In the January 2014 publication of McKnight’s, NASL’s, Cynthia Morton reports that a recent survey was conducted regarding claims under manual medical review for those beneficiaries who exceeded the Medicare Part B cap thresholds. This survey revealed a huge amount of backlogs of therapy claims.  Less than one-fourth of the manual medical review claims for 2013 have been paid, one-third of the claims are still being processed, and another one-third already had been denied. Read McKnight’s Article. In addition, there is a temporary suspension of scheduling ALJ hearings, so your cash flow can be compromised for several years.

So what are providers to do?  It is our responsibility to advocate for our patients to receive the care they are entitled to and deserve. The relationship between therapy and facility is vital to successful patient care and being proactive in the following areas is key to weathering this storm:

  • Nursing documentation should support the need for therapy intervention after all other nursing interventions have been exhausted and documented in the medical record.
  • Adequate recording of resident performance with direct care personnel in the medical record is crucial to reflect an accurate picture of the resident’s acuity of care they require.
  • Therapy documentation must be technical, sophisticated, reflect that the skills of a therapist are vital for the skilled care of that resident’s diagnosis/condition.
  • Therapy care must be reasonable and necessary evidenced in the therapy documentation.
  • Billing department will need to have amplified awareness & expedite their notification process to therapy department/therapy provider of any ADR notifications, decision notifications, claim rejections, denials, appeal decisions, etc. for timely and effective appeals.