The Centers for Medicare & Medicaid
Services (CMS) has agreed to postpone the new Recovery Auditor Contractor (RAC)
contracts until August 15, 2014, because of pending litigation. One of the
current RACs has filed a lawsuit in federal court to protest terms of CMS's
proposed RAC contracts. While the court moves forward with proceedings in the
case, CMS agreed to delay the awarding of new contracts.
Current RACs are
no longer processing manual medical review of Medicare outpatient (Part B)
therapy claims. However, CMS officials have suggested that all claims will be
processed and documentation requests held for post-payment review by new
contractors once contracts have been implemented. Due to the contract
delay, it is likely that therapists will receive the requests for review several
months after payment has been received. Should review determine skilled services
were not needed or provided, payment will be recouped.
other therapy organizations are meeting with CMS to discuss concerns related to
manual medical review, the RAC delay, and the administrative
law judge's (ALJ) appeals delay. The average processing time for manual
medical review appeals is 367 days, and it takes 22–24 weeks for the appeals to be logged into the case processing system.
should continue to be vigilant in their documentation for Medicare services and
remain mindful of their patients' total therapy dollars through their Medicare
Administrative Contractor. Claims that reach the $3,700 threshold
for combined speech-language pathology and physical therapy services will
eventually be reviewed. SLPs should also be aware that limiting
medically necessary services due to a cap or a threshold is a metric analyzed by
the Office of the Inspector General and questionable in ethical practice.
In 2012, 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 was extended until March
31, 2015. The mandate requires review, for medical necessity, of any therapy
claims for combined speech-language pathology and physical therapy services that
reach $3,700. In February 2014, CMS announced that it would perform post-payment
manual medical review only for therapy services provided on or after February
28, 2014, that reach the mandated $3,700 threshold after the new RAC contracts
were in place. At that time, it was anticipated contracts would be implemented
June 1, 2014.
For more information,
contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at