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MEMBER ALERT – Part B Therapy MMR Update

Congress Extends Therapy Caps Exceptions Process and Related MMR Process Through March 31, 2015

April 2, 2014 -- On April 1 the President signed into law the ‘Protecting Access to Medicare Act of 2014’ providing assurances for at least the next 12 months that Medicare beneficiaries may continue to receive medically necessary physical therapy, occupational therapy, and speech-language pathology services under the Part B benefit.  While AHCA was aggressively lobbying with numerous beneficiary and provider group coalition partners for permanently replacing the therapy caps with a more sensible patient-centered medical review and payment system, Congress was only able to agree to stabilize procedure payment rates, and add another 1-year extension of the current therapy cap exceptions process and associated manual medical review (MMR) program.  In short, the provisions impacting Part B therapy services include:

  • The Medicare Physician Fee Schedule (MPFS) rates will remain unchanged through the remainder of 2014.  Your charge masters need not change.  
  • The MPFS rates for at least January through March 2015 will be established through rulemaking (around November) with a 0% Sustainable Growth Rate (SGR) adjustment.  
  • The therapy caps exceptions process is extended through March 31, 2015.  You can continue to use exceptions to furnish necessary Part B therapy services above the $1,920 caps using usual procedures.
  • The associated MMR process is extended through March 31, 2015.  Although CMS has currently ‘paused’ MMR reviews, and a resumption date has not been established yet, you should be prepared to respond to Additional Development Requests (ADRs) for ALL therapy services furnished beyond the $3,700 threshold since the ‘pause’ began in February.  The Centers for Medicare and Medicaid Services (CMS) has indicted that they expect Recovery Audit contractors to conduct post-payment review on these claims once the MMR reviews resume. 
  • Because Congress acted in time and there was no gap your ability to use the exceptions process, you may continue to follow the Advance Beneficiary Notice (ABN) issuance policy as described in CMS guidance described in the prior alerts below.  With a therapy cap exceptions process in place, ABN issuance is not required for medically reasonable and necessary therapy services provided above the cap amount since the claim may be submitted with a –KX modifier for Medicare payment.   

AHCA continues to advocate for a permanent replacement of the therapy caps before these provisions expire on March 31, 2015.  We are also working with CMS to fix administrative problems with the MMR process and will provide updates as they occur.  Please contact Dan Ciolek at dciolek@ahca.org if you have questions or suggestions.  


CMS Clarifies Use of ABNs for Part B Therapy Services

March 28, 2014 -- AHCA recently received an important clarification via email from CMS regarding when Part B therapy providers should issue Advance Beneficiary Notices (ABN’s) related to services provided above the current $1,920 therapy cap. CMS also advised how to properly code this on claims.    

The clarification addresses the following specific questions AHCA/NCAL asked CMS recently as the current, official ABN instructions (here) did not appear to address this possible scenario: If Congress does not act in time and the hard therapy caps resume on April 1, 2014:

1.     Should providers issue mandatory or voluntary ABNs to beneficiaries that request additional therapy services beyond the $1,920 cap threshold?

2.     If claims with services beyond the $1,920 cap threshold are billed in order to receive a non-covered service denial, which modifier should be used?

 

CMS Response:

If the therapy exceptions process isn’t extended, therapists will be required to issue the mandatory Advance Beneficiary Notice of Noncoverage (ABN) for all  Medicare-covered therapy services provided above the cap in accordance with §1833(g)(5)(D) of the Social Security Act which extends the limitation of liability provisions to services over the cap that aren’t paid by Medicare.

With a therapy cap exceptions process in place, ABN issuance is not required for medically reasonable and necessary therapy services provided above the cap amount since the claim may be submitted with a –KX modifier for Medicare payment.

However, if there is no provision for Medicare payment (e.g. hard caps without exceptions), the ABN is statutorily required for services provided above the cap in order to shift financial liability to the beneficiary. 

Therapists must also continue to issue the ABN for therapy services that aren’t medically reasonable and necessary regardless of therapy caps. 

When an ABN is issued, the –GA modifier is applied to the claim.

The –GY modifier is used for services that are statutorily excluded or not a Medicare benefit and never covered by Medicare. For example, once a beneficiary has reached his goals and is discharged from therapy, he may wish to continue on a personal training program with his therapist and pay out-of-pocket. In this case, if the beneficiary wants a Medicare claim filed for the personal training services, the –GY would be applied to the claim.


AHCA Comment:

Proper compliance with Medicare ABN requirements is essential to assure that both beneficiary and provider financial rights are protected. If the therapy caps exceptions process extension is not enacted by March 31, then SNF providers should be prepared to comply with the ABN requirement clarification described above for services furnished above the $1,920 therapy caps threshold.

 

Helpful Reference Links:


March 21, 2014 - SNF operators and therapists should consider how to manage and store the documentation associated with therapy MMR eligible claims that are being paid during the current RAC review ‘pause’ so that it will not be such a burden to locate and prepare to submit therapy MMR additional development request (ADR) responses once the ‘pause’ ends and reviews resume.

AHCA was recently able to discuss the current status of the Medicare Part B therapy manual medical review (MMR) program with an official at the Centers for Medicare and Medicaid Services (CMS).  Many details cannot be finalized awaiting necessary Congressional direction, and other details.  However, CMS was able to share where they are leaning if Congress extends the requirement to review all therapy claims above the annual $3,700 threshold for physical therapy (PT) and speech-language pathology (SLP) services combined, or occupational therapy (OT) services.      

Claims Processing and MMR ADR Generation Activities:

  • Claims with dates of service surpassing the $3,700 threshold in post-pay states by February 21, and pre-pay states by February 28 should have already received MMR ADRs and providers are required to respond to them by submitting requested documentation to the Recovery Audit Contractor (RAC) as usual. 
  • Claims with dates of service surpassing the $3,700 threshold after the above listed dates and up to March 31 remain subject to the current statutory MMR requirement, but due to the RAC ‘pause’, these claims will be paid as long as there are no problems identified by standard edits and other non-MMR related policies.  CMS currently intends to conduct post-pay MMR on these claims later using the RACs once the new RAC contracts are awarded.  
  • During the ‘pause’, Medicare Administrative Contractors (MACs) and other contractors may continue to conduct routine audits within the scope of their review contracts.    
  • There is no current statutory authority for CMS to conduct therapy MMR with claim dates of service beginning April 1.  However, if Congress elects to extend the therapy MMR requirement beyond March 31, then CMS is “leaning towards” eliminating the 11 state pre-pay review requirement and would have RACs conduct post-pay MMR in all states.  This is not a final decision.  However, if therapy MMR moves to 100% post-pay, then CMS is considering extending the review window to 30 days which is the standard for other review contractor requirements.  

Status of RAC Contractor Procurement:

  • The current ‘pause’ in RAC reviews mentioned above is to permit the current RACs to complete their activities under their current contracts by June 1, 2014 and any future reviews will be conducted by companies awarded the new RAC contracts.
  • CMS had hoped to award new RAC contracts by June 1.  However, the complexities of awarding new contracts has hit a snag as numerous bidders have submitted protests that need to be resolved that may result in delays in the contract award dates.
  • In addition, there is a possibility that one or more of the winning RAC contractors may be new and would require a longer period to start-up operations than any current contractors that successfully are able to renew their contract.
  • For the above reasons, CMS is unable to provide an estimate of when therapy MMR audits will resume at this time, but definitely no earlier than June, and likely later.   

CMS Provider Education:

  • CMS indicated that updated provider education materials related to the therapy MMR process will be published on the CMS website as soon as possible after they receive clear direction from Congress regarding whether the therapy MMR program will be extended beyond March 31.

Take Home Message:

  • Although it is encouraging that CMS has currently ‘paused’ therapy MMR review to allow providers to have time to focus efforts on the appeals backlog, and that CMS has listened to provider concerns, and now appears to be leaning towards eliminating pre-pay review if Congress extends the MMR requirement, nothing is written in stone yet regarding future CMS therapy MMR activities.
  • It appears at this time that CMS has every intent to retroactively review all beneficiary claims containing services over the $3,700 threshold that were paid during the ‘pause’ on a post-pay basis  once the new RAC contracts are awarded.  SNF operators and therapists should consider how to manage and store the documentation associated with therapy MMR eligible claims that are being paid during the current RAC review ‘pause’ so that it will not be such a burden to locate and prepare to submit therapy MMR additional development request (ADR) responses once the ‘pause’ ends and reviews resume.

As noted above, much of this this is a description of where it appears CMS intends to go with therapy MMR if it is required to do so by Congress, and is based upon an assumption that Congress would not provide any new directives that differ from current statute.  AHCA staff and members continue in our efforts with Congress to pass legislation that would ease the burden imposed by the current therapy MMR requirement.  We also continue working to educate CMS regarding our therapy MMR concerns so that future policy decisions are reasonable.  Some helpful therapy MMR links are below:   

Please contact dciolek@ahca.org if you have questions.  

Helpful Therapy MMR Links:



MEMBER ALERT – Part B Therapy MMR ‘Paused’

February 21, 2014 - Welcome news from the Centers for Medicare and Medicaid Services (CMS) after hearing last week at the Administrative Law Judge (ALJ) Forum that a significant increase in the number of audits in the Recovery Audit (RA) program over the last several years is a major factor for the 2+ year backup at the ALJ level.  On Tuesday, 2/18/14, CMS announced on its website that it is “pausing” RA audits in preparation for the procurement of new RA contracts and to “allow CMS to continue to refine and improve the Medicare RA Program.”  To obtain a complete copy of the announcement go to http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html

Specifically, CMS states in the announcement that it is in the procurement process for the next round of RA Program contracts.  According to CMS, it is important that the agency transition down the current contracts so that the RAs can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the RA Program.   Several years ago, CMS states that it made substantial changes to improve the RA program, and it will continue to review and refine the process as necessary.  

Per a February 21, 2014 email communication from CMS to AHCA, this ‘pause’ also applies to the Part B therapy MMR process as follows: 

  • February 21, 2014 is the last day for Recovery Auditors to send ADR letters (complex reviews and semi-automated reviews). This date also applies to post-payment reviews of Outpatient Therapy claims over the $3700 Threshold.
  • February 28, 2014 is the last day for MACs to send ADR letters for the Recovery Auditor Prepayment Demonstration (complex reviews). This date also applies to prepayment reviews of Outpatient Therapy claims over the $3700 Threshold.
  • If a provider has already received an ADR letter, or will receive one of the last ones (sent by the end of this month), the provider must comply with the request and submit the records, or a denial will be made on the involved claim(s).
  • Any records that were previously submitted to the Recovery Auditor will continue to be reviewed, and the provider will receive a review results letter, as usual.

This is an extremely positive development for SNF providers that receive the brunt of MMR ADRs due to the needs of the patient population we serve.  This ‘pause’ will permit providers to focus more on furnishing care for their current patients, while working to clear the backlog of current MMR ADRs and related appeals.  Please note that this ‘pause’ does not preclude providers from responding as required to any ADRs they receive, or have already received.  CMS has not yet reported an end-date for this ‘pause’.

AHCA will provide updates to this web page as new information is available.  Please contact dciolek@ahca.org if you have any questions.


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The Pathway for SGR Reform Act of 2013 continues an automatic exception to the therapy cap (Sec. 603, “Payment for outpatient therapy services”). The threshold for Manual Medical Reviews (MMR) for therapy claims in skilled nursing facilities (SNF) is $3,700 for PT and SLP services combined and/or $3,700 for OT services. Claims exceeding this amount are MMR reviewed in either a prepayment or a post-payment scenario, depending on where the facility is located. The MMR process gives Medicare contractors 10 business days to make decisions regarding whether services over the cap threshold of $3,700 will be paid. The Center for Medicare and Medicaid Services (CMS) chose Recovery Auditors (RAs) to conduct prepayment MMR review in 11 states and post-payment MMR review in the remaining states. 

Prepayment MMR review is occurring in these 11 states through 3/31/2014: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. When a therapy claim is submitted that includes services beyond the annual $3,700 exceptions process threshold, the MAC will request that the provider send documentation to the Recovery Auditor (RA) justifying the additional services. The RA is supposed to conduct the prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of its payment decision. 

Post-payment MMR review is occurring in all other states through 3/31/14. For therapy claims that exceed the $3,700 exceptions threshold, the MAC will pay the claim, but will then request that the provider send additional documentation on the justification for the service to the RA, which will conduct a post-payment MMR review and notify the MAC of its payment decision. 

Advance Beneficiary Notice of Noncoverage (ABN) -- Beginning in 2013, CMS revised the beneficiary liability policy related to the therapy cap and exceptions process. Essentially, here are the two ways this new policy works: 

The provider must issue an Advance Beneficiary Notice (ABN) to a beneficiary if he/she does not believe that continued therapy services above the cap limit will likely be determined to be medically necessary, and the beneficiary (or responsible party) must understand and sign the form before additional therapy can be provided. In this case, if the beneficiary approves additional therapy that is later denied by Medicare, the beneficiary is responsible for paying for the services.

The provider must not issue an Advance Beneficiary Notice (ABN) to a beneficiary if he/she determines that continued therapy services above the cap limit is medically necessary. In this case, if the additional therapy beyond the cap limit is later denied by Medicare, the beneficiary is not responsible for paying for the services.


Please visit ABN Notice of Coverage FAQ for more details.



AHCA Says The current audit process is broken and should be replaced… read more​ ​​​
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