In February of 2016, CMS reported that Strategic Health Solutions will be the Supplemental Medical Review Contractor (or “SMRC”) performing post-payment Manual Medical review of all Medicare Part B claims that exceed the $3,700 threshold.

This manual review is required as a result of the Medicare Access and CHIP Reauthorization Act of 2015 (or “MACRA”). This act extended the therapy cap exception process through December 31, 2017 and changed the requirement for manual medical review from all services that exceed the $3,700 thresholds ($3,700 PT/ST combined; $3,700 for OT) to a targeted review. This act also prohibits the use of Recovery Auditors from conducting the reviews.

The claims will be selected for review based on the following criteria:

  • Providers with a high percentage of patient receiving therapy beyond the threshold as compared to their peers during the first year of MACRA
  • Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs), or other rehabilitation providers are subject to review

CMS also states, “Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day”.

Our VP of Compliance services attended a session a few weeks ago at a health care conference and was informed that 500 over threshold ADR letters went out in April and an additional 14,500 over the threshold ADR letters went out in recent weeks. For a sample of this letter, click here.

Look out! If you are a provider with a high percentage of patients receiving therapy beyond the threshold compared to your peers, then you will want to be aware of these ADR notification letters and partner with your rehab provider to ensure all necessary therapy documentation is included in your ADR packets.

For more information, please visit the CMS Therapy Cap Website.