CMS Updates the Manual Medical Review Process (Again)

21 Mar 2016

On February 9th, 2016, CMS announced changes to the Manual Medical Review process for therapy claims above the $3,700 threshold.  As you will recall, the Manual Medical Review process has gone through several changes since its inception in 2012 as a provision of the Middle Class Tax Relief and Job Creation Act.  At various stages, it has included a pre-authorization requirement, standardized pre- and post-payment reviews through Recovery Audit Contractors, a pause in the process altogether, and eventually more targeted reviews.

CMS’s latest update sheds a little more light on the revised process, but more information will be needed in order for providers to fully understand how Manual Medical Reviews will work going forward.  The most recent details as per the CMS website state:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 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 a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews.

CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on:

  • Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA.
  • Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient  physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers

Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day.

The fact that the SMRC will target claims for providers with a high percentage of patients who have exceeded the threshold should be a point of consideration for providers.  Therapists should carefully review their documentation to make sure they are supporting the medical necessity of continued, skilled intervention for patients who have exceeded the $3,700 threshold.  (Actually, this should be occurring at ALL phases of treatment and not just above the therapy cap or beyond the Manual Medical Review threshold AND regardless of payor.)

We will be keeping an eye out for further guidance from CMS on how the Manual Medical Review process will be implemented including how the number of units/hours of therapy provided in a day will be evaluated.  Stay tuned.


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