CMS Announces New Approach to Manual Medical Reviews

Tuesday, February 16, 2016
CMS Announces New Approach to Manual Medical Reviews

To the surprise of APTA and other organizations that were expecting to get more information and provide input on the plan, the US Centers for Medicare and Medicaid Services (CMS) has moved ahead with a system for manual medical reviews for physical therapy and other services that exceed the therapy cap.

Last week, CMS announced that it has contracted with Strategic Health Solutions to serve as a supplemental medical review contractor (SMRC) to conduct a “targeted review process” for claims that exceed the $3,700 cap for physical therapy and speech-language pathology combined, and $3,700 for occupational therapy services. Unlike previous years, in which reviews were conducted for all claims exceeding the thresholds, the new approach allows Strategic Health to select only certain claims for review.

According to CMS, Strategic Health will pay particular attention to 2 main areas: providers with “a high percentage” of patients receiving therapy beyond the thresholds compared with peers; and “therapy provided in skilled nursing facilities, therapists in private practice, and outpatient physical therapy or speech-language pathology providers … or other rehabilitation providers.” CMS writes that an evaluation of the number of units or hours of therapy provided in a day will be “of particular interest.”

The new approach is required as part of changes adopted in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The announcement was made with little warning from CMS, and was apparently developed without input of any stakeholders, including APTA, which made numerous requests to meet with CMS on the subject. The association has requested more information on the new process, and will provide members with details as they become available.

Posted by News Now Staff at 2:04 PM