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Inside Health Policy - CMS Lays Out Targeted Therapy Review Process, But Questions Remain

Michelle M. Stein (, 2/18/2016

CMS quietly released information on how the agency plans to target therapy manual medical reviews as required by the Medicare Access and CHIP Reauthorization Act, in a move that caught some stakeholders by surprise as the policy doesn't match what many were expecting and leaves questions unanswered.


Dan Ciolek, associate vice president for therapy advocacy at the American Health Care Association, said that stakeholders hope to meet with CMS to discuss many of the unanswered questions. He raised concerns that CMS' newly unveiled therapy review process could target costly patients instead of risky providers, doesn't appear to factor in a provider's claims denial rate or historical data, and lacks details on the review process.


Tim Nanof, director of health care policy and advocacy at the American Speech-Language-Hearing Association, says that while the policy CMS has proposed is in compliance with certain parts of the MACRA law, CMS hasn't laid out the best way to identify problematic situations.


CMS on Feb. 9 said in a website post that the agency plans to have a Supplemental Medical Review Contractor (SMRC) take over therapy manual medical reviews for therapy claims over the $3,700 threshold from the Recovery Auditors, as MACRA directed.


The law extended through the end of 2017 the exceptions process for therapy caps, set for 2016 at $1,960 for physical therapy and speech therapy and $1,960 for occupational therapy, and directed CMS to target certain therapy claims over $3,700 for manual medical reviews rather than review every claim above that threshold. The law also provided funds to carry out these reviews, but said those funds cannot go to the RACs.


The agency has tasked the SMRC with selecting therapy claims for review based on:


  • Providers with a high percentage of patients receiving therapy beyond the threshold as compared with their peers during the first year of MACRA implementation.
  • Therapy provided in a nursing home, by therapists in private practice, outpatient physical therapy and speech-language pathology providers, or other rehabilitation providers.


CMS also says that the number of units or hours of therapy provided in a day will be “of particular interest in this medical review process.”


MACRA, which was passed in April 2015, gave CMS 90 days to come up with a new way to target therapy claims, and suggested that CMS could decide to target claims by reviewing providers with patterns of aberrant billing practices compared with their peers, those who have seen a high number of therapy claims previously denied, and newly enrolled providers.


As the MACRA law was debated, AHCA said that targeting manual medical reviews could be a bridge to therapy pay reform.


Cynthia Morton, executive vice president for the National Association for the Support of Long Term Care, said CMS' new policy isn't exactly what Congress seemed to envision in MACRA, as it doesn't appear that a provider's claims denial rate will be taken into account.


In the same vein, Nanof said that the process could have been much more streamlined if it had focused on claims data and targeted outliers who used more therapy than others in the same category of provider. He also said there is concern that CMS doesn't seem to be looking at historical data to help target those outliers but instead will look at large pockets of providers. Morton said it's unclear what seems to be driving the policy.


Ciolek also said there are questions on how the claims targeting CMS is setting up would work. The purpose of the program was to target risky providers, not costly patients, he said. As it stands, it is unclear if CMS will take beneficiaries' clinical factors into consideration when looking at therapy provided. Morton also said the policy CMS has laid out could be problematic for those providers treating beneficiaries with conditions that need more therapy.


Ciolek added that it was surprising the policy came out with so few details and so many unknowns -- including how the review process itself will work. He said stakeholders would like more information as soon as possible so providers can be ready when the SMRC reviews start.


Nanof said he expects the web post is preliminary, and the agency will release more formal guidance before the new review program starts.


Morton said the newly unveiled process let stakeholders down, as therapy organizations had previously met with CMS to discuss the policy. But the policy was released with very little notice to stakeholders after what had seemed a long and mutually collaborative process. -- Michelle M. Stein (