Harmony Healthcare Blog

RAC Auditors Resume Nationwide – SNF Part B Claims at Risk

Posted by Cyndi Ouellette on Mon, Feb 09, 2015


Edited by Kris Mastrangelo

medical-record-documentation-300x199-891219-editedCMS has recently issued a notice and FAQ to organizations of providers as a notification of their intent to resume the Medicare Part B Manual Medical Review process for those beneficiaries over the threshold of $3,700 for outpatient therapy per calendar year.  These reviews were placed on hold as of February 2014 but are set to resume immediately.  The four current Recovery Auditors (RACs) have been approved to resume sending ADRs as of January 16, 2015 for those claims that hit the threshold between March 1, 2014 and December 31, 2014.

The critical areas that facilities should be aware of and prepare for include:

  • Effective immediately, RACs may resume Medicare Part B therapy Manual Medical Review (MMR) for all eligible claims over the $3,700 threshold for claims paid between March 1, 2014 and December 31, 2014.
  • The reviews will be on a post-payment review basis in all states for the 2014 claims over the threshold.
  • 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.
  • There will be 5 waves of reviews conducted to address all 2014 MMR reviews. 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 March through December 2014 will be included in the ADR.
    • Phase 3:  Up to 25 percent of the remaining MMR eligible claims for March through December 2014.
    • Phase 4:  Up to 50 percent of the remaining MMR eligible claims for March through December 2014.
    • Phase 5:  Up to 100 percent of the remaining MMR eligible claims for March through December 2014.

CMS notes that this current resumption only applies to facility-based providers, including skilled nursing facilities.  Providers can be assured that CMS intends to review all claims that are above the $3,700 threshold.  In addition, CMS has not identified a process yet for how they intend to conduct reviews for 2015 MMR eligible claims.  Understanding the process and managing these inquiries in a timely and detailed manner is critical in order to minimize recoupment of Medicare Revenue. All supporting documentation should be present and organized in the medical record in order to assist in streamlining the potential review process.  This includes not only the therapy documentation, but the supporting detail from the Interdisciplinary team identifying the need for skilled intervention including the physician as well as any noted decline or referral from nursing.  

It is important to read the ADR notice carefully, paying attention to dates of service and what is being requested to ensure that all documentation is gathered and submitted.  If you do not submit all of the required documentation, there is potential for total denial of the claim.

Once again, timely submission is critical.  The typical timeframe for a response is 30 days to respond to an ADR, the notice will indicate the time line.  Missed deadlines equate to denied claims.  

Skilled nursing facilities should review their current process for ADR and denials management asking the following questions:

  • Who in the facility is responsible for forwarding the ADR notice to the appropriate parties such as Medical Records, MDS, Therapy Director, DON, Administrator, etc.?
  • Once the notice is received by Medical Records:
    • Who is then responsible for reviewing the details of the ADR and gathering the appropriate medical record information?
    • Who is the most appropriate team member to initially review the record for completeness?  MDS Coordinator, Director of Nursing?
    • What is this person's next step?  Send to the Therapy Director, Director of Nursing, etc. or review?
    • Has the facility designated a clinician or third party expert to write a summary or response letter to the Medicare Contractor supporting the clinical decision making for the rendered services?
    • Who then receives the final compilation, makes the appropriate copies and submits to the requesting entity?
  • Who is responsible to track the process to ensure timely responses from all parties required to review the medical record?
  • Once submitted, who then tracks the system once the package has been sent to the entity to determine successful resolution, or the need for additional steps to appeal an unfavorable decision?
Harmony Healthcare International (HHI) recommends providing ongoing education and training for SNFstaff to ensure all members of the Interdisciplinary team are documenting the skilled care they are providing.  As always, Harmony (HHI)’s Claims Review Specialists are available to assist the facility through this process.

If you need help with preparing for RAC audits or claims management, please click here to contact Harmony Healthcare International or call us at (800) 530-4413. 


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