Regulators outline new process for manual medical review of therapy claims

Officials from the Center for Medicare & Medicaid Services on Tuesday clarified how the Middle Class Tax Relief and Job Creation Act of 2012 will affect the therapy cap exceptions process.

The Middle Class Tax Relief and Job Creation Act of 2012 allows providers to continue to receive payment from Medicare Part B for services above the therapy cap amount of $3,700. The law, however, requires providers to submit exceptions requests to a Medicare Administrative Contractor by one of three phased-in deadlines this fall, said George Mills, the director of the Provider Compliance Group within the Centers for Medicare and Medicaid Services. Mills explained the provider process for exception requests in a Skilled Nursing Facility Open Door Forum Tuesday.

Providers will be told when their deadline is, but Phase 1 will have an Oct. 1 deadline. Mills said that providers can start submitting exceptions process requests in mid-September.

Requests for exceptions can be made in 20-day increments, and MACs have 10 days to conduct a review and make a decision. If a provider doesn’t hear back from their MAC in that time, the request is automatically approved. If a claim is denied, the MAC must explain why and give providers a chance to resubmit.

“I feel like CMS is trying hard to make this work for all parties,” Cynthia Morton, executive vice president for the National Association for the Support of Long-Term Care told McKnight’s. “But we have to remember that the patients needing over $3,700-worth of therapy are often the sickest and frailest patients. Having to wait for approval can be a setback for their recovery.”

Click here for a CMS therapy cap exception process fact sheet. Providers can email CMS with therapy cap exception process questions at [email protected]. To access a podcast of the Open Door Forum and a transcript, click here.