Manual Medical Review Process for Therapy Claims
Medicare Part B Services
A manual medical review (MMR) 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 requires reauthorization annually. It was extended through December 31, 2017, by the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
MACRA modified the MMR process to target claims that exceed the threshold rather than each claim above the threshold, as was previously required. It also prohibited the use of Recovery Audit Contractors (RACs) to conduct the reviews. The $3,700 threshold includes the total allowed charges for services furnished by independent practitioners and all institutional services under Medicare Part B (i.e., hospital outpatient departments, skilled nursing facilities, critical access hospitals).
The manual medical review could apply to all Part B outpatient therapy settings, 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 13 X
- Revenue codes 042X, 043X, or 044X
- Services with the modifiers –GN, -GO, and –GP
However, a review process for therapy services provided on dates of service beginning July 1, 2015, forward is targeted to specific provider types or providers with certain billing patterns, and may not be inclusive of all the settings listed above. For example, staff from the Centers for Medicare and Medicaid Services (CMS) specifically stated that home health claims under Part B are not being reviewed at this time.
The current manual medical review process for therapy services applies to services provided on dates of service beginning July 1, 2015, through December 31, 2017. Targeted post-payment reviews will be prioritized to services over $3,700 that meet the following criteria:
- Services provided in skilled nursing facilities (SNFs), private/group practices, and outpatient facilities;
- Services billed by providers who provide a high number of minutes or hours of therapy per day at the patient level; and
- Services billed by providers who have a high percentage of patients that exceed the $3,700 threshold.
CMS staff specifically stated that home health claims under Part B are not being reviewed at this time.
The contractor responsible for conducting MMR, known as the Supplemental Medical Review Contractor (SMRC), is
Strategic Health Solutions. According to CMS, following are the steps taken in the review process.
- The SMRC will send one Additional Document Request (ADR) for 40 claims per provider. At this time, providers should expect only one request, with the possibility of additional requests if it appears there are significant compliance issues.
- The SMR has 45 days to review the claims and associated medical records and to issue a determination to the provider that addresses all 40 claims under review.
- Once a determination has been issued, the provider may engage the SMRC in a discussion period to provide additional details that may help overturn the initial determination in the provider’s favor.
- Any unresolved denials will then be turned over to the local Medicare Administrative Contractor (MAC) for recoupment, at which time the provider will be given the options of
- paying back funds by check,
- recoupment from future payments,
- applying for an extended payment plan, or
- appealing the decision.
- The SMRC will also educate providers regarding Medicare regulations where compliance issues have been identified.
CMS has instructed the SMRC to compare like providers (e.g., SNF to SNF, private practice to private practice).
What To Do if You are Targeted for Review
These reviews are targeting claims for outpatient speech-language pathology services billed under Part B only. If you receive an ADR letter from Strategic Health Solutions, please follow the instructions in the letter, including pulling all medical records
for the 40 claims requested and submitting the information in a timely fashion in the manner requested by the SMRC (e.g., mail, fax, CD). If you do not submit the documentation requested by the SMRC, these claims will be denied. Once a determination is made, you will need to decide if you want to use the
discussion period to address any negative determinations and engage the SMRC as soon as possible to avoid the appeals process.
- Submit a sample denial:
MMR@asha.org. ASHA has created a dedicated manual medical review e-mail address (
MMR@asha.org) where members are encouraged to send de-identified documents and cases, including denial letters, for presentation to CMS. Before e-mailing, please make sure to remove all patient identification data and include communication from the MAC or SMRC.