Medicare Part B therapy manual medical review fails all parties, says Parkinson
– The American Health Care Association (AHCA) today outlined a framework
specifically addressing the Medicare manual medical review process – a series
of operations initially designed to safeguard against inappropriate Medicare
Part B therapy utilization, but has since spiraled into an unworkable approach
for providers, and threatens beneficiary access to care.
“This is a process that has
failed all parties for over a year now, for hundreds of thousands of Medicare
beneficiaries who require rehabilitation services,” said Mark Parkinson,
President and CEO of AHCA. “We need a
solution and quickly. That’s why we and
our coalition partners are offering a framework that will effectively address
the shortcomings of manual review and ensure continued access to necessary
therapy services for future users.”
As part of its Medicare Part
B therapy cap exceptions process extension in 2012, Congress called for a
manual review component for claims processing to be implemented by the Centers
for Medicare and Medicaid Services (CMS). The procedures - referred to as
manual medical review (MMR) - were hurriedly put in place and, as a
consequence, the claims processing and related appeals systems have become
burdensome for all parties involved, including patients, regulators,
contractors and health care providers.
For example, Congress’ intent
in 2012 was that the MMR system takes approximately ten days to review and
adjudicate. In reality, providers
continue to receive inconsistent and inefficient claims instructions; wait months
– not days -- to receive a payment decision; then wait even longer for
payments. These ongoing systemic
problems, and recent MedPAC and GAO reports regarding MMR flaws, clearly
demonstrate the need for a more efficient and responsive MMR process.
Seeking a common-sense
solution, AHCA along with a coalition of 20 patient, consumer and provider
organizations, recently developed a framework to retool the MMR system that
center on the following three themes:
- Protect beneficiary access from care disruptions by
strengthening the ten day MMR requirement.
- Improve the MMR process by simplification,
standardization, and automation of contractor and provider communications.
- Require a GAO analysis of the MMR process to identify
opportunities to better design and tailor the part B therapy benefit, and to
improve the MMR process to better target medical review of outliers.
AHCA and the coalition will
continue to push this initiative to lawmakers on Capitol Hill during the final
days of the First Session of the 113th Congress.
The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) represent more than 12,000 non-profit and proprietary skilled nursing centers, assisted living communities, sub-acute centers and homes for individuals with intellectual and development disabilities. By delivering solutions for quality care, AHCA/NCAL aims to improve the lives of the millions of frail, elderly and individuals with disabilities who receive long term or post-acute care in our member facilities each day. For more information, please visit www.ahca.org or www.ncal.org.