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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, April 15, 2013 Posted in: Outpatient Rehab

On February 28 we issued a blog that discussed Medicare’s interim solution to providing outpatient therapydocumentation review for patients that had neared or exceeded the 2013 threshold of therapy services CAP allowances. Going forward, with both the interim solution and the updated guidance, payment will hinge upon your waiting for the Fiscal Intermediary (FI/MAC) to begin the review process rather than the facility initiating the manual review. The real catch now is depending on the state you are in, your process will be either a pre-payment or post-payment decision beginning with services dated Apirl 1, 2013. CMS has now updated this information with further guidance posted on its website that describes these details.

The further guidance will need additional clarification as well, because the workflow timelines are not fully detailed in this release.

For example new guidance states this, “Medicare Administrative Contractors (MACs) will conduct prepayment review on claims reaching the $3,700 threshold with dates of service Jan. 1, 2013, to March 31, 2013. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process.”

Given this instruction, it is not clear as to when 10 days is counted. Recognition must occur in their system that the threshold has been reached by either OT alone or PT and SLP together, and then they must elicit records by an additional development request (ADR) in order to perform a manual review within 10 days. Given the best case scenario, as soon as their system recognizes and sends a requests for ADR documentation, the facility has 45 days to respond to an ADR. If you wait until that last day and then add the 10 days for them to review the documentation, you can easily see that the process will beg much attention at the facility level in order to decrease the waiting time for a pre-payment review and decision of payment. For at least the first three months of the year, regardless of state, you are looking for a delay in payment beyond your previous payment cycle. Be prepared – your reaction makes all the difference in how much delay to expect!

Unfortunately, the newest process still does not allow for you to initiate the review, even after March. Regardless of state you must wait for the limit to be billed to the fiscal intermediary/MAC based on the recognized billing thresholds. After their system recognizes the threshold was met, payment process will unfold in one of two ways for all services on or after April 1, 2013; the caveat – your state will determine whether you get paid first and denied later or paid after review of the completed review. Either way, you must provide the services to the beneficiary in advance of the decision!

Documentation must clearly provide reasonable and necessary care for the condition requiring your skilled interventions and all guidance in the Medicare Benefit Policy Manual; 100-02  Chapter 15; Section 220 must be followed as implemented Jan 7, 2013.

Per guidance:

“Prepayment Review:

  • Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.
  • In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor).
  • The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.

Postpayment Review:

  • In the remaining states, the Recovery Auditors will conduct immediate postpayment review.
  • In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. The MAC will send ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision.”

Either way, final payment will always be as a result additional documentation request and review. Whether you obtain and hold on to that payment will depend on your therapist ability to document thoroughly to mandated details and reasonable and necessary care. If you’re not in a prepayment review state, you’ll at least have a smaller days outstanding margin to wait for payment. If clinical documentation has much to be desired, eventually you’ll give away free care whether you were effective or not in reaching that patient’s intended goals.

Both processes mandate in some form: treat now and pay later. Due diligence to chart audits will demand thorough compliance.