There has been a lot of chatter in the industry about the Government Accountability Office’s (GAO) report regarding the quarter 4, 2012 manual medical review process.  According to the GAO, CMS did not provide therapy contractors timely guidance which ultimately resulted in confusion and struggles with implementation of the manual medical review process.  The GAO states that the process appears rushed and inconsistent for all involved (MACs, SNFs, and therapy providers).  My initial thought was, ‘Really?’  You didn’t realize this until now??

According to the GAO, CMS provided the MACs with the manual review process a month before it began and when the reviews started, the MACs were not sure how to manage information sent in from providers that were incomplete nor did MACs have a clear understanding how to count the 10-day review time limit.  In addition, the GAO stated that the MACs didn’t have time to automate their computer systems to handle the volume of pre-approval requests.  Because CMS didn’t provide a clear manual review process, some MACs conducted the manual medical review process differently.  This further increased confusion with therapy providers and compromised efforts to collect information and outcomes of the reviews.

So, now that CMS has streamlined the manual medical review process of claims exceeding the $3,700 threshold to the RACs, CMS feels that the issues faced with the Q4 2012 MMR process will improve tremendously.  Again, my initial thought was—‘Really??’  Have you seen a seamless MMR process thus far?  I haven’t!  As I previously blogged, there are serious issues, confusion, and cash flow problems to say the least.  But you can rest assured that the GAO will have an analysis of the current MMR process in about seven months if we are lucky!  So hang in there and work closely with your therapy provider.  Together we will hike through the constant scrutiny we are facing.

The GAO full report can be found here:


Gina Tomcsik

Director of Compliance

Functional Pathways