Industry Insights

CMS Resumes Part B Therapy Manual Medical Reviews

February 2015
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

The Centers for Medicare & Medicaid Services (CMS) has notified the American Health Care Association (AHCA) and other provider organizations that the Medicare Part B Manual Medical Review (MMR) program is resuming immediately.

The four current recovery audit contractors (RAC) have received approval to begin sending additional development requests (ADRs) for Part B therapy claims that met the $3,700 threshold between March 1 and December 31, 2014. The reviews will be post-payment and include all states. CMS has no finalized plan in place to conduct reviews for 2015 MMR-eligible claims.

The MMR program was stopped in February 2014 due to delays in issuing new RAC contracts, which are currently being held up by pre- and post-award protests as well as problems with the MMR process. The MMR resumption only applies to facility-based providers, including skilled nursing facilities (SNF).

Claims will be reviewed in chronological order, e.g., claims paid in June 2014 will be reviewed before claims paid in July 2014. However, if a provider has very few claims, more than one month’s claims may be requested in the same ADR.

The process for conducting the MMR reviews will include five ADR cycles. The ADR cycles haven’t changed, so providers should expect to receive therapy MMR requests every 45 days as follows:

  • The first ADR sent to each provider will be for one claim meeting the MMR criteria.
  • The second ADR can request up to 10 percent of the total MMR eligible claims paid between March 1, 2014, and December 31, 2014.
  • The third ADR can request up to 25 percent of the remaining MMR eligible claims paid between March 1, 2014, and December 31, 2014.
  • The fourth ADR can request up to 50 percent of the remaining MMR eligible claims paid between March 1, 2014, and December 31, 2014.
  • The fifth ADR can request all of the remaining MMR eligible claims paid between March 1, 2014, and December 31, 2014.

SNFs can expect all Part B therapy claims exceeding the $3,700 threshold to be reviewed during the entire MMR process.

Here are some steps SNFs can take to prepare for the therapy MMR reviews:

  • Notify contracted or in-house therapy providers of the impending ADRs
  • Have therapy identify all Part B claims exceeding the $3,700 threshold
  • Inform administrative staff to watch for mailings from the RAC
  • Alert medical records staff to be prepared for incoming ADRs
  • Ensure the ADR response team reviews the documentation list:
    • Evaluations & re-evaluations
    • Therapy plans of care
    • Certifications & recertifications
    • Progress reports
    • Treatment notes for each treatment day
    • Exception justifications
    • Physician & nursing documentation to support medical necessity

Once an ADR request has been received, SNFs need to ensure all documentation is submitted within the noted time frame.

For more information or assistance, contact your BKD advisor. You also may contact Brian Hickman or Jon Unroe.

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