From NARA on Manual Medical Review

Update on CMS Targeted Manual Medical Review Process

June 6, 2016

NARA has received an update on the implementation of CMS' plans for implementing the targeted manual medical review (MMR) provisions established by Congress in MACRA.  CMS has met, discussed and reviewed a great deal of information from the previous process before implementing the new process.  They acknowledge some providers treat an abundance of chronically ill patients who often exceed the cap due to their conditions and they want to prevent providers of this nature from constantly receiving ADRs which are almost always denied and then overturned.  Following are some items of importance to you:

• The Supplemental Medicare Review Contractor ("SMRC"), Strategic Health Solutions will examine providers who furnish "a lot" of minutes/hours of therapy per day at the patient level as well as providers of service who have a "high" percentage of patients that exceed the $3,700 threshold.  According to CMS, the SMRC is permitted to define what "a lot" and "high" percentage means; however, they have an understanding on how therapy is provided in all settings.  These definitions could evolve over time as the SMRC improves and assesses its data. 
• A different analysis of claims and minutes will be used between individual providers and large groups, for example, if a solo provider is billing 16 hours a day, 365 days a year, this is would be a red flag. 
• The SMRC has been directed to compare like providers such as SNF to SNF, private practice to private practice, etc.
• The review contractor will send one ADR for 40 claims per provider.  Providers should only expect one request with the possibility of additional requests if the provider appears to have significant compliance issues.
• The SMRC has 45 days to review the claims and medical records and issue a determination to the provider which will address all 40 claims under review, some of which may be denied and others approved.  Procedurally, the provider may engage the SMRC in a discussion period to provide additional details that may overturn the initial determination in the provider's favor.  Any denials not resolved during the discussion period will be turned over to the applicable Medicare Administrative Contractor (MAC) for recoupment at which time the provider may appeal the SMRC's determination.
• The SMRC has updated its website and it now includes a sample ADR letter for reference.  https://strategichs.com/smrc/current-smrc-projects/.

CMS does not want to penalize providers who are providing proper services the proper way; however, it is difficult to identify who these providers are with their limited resources.  The change in this process is intended to do more targeted reviews on providers who are providing services up to the threshold or providing inappropriate services beyond the threshold.  Claim reviews will begin with dates starting July 15, 2015 – the SMRC has already begun sending out requests.  Latesha Walker is the contact person for questions providers have about the process.  NARA is already working with Latesha to provide feedback from NARA Members about the process and identifying chronically ill patients.

CMS recognized that there were inconsistencies when the manual medical review was initially rolled out.  The selection of a single contractor should provide consistency in communication and reviews.  There would be a mix of nurses and therapists on staff conducting reviews.  CMS has indicated the ultimate goal of the targeted review process is to turn up legitimate issues and not bother providers who are not posing an issue to CMS.  Providers should, however, focus on ensuring that high dollar claims are properly documented because they may be audited.

NARA will continue to keep you posted on any updates regarding the targeted medical manual review process.

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