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Manual medical review update

from SOG

On April 1 recovery audit contractors began conducting prepayment or postpayment review for outpatient therapy claims exceeding $3,700. Eleven states, including Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri, are subject to prepayment review. All other states are subject to postpayment review. In the prepayment review states, RACs will conduct the manual medical review within 10 business days of receiving the documentation and will notify the MACs of the payment decisions. MACs will then notify the providers. In the postpayment review states, the postpayment review process could take between 30 and 45 days; however, CMS has encouraged RACs to expedite the process.

APTA met with the Centers for Medicare and Medicaid Services on April 1 and on May 7, to discuss the MMR process and to clarify some points of confusion:
  • RACs will not be looking at claims below the $3,700 threshold.
  • RACs will have tracking portals. Providers can go to the portal and see if the documentation they submitted was received and view the status of the decision.
  • RACs will be accepting documentation by fax, mail, CD, DVD, and ESMD (electronic submission). Please note that only providers who are enrolled in Medicare's ESMD system can submit claims electronically.
  • If a provider is has more than one therapy clinic, the MMR will be completed by the RAC with jurisdiction over the region in which the provider's practice is headquartered.
  • In 2013 physical therapists must issue a valid Advanced Beneficiary Notice to patients to collect out-of-pocket payment from Medicare beneficiaries when Medicare deems services "not reasonable and necessary" after the therapy cap is exceeded. CMS further clarifies that PTs must not issue the ABN to all beneficiaries who receive services that exceed the cap amount, only to those whose services the PT believes do not meet the Medicare definition of "reasonable or necessary." If the PT submits a claim with the KX modifier for an exception to the therapy cap, he or she is attesting that the services are reasonable and necessary.
APTA will continue to have monthly meetings with CMS regarding the RAC audits and will be providing feedback on problems providers are seeing. If you have comments or are experiencing issues with the manual medical review process, email advocacy@apta.org. In order to provide accurate and timely information to CSM, APTA members need to let the Health Finance and Quality staff know how the MMR process is being implemented and the impact it is having on your patients and practice more


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