Medicare is implementing manual medical review of all outpatient therapy claims that exceed the $3,700.00 threshold effective April 1, 2013 in 11 states, FL, CA, MI, TX, NY, LA, IL, PA, OH, NC and MO. There are two separate thresholds that will implement manual medical review, $3,700.00 for occupational therapy (OT) and a separate $3,700.00 for physical therapy (PT)/speech language pathology (SLP). When manual medical review is needed it will be completed by the Recovery Auditor Contractor for the region where services were performed.
When Medicare in the above stated 11 states receives a claim for therapy that exceeds the $3,700.00 threshold the Recovery Auditor (RA) will have the Medicare Administrative Contractor (MAC) issue an Additional Documentation Request (ADR) for the associated medical records. The RA must review the medical documentation before payment can be made. The RA will review the claim and medical documentation within 10 business days of receiving the records and will issue their ruling. Then the claim will either be paid or a review results letter will be sent to the provider detailing the rationale for denying the claim.
For all other states the review will be conducted post payment, meaning the RA will review the medical documentation after the MAC has made payment. Any claim beyond the $3,700.00 threshold will automatically trigger the manual medical review process and the MAC will issue an ADR with instructions on where to send the medical documentation. If the RA determines that improper payment was made they will send a demand letter for refund along with the rationale for the denial of the claim.
Providers need to make sure that all Medicare patients have a plan of care that is reviewed and signed by a Medicare certified referring doctor. Also, all documentation must show the medical necessity of the services and document exactly what services were performed and the time spent on each service. There should also be documentation that the services of a licensed, therapist are needed and that there are specific goals that the patient is working towards meeting.
Superior Medical Billing Solutions can complete a chart audit of your patient files to help make sure you are in compliance with professional standards of documentation for therapy services. We can also help with tracking a patient’s progression towards hitting their therapy caps and thresholds so you can be aware of patients that are getting close to both amounts. These are just part of the services provided by Superior Medical Billing Solutions to our clients. If you need a practice management company to help you in these increasingly regulated times, Superior Medical Billing Solutions is here to help you navigate these issues.