In what some members of the therapy community are calling a stealth move, the Centers for Medicare & Medicaid Services (CMS) has updated the therapy cap website with a long-awaited announcement regarding the manual medical review of therapy claims over the $3,700 cost threshold. Late Tuesday afternoon, CMS announced in dripping red ink to the therapy community that it had “tasked’ Strategic Health Solutions, in its capacity as a Supplemental Medical Review Contractor (SMRC), with performing therapy manual medical review on a post-payment basis. One therapy director reported being “smirked” in response to the news that yet another contractor has been assigned therapy claims.  

Much of frustration with the manual medical review process has been tied to the disconnect in communication between the Recovery Auditors (RAs) and the Medicare Administrative Contractors (MACs), and the inconsistencies in providing a detailed reason for denials, which CMS had promised when the program was turned over to the RAs in spring of 2013. Therapy providers have reported thousands of dollars of outstanding revenue stemming from the pre-payment review process (2013 through February 2014) and the bungled communication, requiring many to move to appeals just to establish that additional documentation requests (ADRs) were submitted when the RA claimed otherwise. 

In tasking a SMRC to conduct the therapy manual medical reviews, CMS also announced the parameters to include in post-payment reviews: 

  1. Providers with a high percentage of patients receiving therapy beyond the threshold ($3,700) as compared to their peers during the first year of implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
  2. The evaluation of the number of units/hours of therapy provided in a day.

The CMS announcement also indicated that therapy provided in skilled nursing facilities (SNFs), private practices, and rehab agencies (OPT) or “other rehabilitation providers” were subject to manual medical review. Noticeably absent from the specific listing of providers was outpatient therapy provided in hospital outpatient departments. 

MACRA extended the therapy cap exception process through Dec. 31, 2017 and modified the requirement for manual medical review (MMR) for services over the $3,700 therapy thresholds. MACRA also eliminated the requirement for 100-percent review of all claims exceeding the $3,700 thresholds while introducing this targeted review process. Of note, MACRA prohibits the use of RAs to conduct MMR.

The therapy cap for 2016 is $1,960 for physical therapy (PT) and speech language pathology (SLP) combined and $1,960 for occupational therapy (OT). The 2015 therapy caps were $1,940. The therapy caps are increased based upon an index, whereas the threshold has remained fixed at $3,700 since its original “trial” in late 2012. Like the therapy caps, there is a threshold for PT and SLP combined as well as a threshold for OT. 

Now that CMS has identified a SMRC to conduct MMR, the therapy community will want to refresh its memory on two other therapy reviews by the SMRC: The “Superstorm Sandy” review as well as the review of therapy that stopped just under the therapy cap. Notable is the suspiciously high error rate due to non-response to the ADRs, leaving therapy leaders to wonder. Stay tuned for a special update on the next upcoming Monitor Mondays broadcast set for the morning of Monday, Feb. 15.  

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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