AHCA opposes manual review system for therapy claims, launches provider feedback clearinghouse

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AHCA/NCAL President and CEO Mark Parkinson
AHCA/NCAL President and CEO Mark Parkinson

As part of its pushback against the manual review process for therapy claims, the American Health Care Association has launched a clearinghouse to gather provider feedback. 

Congress called for manual review of Medicare Part B therapy claims pending an overhaul of the payment system. Effective April 1, the Centers for Medicare & Medicaid Services launched a process that involves recovery audit contractors (RACs). Under this system, RACs will be responsible for postpayment review of Part B claims and will undertake prepayment review of therapy claims in states that are part of a RAC prepayment demonstration.

AHCA President Mark Parkinson described this process as “bifurcated, confusing and wholly inappropriate” in a four-page letter sent to Acting CMS Administrator Marilyn Tavenner last week.

“First, we believe the process is likely to have a chilling impact on the ability of Medicare beneficiaries who need therapy to get it,” Parkinson wrote. “The multi-layer review process is likely to cause considerable confusion among providers and beneficiaries as to how much therapy ‘counts' towards the cap and whether the beneficiary would be willing to pay personally for therapy the physician has ordered.”

Parkinson expressed concerns over how the RAC process would affect implementation of Medicare reimbursements for “maintenance therapy” following the Jimmo settlement, and he said the way RACs are paid could create inappropriate incentives. He requested a meeting with Tavenner to discuss alternatives. Rather than using RACs, the association recommended Medicare administrative contractors (MACs) assess postpayment reviews. MACs are "established administrative entities," Parkinson wrote, whereas RACs are fraud and abuse watchdogs.

Providers who encounter issues with the manual review process can email manualreview (at) ahca.org. AHCA believes the clearinghouse will be an efficient way of identifying and analyzing common issues.

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