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  • New Targeted Manual Medical Review System: 6 Things You Should Know

    Editor's note: this story was updated on April 6, 2017 to correct an error in tip 4 below. Originally that tip stated that the 45-day time limit applied to the review contractors. That time period actually applies to providers. On May 18, 2017, tip 4 was further updated to reflect new information from CMS that SMRCs do not operate under a required timeframe for communicating review findings to providers. 

    The much-anticipated changes to the way the Centers for Medicare and Medicaid Services (CMS) conducts its manual medical reviews (MMRs) are under way, with the first round of requests for additional documentation (ADRs) now being sent to providers (here's a sample ADR).

    Here's what you need to know:

    1. The new system targets behaviors.
    The old MMR system was automatically triggered when a provider exceeded the $3,700 mark. The new one does not require MMRs for all claims exceeding the threshold, and instead takes a targeted approach, looking at providers who have provided a high amount of hours or minutes of therapy to patients in a single day.

    2. The reviews fall into 3 practice setting buckets: skilled nursing facilities (SNFs), private practice, and outpatient facilities.
    Home health part B claims aren't a part of the review process.

    3. ADRs will be limited to 40 claims per provider.
    Each claim will be reviewed; some may be upheld and others denied.

    4. Providers have 45 days to respond to additional documentation requests (ADRs) from review contractors.
    CMS has contracted with Strategic Health Solutions (SHS) to serve as the supplemental medical review contractor (SMRC). This is who you'll be dealing with initially should you receive an ADR. If the SMRC requests additional documentation, you'll have 45 calendar days to respond. If you provide a response within the 45-day limit, the SMRC will review the documentation and communicate its review findings, although there is no specific timeframe in which it must do so. After that, the SMRC will take no further action—though it can turn things over to the Medicare administrative contractor for further review.

    5. A "discussion period" allows you to fix errors or add information to the files you submitted.
    Making these changes could help you undo a denial. The discussion period is roughly 30 days, but you must request it.

    6. The process includes comparison with peers.
    Part of SHS's process for determining whether a billing process is potentially aberrant involves comparing providers who are doing the same thing—PTs in private practice, for example.

    The targeted MMR process is part of a wave of changes associated with the Medicare and CHIP Reauthorization Act (MACRA), a sweeping law that addresses payment issues in the aftermath of the repeal of the sustainable growth rate (SGR). APTA is developing a series of fact sheets on MACRA and will continue to monitor the new MMR process and provide updates as more information becomes available.

    Comments

    • CMS has systematically used statistics to manipulate PT's into reducing their treatment of patients. Between the change in practice act that allows only PT's and PTA's to treat and the threat of investigations if anyone averages more than 3 units of treatment a day, patient's have been the forgotten issue in the formula. PT's are now just fighting to stay below the radar and out of bankruptcy court. Patient care is nearly a secondary concern. Congress needs to be approached on CMS tactics. Their abuse of authority continues to threaten the lives and well being of our patients.

      Posted by Brian P. D'Orazio DPT, MS, OCS on 5/25/2016 6:41 PM

    • I wish there was more clarification on the comment " looking at providers who have provided a high amount of hours or minutes of therapy to patients in a single day." Does this mean that MC will be looking at home many hours get billed in a day by an individual PT from all insurers to determine if the PT is billing excessively for the day? Or, does it mean that the PT is billing a MC patient excessive amounts of units/visit?

      Posted by Herbert Silver -> >JX^D on 5/26/2016 12:02 PM

    • From CMS , "patients receiving therapy beyond the threshold as compared to their peers" is how they are going to determine providers are over-treating. How vague is that - can we have some hard numbers CMS?

      Posted by Nancy Reynolds, PT, MEd on 5/26/2016 1:54 PM

    • Brian P. D'Orazio DPT, MS, OCS Is right. Time for those who have influence to lead the fight and claim our respect and our place before we are all forced into closing down or working for big intituitions.

      Posted by James Mawhiney -> CIS_=O on 5/28/2016 2:42 PM

    • This system benefits those practice's who provide minimal hands on treatment in high patient volume settings. Unfortunately, providers get paid for what they say they do, which in many settings are not the services that they actually provide. This system rewards those types of clinics and penalizes providers who have developed their skills, who spend time with their patients, and care about the success/outcomes of their patients. Medicare and Medicaid have grown and expanded over the years. They utilize outside firms to review cases they should be doing themselves. It is inherent in that model that the more denials made, the greater the justification for their contract. Over time, the human body has not changed much. How many rules, policy, and procedural changes has Medicare forced upon our profession just in the last decade alone. How many more will there be in the upcoming years and to what end?

      Posted by Andrew C. Hillyer, MSPT on 5/30/2016 11:24 AM

    • Reading this while I spend personal time trying to accurately document MCR. Hating my profession more and more, treated as if I am fraudulent as I treat in constant fear of harassment.

      Posted by Julian on 6/6/2016 10:21 PM

    • Is SHS paid based on commission? Any relationship SHS to regional intermediaries contracted w CMS? If ADRs in OP/SNF is anything like those in home health, would suggest that it is very important to meet time deadlines & be sure charts are good - they are looking for reasons to deny/hold up payments. This year, 2016, our Agency just started getting reimbursed on 40 charts from 2011 - slowly getting paid about one chart every 3-4mo. Most common denial reason "no medical necessity" for PT on new TKR & THR clients. later, "no STG" (no requirement for same in regs at the time and usual discharge within 2-3 weeks). They try to outlast you & get you to negotiate for 25cents on the dollar. Save for operations funds!

      Posted by Janet M Shannon PT DPT on 6/8/2016 9:11 PM

    • Medicare sourced data-drilling to this private company: https://www.cbrinfo.net/ You can get this data for yourself (not your facility or your PTA) - its based on your NPI. Yes, it's very easy for Medicare to create billing profiles comparing your billing behavior to state and national peers in similar settings. Easy for you, too. Question: If you KNOW you are a billing outlier, what should you do?

      Posted by tim richardson on 8/23/2017 3:31 PM

    • Has anyone on this board been through the "targeted review"?

      Posted by James Mawhiney -> CIS_=O on 5/10/2018 2:50 PM

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