APTA Meets With CMS for Clarification on New Medical Manual Review Process
Yesterday,
APTA along with other therapy stakeholder organizations met with the Centers
for Medicare and Medicaid Services (CMS) to discuss implementation of the
manual medical review (MMR) process for outpatient therapy claims exceeding
$3,700. As reported March 22 in News Now, recovery audit
contractors (RACs) will complete 2 types of review for claims processed on or
after April 1, 2013—prepayment review for states within the Recovery Audit
Prepayment Review Demonstration, and immediate postpayment review for the
remaining states.
CMS
assured stakeholders that the agency would have the necessary safeguards in
place to ensure appropriate and fair medical review by RACs. Prior to the
meeting, the therapy organizations sent a detailed list of questions to CMS
regarding the use of the advanced beneficiary notice (ABN), RAC administration,
and outreach education to Medicare contractors, providers, and patients. CMS
indicated that it plans to issue a written FAQ of the questions submitted in
the coming weeks.
During
the meeting, CMS clarified the following:
- When claims exceed the $3,700 threshold in the
states under postpayment review, the claim will be paid automatically, and
providers will receive an additional development request (ADR) from the
Medicare administrative contractor (MAC). The provider should send the ADR
directly to the RAC. If the ADR is sent to the MAC, the MAC will forward
it to the RAC for review, which will slow down the review process as the
10-day clock does not begin until the RAC receives the ADR.
- The RAC will not automatically deny coverage if
an ADR is not received; it will reach out to the provider to request the
information.
- After the RAC reviews the ADR, it will send the
provider a detailed review letter either stating there is no finding of
error or denying the claim. This letter will be sent by US mail, but all
payments and adjustment of payments will be made electronically.
- Providers will be able to track claims
submitted to the RAC through a claims status portal, and provider
submission requests will still be sent via mail or fax (the provider can
also send a DVD or CD to the RAC). Providers who are enrolled in
Medicare's ESMD system can submit claims electronically.
- If the provider is has more than 1 therapy
clinic, the MMR will be completed by the RAC with jurisdiction over the
region in which the provider's practice is headquartered. RACs will look
only at claims above the $3,700 threshold, and claims will be reviewed on
a claim-by-claim basis and will not be bundled (first claim in, first
claim out).
- Providers should use the ABN in the same manner
for claims above and below the therapy cap. This means that ABNs should be
issued only for services that the provider believes are not medically
necessary and coverage will be denied. If the patient refuses to sign an
ABN, the provider has no obligation to provide therapy that he or she believes
will be denied for lack of medical necessity.
In
the coming days, APTA will provide additional resources to members on the application
of the 2013 MMR process. Resources and the latest information on the therapy
cap can be found on APTA's 2013 Medicare Changes webpage.
APTA Seeks Member Comments on Walking for Surgeon General Call to Action
To
address the public health problem of physical inactivity, the Department of
Health and Human Services is accepting comments on walking as an effective way
to be sufficiently active for health. The information collected will help frame
an anticipated Surgeon General's call to action on this issue.
APTA
will submit comments by the April 30 deadline. APTA members are encouraged to send
their recommendations to APTA to be included in the association's submission to
HHS.
The
notice requests
information on ways to increase walking and community walkability on the
following 2 topics:
(1) Barriers
to walking for youth, adults, seniors, people with developmental injury and
chronic disease-related disabilities, racial and ethnic minorities, and
low-income individuals.
(2) Evidence-based
strategies for overcoming those barriers and their reach and impact to increase
physical activity at the population level and among the above-mentioned
subpopulations
Send
your comments by COB April 26 to Lisa Culver, PT, DPT, MBA,
senior specialist, APTA department of clinical practice.
Section on Geriatrics Donates $50,000 to the Foundation
A recent $50,000 donation by the
Section on Geriatrics to the Foundation for Physical Therapy will be allocated
toward the Marilyn Moffat Endowment Fund for Geriatric Research ($25,000) and
the Center of Excellence for Health Services/Health Policy Research ($25,000).
Established in 2007, the Marilyn
Moffat Endowment Fund for Geriatric Research supports emerging investigators
examining methods to facilitate the translation of research into current
physical therapy practice with aging adults.
The Center of Excellence is a new
initiative with a goal to provide health services and health policy research
training to prepare physical therapist scientists to examine physical therapy
resource utilization, costs, and quality. The purpose of the research is to
identify the most effective ways to deliver, organize, finance, and assess
outcomes of health care services.
Read
more about the donation in the Foundation's press release.
If
you're not receiving the Foundation for Physical Therapy's monthly News &
Events e-newsletter, sign up today and stay current with the latest
information on research supported by the Foundation, funding and awards, and
events. The newsletter also provides links to information about the
Foundation's trustees and staff; scholarships, fellowships, and grants; and how
to make a donation.