Policy Analysis: The Maze of Manual Medical Review Medicare officials clarify concerns and offer to review questionable denials of therapy claims. Policy Analysis
Policy Analysis  |   August 01, 2013
Policy Analysis: The Maze of Manual Medical Review
Author Notes
  • Tim Nanof, MSW is ASHA director of health care policy and advocacy.
  • Lisa Satterfield, MS, CCC-A is ASHA director of health care regulatory advocacy.
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   August 01, 2013
Policy Analysis: The Maze of Manual Medical Review
The ASHA Leader, August 2013, Vol. 18, 18-19. doi:10.1044/leader.PA1.18082013.18
The ASHA Leader, August 2013, Vol. 18, 18-19. doi:10.1044/leader.PA1.18082013.18
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 questions:
  • 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.
Detailed justification
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 requires.
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 CMS officials.
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August 2013
Volume 18, Issue 8