CMS is targeting outpatient therapy providers that stopped therapy services just under the therapy cap.  More than 350 therapy providers will receive letters from CMS’ review contractor, Strategic Health Solutions to review claims from August 2012 through March 2013.

Through CMS’ data mining and analysis, outpatient therapy providers who stopped or held therapy services just under the therapy cap are the focus.  Therapy providers who stopped therapy at or near the cap and then resumed under a new benefit period are now subject to medical necessity review.  Therapy providers who thought stopping therapy at the cap and then resume therapy under the new benefit period would save the patient money (the patient was liable for therapy over $1880 in 2012).  This practice is most likely the cause for this specific medical review.

The ADR notification letter reads like this:

Analysis of Medicare claims data between August 2012 and March 2013 identified provision and billing for therapy services that either stopped or delayed just under the allowed therapy cap.  This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.908(b).  StrategicHealthSolutions LLC is requesting additional documentation for these claims for supplemental medical review of outpatient therapy services authorized by CMS.”

If you receive an ADR notification letter from Strategic Health Solutions, make sure you carefully read the letter and follow their instructions for submitting the ADR packet.  Therapy providers have 45 days from the date of the letter to submit documentation to support the claims.  Strategic Health Solutions has 60 days from the receipt of your ADR packet to provide a response.

Please ensure your on-site therapy manager is aware of the ADR and is involved in collection and review of the therapy documentation.  Therapy managers should inform the RM and Functional Pathways’ denials department of the ADR notification request.

Gina Tomcsik

Director of Compliance

Functional Pathways

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