Tuesday, May 24, 2016 New Targeted Manual Medical Review System: 6 Things You Should Know 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. The review contractor has 45 days to respond with its decision. 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. Once you submit your information, the SMRC has 45 days to get back to you with a decision. 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.