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Supplemental Medical Reviews for Outpatient Therapy Under Medicare (2012-present)


12/13/2013

AOTA participated in a call with the Centers for Medicare & Medicaid Services (CMS) December 12, 2013 to discuss ongoing, supplemental reviews of outpatient therapy provider claims. Whereas traditional Medicare Administrative Contractors (MACs) or Recovery Audit Contractors (RACs) focus reviews on claims data within their specific jurisdiction, specialty contractors are hired to conduct specific reviews of certain sets of national claims data for a set period of time.

The agency has hired specialty contractor StrategicHealthSolutions, LLC, for two therapy-related review projects. The contractor is conducting nationwide, supplemental reviews of therapy provider claims in the following two areas:

  • Therapy Project 1. CMS has requested StrategicHealthSolutions, LLC to identify providers who stopped or delayed billing for a specific beneficiary at a figure just below the $3,700 threshold between August 1, 2012 and March 31, 2013. The stated purpose is to investigate whether providers were attempting to avoid the manual medical review process for claims over the threshold amount. AOTA has asked CMS to specify whether the contractor is looking to identify beneficiaries who required additional occupational therapy and did not receive it, or to identify beneficiaries who received unnecessary services, or something else altogether. CMS responded that the contractor’s criteria and findings will be made public in an upcoming report.
  • Therapy Project 2. This project is designed to identify therapy providers who billed for services provided during Hurricane Sandy. StrategicHealthSolutions is looking at claims data from all therapy providers in all counties that were presidentially-declared disaster areas in order to identify only providers who billed claims when they were actually shut down due to loss of power or flooding. CMS has acknowledged that some providers in disaster areas may not have had an interruption to their business operations, but stated that their decision to cast a wide net was based on “unusual/suspicious data findings and communications from providers/clinicians in the affected areas.”

AOTA is closely following the status of these reviews and ensuring the agency and those on Capitol Hill are aware of the reimbursement and review environment in which occupational therapy providers are operating. Members affected by these supplemental reviews can contact Regulatory Affairs staff (regulatory@aota.org) with questions or information about their experiences with StrategicHealthSolutions. For additional information, see: CMS Factsheet on Supplemental Medical Review Contractors (SMRCs). AOTA will post a copy of the final report when it is available.