CMS Resumes Part B Therapy Manual Medical Review (MMR) Program

Late last week, the Centers for Medicare and Medicare Services (CMS) sent a notice and a FAQ document to organizations representing providers that they were resuming the Medicare Part B therapy manual medical review (MMR) program immediately.  As you may recall, the MMR program was implemented by CMS in October 2012 as part of a previous extension of the therapy caps exceptions process.  Under MMR, Medicare recovery audit contractors (RACs) are to review Part B therapy claims over a $3700 threshold per beneficiary per year.  Due to problems in the MMR process and delays in issuing new RAC contracts, the therapy MMR program was put on a 'pause' at the end of February 2014.

Below is a summary of the key elements of the MMR resumption that AHCA members and their clinical and billing staff should be aware of and prepare for:

1. Starting immediately, RACs may resume part B therapy MMR for all MMR eligible claims over the $3700 threshold for claims paid between March 1, 2014 and December 31, 2014.
2. The reviews will be post-pay review only in all states for the 2014 claim reviews.
3. Claims will be reviewed in chronological order so that, for example, claims paid in March 2014 will be reviewed before claims paid in April 2014.
4. There will be 5 waves of reviews conducted to address all 2014 MMR reviews which AHCA estimates will be conducted from February through August 2015.  Providers with therapy MMR eligible claims should expect to receive therapy MMR additional development requests (ADRs) approximately every 45 days as follows:

• Phase 1 - One claim review request will be issued in the ADR.
• Phase 2 - Up to 10 percent of the total MMR eligible claims for 3/14-12/14 will be included in the ADR.
• Phase 3 - Up to 25 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 4 - Up to 50 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 5 - Up to 100 percent of the remaining MMR eligible claims for 3/14-12/14

CMS notes that this current resumption only applies to facility-based providers, including skilled nursing facilities.  In addition, CMS has not identified a process yet for how they intend to conduct reviews for 2015 MMR eligible claims.  While CMS state they do not plan to post additional information regarding these reviews, AHCA will continue to seek further clarification.

AHCA has been, and continues to be very concerned with the serious flaws in the arbitrary $3700 therapy MMR threshold that Congress established, and how CMS has interpreted to mean that 100 percent of claims above this threshold must receive burdensome complex review, regardless of beneficiary condition, or provider history of compliance with Medicare policy.

AHCA is actively engaged with Congress in advocating for therapy reforms like the therapy cap repeal provisions reported out by the Senate Finance Committee in the 113th Congress.  However, since that may take some time, we are also seeking immediate reforms to the therapy MMR program as a bridge to the larger reforms, and are asking Congress to require CMS to target MMR reviews and education efforts to providers with a history of improper payments rather than the cumbersome 100 percent review process described above.

If you have any questions please feel free to contact Danie Ciolek, Senior Director, Therapy Advocacy, at dciolek@ahca.org or 302-740-7888.