Here we go again, therapy providers. Brace yourself for profiling, data analytics, a new manual medical review process, and yet another contractor assigned to the task of scrutinizing services. In other words, this is a horse of a different color. 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through Dec. 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows for a targeted review process.

Therapy constituent groups had expected more input to the process for manual medical review following significant issues with the Recovery Auditors (RACs). Without input from the therapy groups, the Centers for Medicare & Medicaid Services (CMS) surprised the therapy community with the announcement that the Supplemental Medical Review Contractor (SMRC) had been chosen to conduct the reviews. The announcement of how the reviews would be conducted was also somewhat of a surprise, as it differed from expectations created by MACRA.

CMS has not posted any further information. However, members of the nation’s therapy constituent groups recently have been receiving email updates and blog post updates on a recent meeting with CMS to review the process and answer questions. The American Physical Therapy Association (APTA) in particular, via the PTinMotion news blog, provided a few tidbits of information to subscribers:

  • The old manual medical review (MMR) system was automatically triggered when a provider exceeded the $3,700 mark. The new one does not require MMRs for all claims exceeding the threshold, and instead takes a targeted approach, looking at providers that have provided a high amount of hours or minutes of therapy to patients in a single day. 
  • The reviews fall into three practice setting buckets: skilled nursing facilities (SNFs), private practices, and outpatient facilities.
  • Additional documentation requests (ADRs) will be limited to 40 claims per provider. Each claim will be reviewed; some may be upheld and others denied.
  • Once you submit your information, the SMRC has 45 days to get back to you with a decision. After that, the SMRC will take no further action, although it can turn things over to the MAC for further review.
  • A “discussion period” allows you to fix errors or add information to the files you submitted.  Making these changes could help you undo a denial. The discussion period is roughly 30 days, but you must request it.
  • The process includes comparison with peers. Part of Strategic Health Solutions’ process for determining whether a billing process is potentially aberrant involves comparing providers who are doing the same thing – PTs in private practice, for example.

So, what are the next steps in preparing yourself for the next wave of manual medical reviews?

  1. Profile your practice and therapy claims costing over $3,700. If you listen to Monitor Mondays and are familiar with Frank Cohen’s segments, you know that the first of the next steps is to profile your practice and determine your risk points. For those in private practice, the ability to profile, per individual providers enrolled in your group, can be achieved for 2012, 2013, and 2014 in the data that CMS has made publically available. Unfortunately, this type of data transparency and the ability to compare are not readily available for therapy provided in skilled nursing facilities, hospitals, and rehab agencies.
  2. Review the number of units and minutes of therapy provided in a day. While the therapy community is still at something of a loss as to the inclusion of “time” per day in this review, nonetheless, know your numbers and start preparing for the appeals right from the beginning.
  3. Review all the information posted to the SMRC’s page on this project. Strategic Health Solutions (SHS) has updated its website to include a sample ADR letter. Be familiar with the letter and alert those who receive the mail. Keep in mind that the therapy community’s experience with SHS in two previous reviews was not positive in that they posted high denial rates based upon “no response” to the ADR request, leaving many providers wondering where the ADR letters were sent.
  4. Use electronic submission of medical documentation (esMD) to submit your ADR requests. If you don’t know about esMD, tune in to a complimentary RACmonitor webcast on Tuesday, June 28. You can register online here:  
  5. This broadcast will include Joyce Davis from CMS as well as a Nicole Smith Nicole Smith, vice president of operations and government services at Vyne (formerly MEA/NEA). During the initial round of MMR review with the RACs, MEA worked with smaller providers to get them on esMD and submit their ADRs with confidence.  

As always, be sure to tune in to our Monitor Mondays broadcasts for updated information on the therapy MMR process. 

About the Author

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practice. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Monday where she serves as a senior national correspondent.

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