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Eli's Rehab Report

Therapy Caps:

Manual Medical Review Process Gets Tweaked

High amounts of therapy beyond the threshold could flag you.

You may not get reviewed after all for therapy claims over $3,700 — but you’re not completely off the hook either. The Centers for Medicare & Medicaid Services (CMS) announced in February a “more targeted” approach to the Manual Medical Review (MMR) process.

The MMR process takes place when therapy claims exceed the $3,700 cap. Historically, all these therapy claims (OT standalone and PT/SLP combined) get reviewed, but the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) called for some changes:

1. The therapy cap exceptions process is good until Dec. 31, 2017;
2. Recovery Audit Contractors (RACs) are no longer allowed to conduct MMR; and
3. The review process will be more targeted. 

Know Who’s Reviewing What

If you’re up for review, you’ll be hearing from Strategic Health Solutions. This is a Supplemental Medical Review Contractor (SMRC) CMS has chosen to do the task. Reviews are to be conducted on a post-payment basis. According to the CMS website, reviews will be 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 SNFs, therapists in private practice, and outpatient physical therapy or speech-language pathology providers or other rehabilitation providers.

Take note: “Of particular interest” will be the number of therapy units/hours provided in a day, CMS says.

“APTA remains hopeful that the targeted manual medical review as mandated under the MACRA legislation will pose less administrative burden on physical therapists, but we are very concerned about the recent announcement by CMS that named Strategic Health Solutions as the Supplemental Medical Review Contractor,” says Roshunda Drummond-Dye, JD, director of regulatory affairs for the American Physical Therapy Association (APTA).

“The information provided by CMS, to date, is very broad and lacks detail,” Drummond-Dye continues. “It is our number one priority to work with CMS to ensure that the new manual medical review process is in fact a ‘targeted’ process focused on those providers with aberrant or abusive billing practices.”