TARGETED MEDICAL REVIEW-THE EVOLUTION OF MMR

Early this month CMS released its definition and plan for what targeted medical review would look like.  For perspective (courtesy of AHCA Email update 2/10/16), “the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted last April contained provisions to replace the problematic Part B therapy Manual Medical Review (MMR) process, which required 100 percent review of all claims above a $3,700 annual per-beneficiary threshold with a targeted review program for claims over the $3,700 threshold. The Centers for Medicare & Medicaid Services (CMS) was instructed to implement the targeted approach no later than 90 days of enactment, and that deadline expired last July. Since then, as we have informed you previously, there have been limited reviews of MMR eligible therapy claims from 2014 that were in the review pipeline prior to the enactment of MACRA. However, no targeted reviews of MMR eligible claims from 2015 to present have been conducted as we were waiting for CMS to develop a new review process that complied with MACRA.”

Details of the proposed targeted medical review are found at CMS’s Therapy Cap Webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html and are shared below:

Therapy Cap

Manual Medical Review of Therapy Claims above the $3,700 Threshold

Update February 09, 2016

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.

For CY 2015, the limit on incurred expenses (therapy cap) is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined and $1,940 for occupational therapy (OT) services.

What now? NASL, AHCA and many other therapy organizations are pursuing conversations with CMS to further digest and understand the implied targeted review.  Many concerns exist including the basic understanding of who are “peers”, why is OT not listed specifically, how will SMRC know when claims are over the threshold and at what % compared to their peers and so on.  Stay tuned.

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