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While Connolly was the first Recovery Auditor to post the Centers for Medicare & Medicaid (CMS)-mandated manual medical review of therapy services costing over the $3,700 threshold (as reported in RACMonitor), more information is becoming available to the therapy community about the special RAC process that will be implemented. Performat, the Region A RAC has posted six issues for post-payment review states, and HDI, the Region D RAC has posted seven issues. CGI, the Region B RAC has not posted issues, however Illinois providers have reported receiving requests for prepayment review.

CMS has posted a general slide presentation on the topic offering little in the way of information that hasn’t already been provided to therapy stakeholders. Of note is the confirmation that electronic submission of medical documentation (esMD) will be accepted for submission of medical records as well as the PWK process, wherein documentation can be sent with the claim for prepayment review.

Rehab providers that were frustrated with the manual medical review process in place during the fourth quarter of 2012, wherein only faxes or snail mail were permitted (thereby delaying a time-sensitive process and holding up patient therapy), should investigate the esMD process and select a vendor sooner rather than later. Caution should be exercised, however, with the PWK process of submission of records with claims until there is a clear understanding of what the prepayment additional documentation requests (ADRs) will look like and CMS provides further guidance on the topic.

NGS, the J13 Medicare Administrative Contractor, along with Performat, the Region A Recovery Auditor, conducted an “ask the contractor” webinar this week on the Recovery Audit process. The presentation included background information from both NGS and Performant and information about the CMS-mandated manual medical review of therapy services costing over the $3,700 threshold. NGS solicited questions in advance of the webinar and must have been surprised to get my list of 10 focused and direct inquiries about the program. So surprised, in fact, that they emailed me back and suggested that I contact NGS customer service. Rather than do that, I contacted Performant and was able to have a conversation with one of its staff members who was knowledgeable about the topic of therapy manual medical review. I also was able to confirm that questions submitted during the webinar via the chat box would be answered, and indeed they were.

Here is a sampling of the responses to my questions:

  1. Performant will be posting the therapy issues once they have received approval from CMS, the approval process is currently underway. Providers can monitor the issues under review page managed by Performant.
  2. Provider outreach, such as that which took place when the permanent RAC program first rolled out, may or may not be done. But NGS has indicated that it is doing a May therapy update webinar, and it likely will address manual medical review during that session.
  3. A therapy plan of care is likely to span several claims, and each claim can be reviewed as new therapy dates of services are added.
  4. Providers will have 30 days to submit records in response to an ADR request, but the 10-day clock for RAC prepayment review will not start until the records are received.

I already have started working on a new batch of questions and encourage reader to Scrapbook their way to success with Recovery Auditors.

About the Author

Nancy Beckley, president of Nancy Beckley & Associates LLC, is certified in healthcare compliance and has extensive experience specializing in rehabilitation and compliance. She has been with RACmonitor as a senior contributor and a popular panelist on Monitor Mondays since its 2009 launch.

Contact the Author


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Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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