Businessman Analyzing Document
10th Feb

All four current RAs received approval on January 16, 2015, to begin issuing ADRs to providers for manual medical review of 2014 therapy claims on a post payment basis. The CMS procedures apply to claims made by outpatient therapy facilities, including skilled nursing facilities, outpatient hospitals, rehabilitation agencies, and comprehensive outpatient rehabilitation facilities.

Recovery Auditors received approval on January 16, 2015, to resume the Part B manual medical review (MMR) on a post-payment basis of claims over 3,700 from March 2014 to December 2014.

All eligible claims will be reviewed in chronological order, based on the month in which they were paid.

  • All eligible claims paid in March would be reviewed prior to the claims paid in April
  • Claims paid in April would be reviewed prior to claims paid in May
  • If a provider has a low number of claims (for example, 1 or 2 claims) paid per month, more than one month’s worth of claims can be requested in the same additional documentation request (ADR).

ADRs will be issued in five cycles:

  1. The first ADR sent to each provider for these claims will only request the documentation for one claim. Any provider with one or more claims meeting the criteria above can receive an ADR.
  2. The second ADR sent to a provider can request up to 10% of the total number of eligible claims. For example, a provider had a total of 28 claims paid between March 1, 2014 and December 31, 2014.
    1. 3* claims can be included in the second ADR. [* rounded to the nearest whole number]
  3. The third ADR sent to a provider can request up to 25% of the remaining eligible claims.
    1. For example, a provider had a total of 28 claims paid between March 1, 2014 and December 31, 2014.
      1. 1 claim was requested in the first ADR,
      2. 3 claims were requested in the second ADR, leaving 21 claims not yet requested
      3. Therefore, 25% (6 claims) of the 24 claims can be included in the third ADR.
  4. The fourth ADR sent to a provider can request up to 50% of the remaining eligible claims.
    1. For example, a provider had a total of 28 claims paid between March 1, 2014 and December 31, 2014.
      1. 1 claim was requested in the first ADR,
      2. 3 claims were requested in the second ADR,
      3. 6 claims were requested in the third ADR, leaving 18 claims remaining.
      4. Therefore, 50% (9 claims) of the 18 claims can be included in the fourth ADR.
  5. The fifth ADR sent to a provider can request up to 100% of the remaining eligible claims.
    1. For example, A provider had a total of 28 claims paid between March 1, 2014 and December 31, 2014.
      1. 1 claim was requested in the first ADR
      2. 3 claims were requested in the second ADR
      3. 6 claims were requested in the third ADR
      4. 9 claims were requested in the fourth ADR, leaving nine (9) claims remaining.
      5. Therefore, 100% (9 claims) of the 9 remaining claims can be included in the fifth ADR.

The ADR cycles have not changed and remain at 45 days between ADR letters.

CMS does not plan to post any additional information regarding these reviews.

For more information, please review the procedures and Q&A document provided to NASL and other provider groups.

 

Sheila Capitosti

VP of Clinical/Compliance Services

 

 

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