A manual medical review process
for therapy services is being implemented for service claims that exceed the
$3,700 threshold. This is a new process that was mandated by the Middle
Class Tax Relief and Job Creation Act of 2012. The $3,700 threshold includes
the total allowed charges for services furnished by independent practitioners
and institutional services under Medicare Part B (i.e., hospital outpatient
departments, skilled nursing facilities). The threshold does not apply to
services in critical access hospitals.
In a meeting between ASHA and the
Centers for Medicare and Medicaid Services (CMS), we learned that CMS has
decided to implement the manual medical review process in three phases by
assigning each provider to one of three groups based on facility type, claims
volume, and payment, with adjustments to evenly distribute the workload among
Medicare Administrative Contractors (MACs).
- Phase I (October 1,
2012–December 31, 2012) requires providers with a higher volume of payments
reaching the $3,700 threshold to participate in the review process.
- Phase II (November 1, 2012–December 31, 2012) adds mid-range volume
- Phase III (December 1, 2012–December 31, 2012) incorporates
the remaining, low-volume providers.
It is unclear at this time if
the program will continue after December 31, as Congressional action will be
required to continue the mandate.
Each provider subject to participating
in a phase will be notified via U.S. Mail. There will also be a posting on the
CMS website that identifies the providers in Phase I and Phase II
Providers will be able to request pre-approval for services
above $3,700. The MACs will use the coverage and payment policy requirements
currently in the Medicare Benefit Policy manual and any applicable local
coverage decisions. They will have 10 business days to respond to a pre-approval
request. Requests that do not receive notification within 10 days are
automatically approved. Claims submitted above the $3,700 threshold without
approval will be stopped, and the standard medical review process will apply,
which allows 45 days for the provider to submit records and 60 days for the MAC
CMS is hosting a Special Open Door Forum: Manual Medical
Review of Therapy Claims conference call to offer an opportunity for education
and questions. Participants may submit questions in advance to [email protected].
Special Open Door Forum: Manual Medical Review of Therapy
Claims Conference Call
Date: Tuesday, August 7,
2012, from 2:00 p.m. to 3:30 p.m. (EST)
Conference ID: 16032541
Communications Relay Services are also available at 7-1-1 or
CMS will also be issuing a Medical
Learning Network (MLN) Matters article on the topic. Providers
can subscribe to the electronic mailing online. In addition, CMS has shared
two handouts with ASHA on the topic.
As CMS updates
its website and offers more information, ASHA will post the information on our
web page, Overview
of the Medicare Therapy Cap Exceptions Process.
For more information,
please contact Lisa Satterfield, ASHA's director of health care regulatory
advocacy, at [email protected].