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 providers.
- 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 categories.
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 to respond.
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 firstname.lastname@example.org.
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)
Dial In: 800-603-1774
Conference ID: 16032541
(TTY Communications Relay Services are also available at 7-1-1 or 800-855-2880.)
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@example.com.