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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. 

·       Due 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. 

·       As 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 targeting processes. 

    • 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.

·       The RACs must still comply with Additional Documentation Request (ADR) limits so that providers are not overwhelmed with reviews.

·       The RACs must still comply with the 5-phase therapy MMR cycle for eligible 2014 claims. 

    • 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.   

·       Providers continue to have 45 days to respond to the MMR ADR letter.

·       The 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 meetings.

·       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 RACs.

·       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 targeting.

·       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 available. 

If 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 at dciolek@ahca.org.

Helpful Therapy MMR Links:

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