CMS posted last night with final guidance on the Manual Medical Review for therapy claims above $3,700. 

Medicare Administrative Contractors (MACs) will conduct prepayment reviews until March 31, 2013 then beginning April 1, 2013 Recovery Audit Contractors (RACs) will conduct all reviews for all claims processed on or after April 1, 2013 that are over the threshold.

The Recovery Auditors will conduct two types of reviews: prepayment (in certain “demonstration”states) and postpayment in remaining states.

The RACs will conduct the prepayment reviews in a “demonstration” for the following statesFlorida, Pennsylvania, Ohio, North Carolina, Illionis, Louisiana, New York, Texas, California, Missouri, and Michigan

This is the process for prepayment reviews in “demonstration” states:

  • Claims submitted in the RAC Prepayment Review Demonstration states will be reviewed on a prepayment basis
  • The MAC will send an ADR to the provider requesting the additional documentation be send to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor)
  • The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision

All other remaining states, the RACs will conduct immediate postpayment review. 

This is the process for postpayment reviews in the remaining states that are NOT “demonstration” states:

  • Recovery Auditors will conduct immedicate postpayment review
  • In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim
  • The MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor
  • Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision

It is extremely important that business office managers/finance departments inform their on-site therapy manager immediately when an ADR is received.  The on-site therapy manager will collect all pertinent therapy documentation and will provide the documentation to the facility designee for submission to the RAC.  All pertinent documentation must be submitted timely for the review. Failure to submit all necessary documentation timely will increase your risk of not getting the therapy claim paid. 

Please share this information with those who manage/process therapy claims in your facility.

To review CMS’ guidance, please click here.

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