The Centers for Medicare and Medicaid Services (CMS) released their long-term solution to meeting the mandated requirements for the manual medical review process. The mandate requires any therapy claims for combined speech-language pathology and physical therapy that reach $3,700 to be reviewed for medical necessity.
The preapproval process implemented in 2012 no longer applies. For services rendered between January 1, 2013, and March 31, 2013, the Medicare Administrative Contractors (MACs) will conduct prepayment review on claims that have reached the $3,700 threshold. CMS requested MACs conduct these manual medical reviews within 10 days.
For services rendered on or after April 1, 2013, Medicare Recovery Auditors will conduct the medical reviews. Reviews have been divided by state into two categories:
- Claims submitted from Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri will be classified under the "Recovery Audit Prepayment Review Demonstration" and automatically undergo prepayment review. Prepayment review occurs when services have been rendered, claims are submitted, but the claim is stopped prior to adjudication for review.
- The MAC will send an Additional Document Request (ADR) to the provider requesting that the documentation be sent to the Recovery Auditor. The process for submitting the documentation is to be determined by the MAC and the Recovery Auditor.
- The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.
- Prepayment review of claims always results in an "initial determination" and is assessed on the current claim. Once the status has been determined (i.e., services were or were not reasonable and necessary), the claim will be processed.
- Claims submitted from the remaining states not listed above will undergo an immediate postpayment review by the Recovery Auditors.
- Postpayment review occurs when the services have been rendered, claims are submitted, the claim is adjudicated for payment, and the claim is paid.
- The MAC will flag the claims that meet $3,700 threshold and then send an Additional Document Request (ADR) to the provider requesting that the documentation be sent to the Recovery Auditor. The process for submitting the documentation is to be determined by the MAC and the Recovery Auditor.
- The Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision. CMS did not indicate a timeframe for notification to the provider.
- Postpayment may result in no change to the initial payment to the provider or may result in a "revised determination" that would require the provider to pay back monies for services determined to be "not reasonable or necessary." The provider will be notified of any payment determination, and if necessary, be given the options of
- paying back funds by check,
- recoupment from future payments,
- applying for an extended payment plan, or
- appealing the decision.
A manual medical review process for Medicare Part B therapy services that exceed a $3,700 threshold was mandated by the Middle Class Tax Relief and Job Creation Act of 2012 and extended for services in 2013 by the American Taxpayer Relief Act of 2012. The process implemented by CMS in 2012, including a pre-approval process, proved to be problematic for both providers and Medicare. Early in 2013 CMS released interim guidance for the manual medical review process, instructing the MACs to conduct prepayment review on the claims reaching the $3,700 threshold and to complete such reviews within 10 days.
The manual medical review applies to all Part B outpatient therapy settings for services after January 1, 2103, including
- Private practice—therapy and/or physician offices
- Part B skilled nursing facility care
- Home health agencies (Type of Bill 34X)
- Outpatient rehabilitation facilities
- Comprehensive outpatient rehabilitation facilities
- Hospital outpatient departments, excluding all critical access hospitals, but including
- type of bill 12X or 13X
- revenue codes 042X, 043X, or 044X
- services with the modifiers –GN, –GO, and –GP.
Manual Medical Review Process for Therapy Claims
Contact CMS with questions about the therapy cap review process at firstname.lastname@example.org.
Contact Lisa Satterfield, MS, CCC-A, ASHA director of health care regulatory advocacy, at email@example.com.