation validation
A postpayment ADR can be contained when approached systematically and proactively.
Resource Links
https://www.wpsgha.com
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-409
