Under the new Medicare manual medical review process, should
providers submit claims for a beneficiary's services as they are provided or submit them on one claim for review in a batch?
Medicare providers are grappling with many complex questions
related to a new manual medical review process for outpatient therapy claims
that exceed $3,700 per beneficiary per year. ASHA is working with key federal
officials to discuss issues, concerns and specific cases.
Under the 2013 manual medical review process, Medicare
recovery auditors are reviewing claims for services rendered on or after April 1. Medicare claims for patients in 11 states
automatically undergo prepayment review, and claims from the remaining states
undergo an immediate postpayment review.
ASHA, the American Physical Therapy Association and American
Occupational Therapy Association have requested monthly meetings with key staff
from the Centers for Medicare and Medicaid Services to clarify questions and
concerns raised by the associations' members.
In the most recent meeting, CMS officials clarified several
- Each individual claim for a beneficiary who has surpassed
$3,700 in therapy services in 2013 will require all of the documentation
necessary for reviewers to determine that skilled services are reasonable and
medically necessary. For more on what constitutes skilled versus unskilled
services, see "On the Pulse" and also the explanation on ASHA's website.
- Reviewing systems, however, cannot track cases by patient or
create a file for a beneficiary who has exceeded the threshold. Therefore,
reviews are likely to be performed by different reviewers whose determinations
may vary, and one denied claim for a beneficiary does not necessarily indicate
that all of the beneficiary's subsequent claims will be denied.
- CMS suggested that to avoid this scenario, a provider could
wait and report all of the services on one claim to be reviewed at the same
time. Because the review is based on the claim, not the individual date of
service, the batched services will receive a more consistent review. This
option, however, raises a concern: If the claim for multiple dates of services
is denied, the provider receives no reimbursement for those services. If the
beneficiary lives in any of the 39 states that have postpayment review, the
provider would be required to return the Medicare payments received for this
beneficiary. Although the process can be burdensome, submitting claims more
regularly limits potential liability, especially given the contractors' requirement to perform a review within 10 days of receiving the claim.
Response to additional document request
CMS officials also addressed what providers should do if
they receive an ADR—additional document request—from a recovery auditor. The
ADR is the provider's first indication that a manual medical review is necessary.
ASHA raised a specific case: An SLP received an ADR that
requested an extensive list of items—including a re-evaluation by a physician,
psychiatric notes and nutritional evaluation—to justify medical necessity of
services beyond the $3,700 limit. The ADR didn't indicate that the items were "suggested" rather than required.
CMS said that the provider should respond to an ADR by
submitting the documentation necessary to support payment of the claim, and not
necessarily all the items listed in the request. The officials also noted that
CMS staff is developing standardized letters—with a narrowed list of documents
needed to determine necessity for therapy—that should be available soon.
ASHA is also concerned about the lack of detail and
specificity in denial notices. Providing clear feedback and rationale for the
denial is critical to improving the review process and ensuring Medicare
beneficiaries are not denied the medically necessary care the exceptions
process allows. ASHA has sent CMS copies of denials that state only that the
service was not reasonable or necessary, without the detailed justification CMS
If a claim is rejected for inadequate documentation, the
beneficiary could continue to receive services if the provider submits the
necessary information and the denial is reversed. This situation is quite
different from a rejection based on a reviewer's determination that skilled services are not necessary or were not provided.
CMS requested copies of communication from contractors that
is unclear or inconsistent with Medicare policy. Members who have received
these documents can send them to MMR@asha.org; ASHA staff will forward them to