CMS Announces Plan for Medical Review of Therapy Claims Above $3,700 Threshold
CMS has released information about its plans for implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provisions regarding the manual medical review process for outpatient therapy services over the annual threshold. By way of background, the Medicare program has an annual limit on the amount of expenses a patient can accrue for outpatient therapy services in a given year; the 2016 limits are $1,960 for physical therapy (PT) and speech-language pathology (SLP) combined and $1,960 for occupational therapy (OT). Exceptions to the therapy cap are allowed through December 31, 2017 for reasonable and necessary therapy services, but services totaling more than $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. Prior to MACRA, manual medical review was required for all cases in which services exceeded these thresholds. MACRA directed the HHS Secretary to replace the manual medical review process with a new process using such factors as the Secretary determines to be appropriate.
According to a February 9, 2016 CMS web post, CMS has named Strategic Health Solutions the Supplemental Medical Review Contractor to perform post-payment reviews of selected therapy claims, with a focus on:
- Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA; and
- Therapy provided in SNFs, therapists in private practice, and outpatient PT or SLP providers or other rehabilitation providers.
CMS notes that the number of units/hours of therapy provided in a day is of “particular interest” during the medical review process.