Updated on: November 29, -0001

Provider Profiling and Targeted Reviews: Get Ready for Manual Medical Review of Outpatient Therapy Claims

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Original story posted on: February 17, 2016

People in the therapy community often whisper about providers that are the subject of an audit, probe review, or investigation, secretly surmising that “they must be doing something wrong.” 

Other providers sometimes breathe a secret sigh of relief, thinking “I have been documenting this way and billing these codes for (fill in the blank) years, and they are paying me, so everything must be OK.” 

Fluff up your pillows, because you may be in for sleepless nights wondering about the formulary for profiling therapy providers – even if you never exceed the $3,700 therapy threshold for manual medical review.

Let’s start back at the beginning of therapy manual medical review, after the 2014 cessation of activities among the current Recovery Auditors (RAs). Pre-payment review (in 11 states) stopped, as did post-payment review at the end of February 2014. All therapy over $3,700 was paid, but subject to review when the new RAs were announced. 

By 2015, the Centers for Medicare& Medicaid Services (CMS) announced that the current RAs would begin a staged five-wave additional documentation request (ADR) process of reviewing therapy claims. These reviews started with institutional claims from 2014 (for hospitals, SNFs, rehab agencies, CORFs, etc.). The review of private practices and physician offices for 2014 claims over $3,700 has yet to get underway.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 extended the therapy cap exception process through Dec. 31, 2017 while also modifying the requirement for manual medical review of claims over the threshold.  Out is the requirement for manual medical review of all claims exceeding the threshold. In are targeted reviews. 

The targeted review criteria contained in MACRA, Section 202(b), require the Secretary of the U.S. Department of Health and Human Services (HHS) to limit manual reviews by “utilizing such factors as the Secretary determines to be appropriate,” including scenarios in which:

“The therapy provider has had a high claims denial percentage for therapy services under this part or is less compliant with applicable requirements under this title.”

“The therapy provider has a pattern of billing for therapy services under this part that is aberrant compared to peers or otherwise has questionable billing practices for such services, such as billing medically unlikely units of services in a day.”

“The therapy provider is newly enrolled under this title or has not previously furnished therapy services under this part.”

“The services are furnished to treat a type of medical condition.”

“The therapy provider is part of group that includes another therapy provider identified using the factors determined under this subparagraph.”

Review criteria in the MACRA legislation contrasts with criteria listed in the CMS announcement on Feb. 9, specifically as it pertains to providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA implementation, and the evaluation of the number of units/hours of therapy provided in a day.

Notable is the indication that the review will consider the number of units/hours provided in a day, which is straying from the original intent to determine medical necessity of therapy over the $3,700 threshold.

Of concern to the therapy community is communication on how the process will unfold in the new reviews, and how providers will get final resolution on the legacy reviews yet to be finalized.

This story was first covered in “Stealth” Move by CMS: RAs Out for Therapy Manual Medical Review.”

Stay tuned for continued updates on the next upcoming Monitor Mondays broadcast, set for the morning of Monday, Feb. 22.

About the Author

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practice. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, for which she serves as a senior national correspondent.

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nancy@nancybeckley.com

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editor@racmonitor.com

Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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