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.