The Manual Medical Review mess

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L

What a mess — and that's probably an understatement! Medicare Part B decided to roll out its new manual medical review process by dividing providers into three phases. If you are unfortunate to be part of the Phase One group, you have my deepest sympathies.

For example, one of my clients provided me with the following update: “They (the Fiscal Intermediary, FI) are mailing their responses and the letters are dated within the 10 days, but it is taking another 5-10 days to receive the letters. They are sending the letters to the address you have on file, not what is on the transmittal sheet you send them. So our letters are going to the billing department, not the clinic. Also, if you have multiple disciplines that are both requesting more visits, the letters do not specify what discipline the letter is in response to.”

By law, the FI's are required to provide a response within 10 days of receiving our request for the manual medical review. Other issues seem to include FIs claiming they have not received the request, although the provider receives an “OK” confirmation on the fax transmittal sheet.

There is much aggravation, and many providers have been filing complaints to express these concerns. Unfortunately, the mess and confusion is about to double as the Phase Two group has already started the process.

Sometimes, I wish I could wave a magic wand at CMS or the Fiscal Intermediaries and resolve the most basic issues. But I don't think that wand will ever exist. As a consultant, I have advised my clients to be as pro-active as possible, and have everything perfect when submitting the request.

For example, my grandmother recently underwent hip surgery. Previously in the calendar year, she received outpatient physical therapy for another condition. She has the diagnoses required to meet the automatic exceptions criteria, but when she contacted her outpatient clinic to schedule her visits, she was told she had maxed out her benefit and would have to pay privately.

Luckily, my grandmother did not require inpatient rehab, but only received a few visits of home health therapy before advancing to the outpatient therapy level. She was very upset about the lack of information she received on why her Medicare was being limited. I talked with the outpatient clinic, and we were able to submit all of the paperwork correctly and get the approval.

However, we could have avoided the delay in care had the outpatient clinic realized it could submit the request as soon as it was notified of her rehabilitation needs. I also think this same scenario could be applied to our LTC residents when we can anticipate their rehab needs. For example, if a patient will continue to require therapy, and is transitioning from Medicare Part A to the Part B benefit, don't wait for this transition to occur to begin submitting the manual medical review process.

These new regulations may have made a mess of everything, but at least from our end we can be pro-active to avoid delays in care. And we can voice loudly our complaints and the risk to our patients.

Shelly Mesure ("Measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.

Rehab Realities

Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.