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    GAO Says 115,000+ Medicare Beneficiaries Affected by Manual Medical Review in 2012

    The Government Accountability Office's (GAO) mandated report on the implementation of manual medical review (MMR), part of the therapy cap exceptions process, estimated that the Centers for Medicare and Medicaid Services (CMS) received more than 167,000 reviews, affecting more than 115,000 Medicare patients, over a 3-month period.

    Between October 1, 2012, and December 31, 2012, CMS-contracted Medicare administrative contractors (MACs) reviewed 110,000 preapproval requests and 57,000 claims for services that were not preapproved. These were the 2 types of MMRs being implemented during the last 3 months of 2012. Of the estimated 110,000 preapproval requests reviewed, the MACs affirmed 80,500 (73%) and did not affirm 29,500 (27%). The MMRs of claims without approvals resulted in 19,500 (34%) claims affirmed for payment and 37,000 claims (66%) not affirmed for payment.

    The GAO report, required by the Middle Class Tax Relief and Job Creation Act of 2012, also looked at the implementation process as carried out during those 3 months. (The report did not review the new MMR process that began April 1, 2013.) CMS did not issue complete guidance at the start of the MMR process in 2012, and so the MACs encountered implementation challenges, said GAO, such as a lack of fully automated systems for tracking the reviews of preapproval requests in the time allotted.

    APTA continues to advocate for a less burdensome and more streamlined approach to manual medical review, including advocating for revisions to the new MMR process that began on April 1, 2013, in which outpatient therapy claims exceeding $3,700 are reviewed by recovery audit contractors.


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