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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, March 1, 2013 Posted in:

Just when we thought we didn’t really have a solution for the Therapy Caps Manual Medical Review, the APTA released a bulletin recently that states CMS has decided how it will manage the 2013 process previously referred to as Manual Medical Review to approve therapy services beyond the Cap.

From Oct. 1, 2012 until Dec. 31, 2012, Manual Medical Review required seeking approval from the fiscal intermediary for up to an additional 20 visits once the threshold of $3,700 was reached and after attesting and applying the KX modifer for $1,900 of combined  PT/SLP or the OT benefit alone in the outpatient therapy setting. Going forward, this will now hinge upon your waiting for the Fiscal Intermediary (FI/MAC) to begin the review process. Just how much treatment do you provide past $3,700 to allow their ADR request and pre-payment review process to be elicited?

Why is this significant? It realigns the approval with a process already utilized by FI/MACs – “prepayment review,” and possibly consolidates their work into one rather than two separate review processes. How so?

Recall that previous instruction for 2012  covered each of these questions below in “quotations.”

Will claims that are pre-approved be guaranteed payment?

Answer: Authorization does not guarantee payment. Retrospective review may still be performed.”

My comment: Past process maintained a two-step process. FI/MACs had to ‘look again.

“Why would a Medicare contractor review therapy that has been pre-approved?

Answer: There are many reasons retrospective review would be needed after a pre-approval: clinically inappropriate modalities; patient’s clinical therapy needs do not match what was reported. For example:

  • Patient’s functional level is greater than reported;
  • Patient reached functional independence more quickly than predicted;
  • Excessive or inappropriate therapy was furnished, e.g.;
  • Therapy more often or of longer duration than is medically r/n;
  • Therapy provided to clinical treatment area not reasonable and necessary, e.g. therapy to shoulder when knee is the issue.”

My comment: In prepayment review, they see documentation after services have been provided; they can establish if all the above were actually completed, thus reducing CMS payment risk and no further need to review the same claim twice. If you did not meet the conditions, just as before, you still would not be paid. For FI/MACs this is less work to review just once.  The burden/risk is completely upon the documentation of provider ‘in retrospect.’

“What happens if I request pre-approval and gain approval for 20 treatment days and I actually furnish 30 treatments?

Answer:  The claim will be subject to prepayment medical review.”

My comment: Inspection after the fact keeps the FI/MAC from doing this step TWICE. Seeing that previously it was already OPEN to prepayment review even if the approval process and additional sessions were rendered.

So you have to ask, is this ‘interim’ process a good alternative? It depends who is asking the question. Although not exhaustive, what are a list of the present questions/concerns?

  • Medicare beneficiaries must wait for the FI to initiate the ADR; when bills are  dropped generally monthly, this will add time for the FI to recognize that the threshold WAS met (previously you could solicit approval upon you  knowingly ready to reach the threshold). This adds additional delay to  access of care.
  • Once the ADR is requested, the process may wind its way through the fiscal departments rather than directly to the requesting party as allowable in the manual medical review process.
  • Once the ADR has been sent, information copied and returned to begin the 10 day turnaround of approval to occur, will it be for individual service dates or up to 20 days as previously discussed? Not covered in this quick  interim discussion.
  • The  interim instruction does not state whether an ABN is recommended for any care provided awaiting the pre-payment review. Since ABNs must be  specific, why would you alert the beneficiary that it ‘may not be paid’ when in fact you are attesting to the medical necessity and supplying the  rationale and documentation that it is necessary?
  • It  appears that this process reduces the administrative work required at both the provider and FI for administrative steps. The provider still must keep track of billable care but this eliminates the request processes and the FI adds an additional flag for total paid service to produce an ADR they are  already accustomed to handling – now with a speedier turn around.
  • A clinic assured of their documentation and practices may choose to provide services as necessary and take the chance/risk that approval is forthcoming. Does this make administrative review of documentation have tighter controls to gear up for possible denial process reviews?
  • I  am certain you are thinking of a few questions/issues yourself. Don’t be  shy and add those to the comment of this blog. We can always forward the list to the provided ‘comments to CMS on caps’ email address.