Written By: Kathy Boyarko, PT, CDP, Program Development Manager
As you may have noted, the Manual Medical Review process for Medicare Part B therapy patients receiving outpatient therapy in 2013 is a little different than it was for 2012. The pre-approval process for Medicare Part B patients who are over their threshold of $3700.00 is no longer required; however, an ADR or additional development request will be generated and sent to the facility once the claim is billed for each of these patients that exceed their threshold. This new process is more streamlined and provides an opportunity to better prepare and meet the ADR requirements.
Last fall Medicare was overwhelmed with all of the MMR reviews and the process was not successful. Therefore this year the reviews are going to be performed by RACs or Recovery Audit Contractors, which are specialists that contract their services to Medicare to perform the auditing for them. When Part B patients reach the $3700.00 threshold, the regional MAC (Medicare Administrative Contractor) will send the provider (the facility) an ADR letter. Remember, this letter is not a denial as it is just a request for more information. The facility will have 30 calendar days from the date on the letter to respond to the ADR. Some RAC ADRs have been asking for more information than the MACs have asked for in the past.
- A copy of the billing submitted (CPT codes). If they ask for this you will need to do a review to ensure that what was billed matches the documentation for what was billed. Occasionally a therapist may mistakenly document their daily note in the incorrect CPT code box. This would cause a problem and be a red flag for denial. Any errors found should be corrected and then the billing report re-printed before being sent in.
- A copy of the professional license of the provider. It is recommended that all therapists make several copies of their licenses for the RMs to keep in a folder to have on hand when needed. This can be completed now before you get an ADR and then only have a limited time to respond.
- An abbreviation list. Medicare does not have an official abbreviation lists and recommends that each facility has their own. Find out if your facility does and make several copies of it to have on hand.
- Justification when the certification of the POC is delayed more than 30 days. If your physician fails to sign the POC within 30 days there needs to be a written explanation of why it was delayed.
The RAC auditors have 10 days to review the information and make a determination. If they are unable to review within the allotted time frame, the claim will be paid.
If you receive a denial after submitting the requested ADR information, you will need to follow the normal steps for a redetermination. If this is denied you can follow the normal steps for a reconsideration. If the reconsideration is denied, you can request an ALJ, or Administrative Law Judge hearing. Blue Sky recommends completing all the steps of the auditing process and has an excellent rate of recovery for our claims.