Update - July 31, 2015
As you are aware,
the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted in 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 $3700
annual per-beneficiary threshold with a targeted review program for
claims over the $3700 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 has
recently expired. Several of you have
been contacting us recently as CMS has not posted any substantive updates to
date, and you continue to receive therapy MMR ADRs.
Since the enactment
of MACRA, AHCA and other therapy professional and provider organizations have
been in regular contact with CMS to clarify the intent of the legislation, ask
questions, and provide recommendations regarding implementation. Part B therapy MMR is in a very fluid state currently,
but is moving in a positive direction. This message provides an update as
to the status of the CMS implementation of the new targeting requirements based
upon these communications with CMS.
Currently, the only MMR taking
place is for MMR-eligible claims paid in 2014.
· This is post-payment review only
for facility-based providers such as SNF.
- Pre-payment review stopped
in February 2014.
to contracting issues, the Recovery Auditors (RACs) assigned the 2014
facility-based provider claims for review earlier this year will continue to
conduct MMR on these claims.
of mid-July the RACs were instructed to stop 100 percent review, and instead
conduct targeted review of the 2014 claims using their existing proprietary
- RACs are incentivized to identify improper payments,
and the new targeting instructions (instead of 100 percent review) will
likely reduce review volume for providers with low MMR denial history.
RACs must still comply with Additional Documentation Request (ADR) limits so
that providers are not overwhelmed with reviews.
RACs must still comply with the 5-phase therapy MMR cycle for eligible 2014
- This means that providers should not receive any
more than five MMR ADR letters from RACs, and these letters cannot be
sent no earlier than 45 days from the prior MMR ADR letter.
continue to have 45 days to respond to the MMR ADR letter.
RACs continue to have 60 days to make a decision on these post-payment reviews.
By late 2015, CMS intends to
implement the new targeted MMR program per MACRA legislation requirements for
remaining eligible claims paid through 2017.
· AHCA and other therapy provider
and professional associations are communicating with CMS in writing and via
· No start date has been established
by CMS so no MMR for 2015 claims is currently being conducted.
· CMS has not decided if the
Medicare Administrative Contractors (MACs) or Supplemental Medical Review
Contractor (SMRC) will conduct the new MMR, but it definitely will not be the
· CMS has not determined how the
targeting of claims will be conducted, to comply with the MACRA legislative
requirements, but only claims above the $3700 threshold will be subject to the
· CMS has not yet determined if the
new targeted MMR reviews will be conducted on a pre-pay or post-pay basis.
The three prior iterations of the Part B therapy MMR
program implementation/revisions were fraught with serious problems that
directly impacted beneficiary access to care and provider cash-flow. AHCA is cautiously optimistic that this
fourth iteration will be more reasonable as CMS is taking the prudent routes
of: 1) applying a retroactive targeted
approach to 2014 claims already in the RAC review pipeline to reduce burden,
and 2) seeking stakeholder input before implementing the new MACRA required
targeting methodology moving forward. We
will continue to update you as soon as substantive information becomes
you have any questions regarding the new targeted MMR process, or continue to
have unresolved problems with the prior 100 percent review MMR process, please
feel free to contact Daniel E. Ciolek, AHCA Senior Director of Therapy Advocacy
Helpful Therapy MMR Links: