CMS Announces Updated Review Process for Part B Therapy

According to the Centers for Medicare and Medicaid Services (CMS), the therapy cap exception process was extended through Dec. 31, 2017 by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The act, signed into law April 16, 2015, modified the requirement for manual medical review for services over the $3,700 therapy thresholds, allowing a targeted review process as opposed to the manual review of all claims that exceeded the thresholds. Additionally, MACRA also prohibited the use of Recovery Auditors to conduct the reviews.

According to CMS, it has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this targeted medical review process on a post-payment basis. The information available confers that the SMRC will be selecting claims for review based on the following:

• Providers with a high percentage of patients receiving therapy beyond the threshold, as compared to their peers during the first year of MACRA (with special interest in the number of units and hours of therapy provided per day).
• Therapy provided in Skilled Nursing Facilities (SNFs), therapists in private practice, and outpatient  physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers.

There is no additional information provided by CMS to identify what amount of therapy services delivered will trigger an interest by the auditors, however, a facility with service delivery patterns that appear to be an outlier as compared to peer facilities would likely be at risk of a review.

Contact: Michelle Synakowski, msynakowski@leadingageny.org, 518-867-8850.