New Study Shows Congress’s Part B Outpatient Therapy Medical Review Plan Not Working

33% of MMR reviews are 10 or more months overdue and others seldom timely

Washington, DC – The National Association for the Support of Long Term Care (NASL) today released survey results of its members that show the Manual Medicare Review (MMR) process ordered by Congress is seldom conducted in the required 10 days. In fact, the survey shows at least 33% of the submitted MMR claims since January 1, 2013, are still waiting processing by Medicare contractors.

“Clearly claims are not reviewed in a timely manner. The MMR process as it is today is very troubling for providers – typically therapists – and patients and it has a disproportionate impact on beneficiaries in skilled nursing centers,” stated Cynthia Morton, Executive Vice President of NASL. “Excessive delays in medical review processing will eventually cause a very real access to therapy problem.” 

Congress mandated a timely manual medical review of claims over the exceptions limit of $3,700, with the intent that it not disrupt patient therapy. Since the survey shows the system is not working, NASL has joined with a coalition of 20 patient, consumer and provider organizations to urge Congress to retool the MMR system to achieve these goals:

1. Protect beneficiary access from care disruptions by strengthening the ten day MMR requirement.
2. Improve the MMR process by simplification, standardization, and automation of contractor and provider communications.
3. Require a GAO analysis of the MMR process as a follow up to the first report that revealed the problems.

“The bottom line is that Congress must insist on timely MMR review as patients exceeding the exceptions cap are the most vulnerable Medicare beneficiaries. We call on Congress to revisit this issue and insist MMR achieve its goal to identify claims outliers and not cause such disruption to the entire processing and payment system,” stated Morton.

According to research for NASL conducted by The Moran Company, fully 72% of the MMR reviews for physical therapy/speech language pathology claims and 82% of the medical reviews for occupational therapy claims are for nursing center patients.