Medicare Compliance & Reimbursement

Assemble — and prepare — your ADR response team now.

The Manual Medical Review (MMR) program is back — so brace yourself for an onslaught of additional development requests (ADRs) for your therapy claims from your recovery audit contractor (RAC).

Facilities: CMS is Picking on You

The Centers for Medicare & Medicaid Services (CMS) announced the resumption of MMRs for Medicare therapy claims exceeding the $3,700 threshold for outpatient therapy per calendar year. Although paused since February 2014, CMS has approved the four current RACs to resume sending ADRs as of Jan. 16, 2015. 

CMS had placed the therapy MMR program on hold due to problems in the MMR process and delays in issuing new RAC contracts, explains Dan Ciolek, PT, MS, PMP, senior director of therapy advocacy at the American Health Care Association (AHCA) in Washington, D.C.

Impact: The current resumption applies to only facility-based providers, such as skilled nursing facilities (SNFs). 

CMS issued both a notice and an FAQ document. In the notice, CMS specified that the RACs’ reviews would focus on post-payment claims. CMS also noted that “approval includes both complex medical necessity reviews and complex coding reviews.”

RACs will issue ADRs for all Part A claims that hit the Medicare Administrative Contractor’s (MAC’s) system edit, which identified claims of outpatient therapy where the billed amount was above the $3,700 threshold for the beneficiary, and were paid on March 1, 2014 through Dec. 31, 2014, CMS says. Claims would include facility Part B claims paid through the Fiscal Intermediary Shared System (FISS). 

If you have beneficiaries whose therapy claims have exceeded the threshold, you will definitely face MMR ADRs (for the ADR timelines, see “What To Expect: Understand The 5 ADR Cycles” on page 43). Here’s what the experts say you need to do now to weather the waves of ADRs — and minimize your revenue losses in the process:

1. Keep an Eye Out for Mailings

Mistake: Don’t miss out on responding to ADRs simply because nobody at your facility is looking out for communications from the RAC. Alert your administrative staff to watch for mailings from the RAC, stressed Suzy Harvey, managing healthcare consultant for Springfield, MO-based BKD CPAs & Advisors, in a recent analysis. And alert your medical records staff to prepare for incoming ADRs.

Also, make sure you know who is responsible for forwarding the ADR notice to the appropriate parties, such as medical records, MDS, therapy director, director of nursing (DON), etc., said Cyndi Ouellette in a Feb. 9 blog posting for Topsfield, MA-based Harmony Healthcare International.

2. Designate the Responsible Parties

Your ADR response team should include all key staff members. Identify who in your facility is responsible for reviewing the details of the ADR and gathering the appropriate medical record information, Ouellette said. Identify who is the most appropriate team member to initially review the record for completeness, such as the MDS coordinator or DON. 

Don’t forget: Also, remember to notify both contracted and in-house therapy providers of the impending ADRs, Harvey stated. 

You may need to designate a clinician or third-party expert to write a summary or response letter to the RAC supporting the clinical decision-making for the rendered services, Ouellette noted. And when you have the final compilation of documentation, determine who makes the appropriate copies and submits the package to the RAC, as well as who is responsible for tracking the progress to ensure timely responses from all parties required to review the medical record.

Finally, identify “who then tracks the system once the package has been sent to the entity to determine successful resolution, or the need for additional steps to appeal an unfavorable decision,” Ouellette stated.

3. Identify the Therapy Claims

Have your therapy staff identify all therapy claims exceeding the $3,700 threshold, Harvey advised. Remember that RACs will send post-payment ADRs for therapy claims exceeding the threshold between March 1 and Dec. 31, 2014. The reviews will include all states.

And don’t think that RACs will cherry-pick only a few claims — you can expect the RAC to review all therapy claims exceeding the $3,700 threshold during the entire MMR process.

RACs will review claims in chronological order, based on the month in which Medicare paid them, meaning that they’ll review claims paid in June 2014 before those paid in July 2014. “However, if a provider has very few claims, more than one month’s claims may be requested in the same ADR,” Harvey noted.

4. Don’t Overlook Older Claims

But Part B therapy claims between March 1 and Dec. 31, 2014 won’t necessarily be the only ones you’ll see in the ADRs.

Inside scoop: A provider recently contacted AHCA, noting that it had received an ADR letter asking for documentation on a claim dating back to October 2013, Ciolek tells Medicare Compliance & Reimbursement Alert. The purported reason for including this older claim in the ADR request was that Medicare actually paid the claim after March 1, 2014.

Although providers typically don’t submit claims this late, and Medicare doesn’t usually pay claims so late, don’t be surprised if you see this, Ciolek notes. This is “a nuance in interpretation” of the ADR claim timeline of March 1 through Dec. 31, 2014. CMS is focusing on claims technically paid during this timeframe.

CMS has informed AHCA that, despite the identified March through December 2014 timeframe, the MMR ADRs could go back farther, as in the case of this provider, Ciolek relates. So if you have older claims that Medicare actually paid after March 1, 2014, prepare to have information on these claims available. 

Caveat: Still, if an older claim pops up on an ADR, take a closer look at it — did Medicare actually pay the claim before or after March 1? Ensure that CMS isn’t inaccurately pulling claims for review.

And if you have evidence that Medicare paid the claim before March 1, send a query to the email listed on the MMR therapy webpage (www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html), Ciolek advises. If Medicare paid the claim before March 1, CMS shouldn’t have included it as part of this wave of MMRs.

5. Review the Documentation List

Beware: Read the ADR notice carefully, “paying attention to dates of service and what is being requested to ensure that all documentation is gathered and submitted,” Ouellette instructed. “If you do not submit all of the required documentation, there is potential for total denial of the claim.”

Ensure that all supporting documentation is present and organized in the medical record, so you can assist in streamlining the review process, Ouellette advised. “This includes not only the therapy documentation, but also the supporting detail from the interdisciplinary team identifying the need for skilled intervention including the physician as well as any noted decline or referral from nursing.”

According to Harvey, your ADR response team should review the documentation list, which includes:

• Evaluations and re-evaluations;
• Therapy plans of care;
• Certifications and recertifications;
• Progress reports;
• Treatment notes for each treatment day;
• Exception justifications; and
• Physician and nursing documentation to support medical necessity.

6. Meet the Deadline — Or Pay the Price

After you receive an ADR request, ensure that you submit all documentation within the noted timeframe, Harvey said.

Pitfall: “Timely submission is critical,” Ouellette stressed. “Missed deadlines equate to denied claims.” 

The MMR response timeline for ADRs is 45 days, Ciolek says. CMS had recently changed all ADR response timeframes to 45 days, so this is standard now.

Bottom line: “Understanding the process and managing these inquiries in a timely and detailed manner is critical in order to minimize recoupment of Medicare revenue,” Ouellette cautioned. 

Resources: To read CMS’ notice, visit www.ahcancal.org/facility_operations/therapyservices/Documents/Recovery Auditor review of Therapy threshold claims.pdf. To access the FAQ document, go to www.ahcancal.org/facility_operations/therapyservices/Documents/RAC Questions and Answers for Therapy Claims.pdf.