The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted last April contained provisions to replace the problematic Part B therapy Manual Medical Review (MMR) process, which required 100 percent review of all claims above a $3,700 annual per-beneficiary threshold with a targeted review program for claims over the $3,700 threshold. The Centers for Medicare and Medicaid Services (CMS) was instructed to implement the targeted approach no later than 90 days of enactment, and that deadline expired last July. Since then, there have been limited reviews of MMR eligible therapy claims from 2014 that were in the review pipeline prior to the enactment of MACRA. However, no targeted reviews of MMR eligible claims from 2015 to present have been conducted as we were waiting for CMS to develop a new review process that complied with MACRA.

Soon after the enactment of MACRA, a coalition including AHCA and other therapy professional and provider organizations contacted CMS and met with agency staff in June 2015 to clarify the intent of the legislation, ask questions, and provide verbal and written recommendations regarding implementation. At that time CMS assured the coalition they would interact with AHCA prior to implementation so that we could prepare our members regarding the new process. However, despite frequent repeated requests to meet again, the agency staff has not agreed to meet with AHCA.

On February 9, with no other public notice, CMS posted the following on its Therapy Cap Webpage:

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Update February 9, 2016

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews.

CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on:

• Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA.
• Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers.

Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day.

For CY 2015, the limit on incurred expenses (therapy cap) is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined and $1,940 for occupational therapy (OT) services.

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AHCA is extremely concerned about these developments. The three prior iterations of the Part B therapy MMR program were implemented with negligible provider input, and as a result were fraught with serious problems that directly impacted beneficiary access to care and provider cash-flow which spurred Congress to change the program. However, similar to the prior iterations, the February 9 posting by CMS announces a policy that was not developed in a transparent manner and does not contain sufficient detail.

AHCA has numerous questions associated with the new review policy and operational processes that we will be asking for CMS to clarify so that you can have a clearer understanding of what you can expect, and what you will need to do if your Part B therapy claims are selected under this new targeted review process. In particular, we are concerned whether beneficiary characteristics or provider error rate with prior MMR experience are factors in the new targeting methodology, or just high-cost patients. We will provide updates to you as soon as we receive more information.

Until then, the most significant piece of information contained in the CMS announcement is that these targeted Part B therapy reviews will not be performed by the Medicare Administrative Contractors (MACs) or Recovery Audit Contractors (RACs) that you are familiar with. Instead, CMS has contracted with Strategic Health Solutions to be the Supplemental Medical Review Contractor (SMRC) performing this medical review on a post-payment basis. Please alert your front-office billing and medical review support staff to keep an eye out for, and do not disregard, any Additional Development Request (ADR) letters from this Medicare contractor.

Members with questions regarding the new targeted MMR process should contact Dan Ciolek.