GAO Submits Report on 2012 Manual Medical Review Process

August 2, 2013
Rick Gawenda

On July 10, 2013, the United States Government Accountability Office (GAO) released a report on the implementation of the 2012 manual medical review process for outpatient therapy services. Excerpts from the report can be found below.

The Centers for Medicare & Medicaid Services (CMS) implemented two types of manual medical reviews (MMR)–reviews of preapproval requests and reviews of claims submitted without preapproval–for all outpatient therapy services that were above a $3,700 per-beneficiary threshold provided during the last 3 months of 2012. CMS officials estimated that the MACs reviewed an estimated total of 167,000 preapproval requests and claims for outpatient therapy service above the $3,700 threshold provided from October 1, 2012, through December 31, 2012. Of these reviews, CMS estimated that 110,000 were for preapproval requests and 57,000 were for claims submitted without prior approval. However, due in part to the lack of automation, CMS officials reported that the total number of reviews should be considered estimates of the results of the MMR process at the time of this report. CMS estimated that the MACs affirmed about two-thirds of the preapproval requests and about one-third of the claims submitted without preapproval. Because providers can appeal denials of payment, the final outcome of the MMRs remains uncertain. CMS also estimated that by December 31, 2012, over 115,000 beneficiaries were affected by the reviews in 2012, a number that will rise as more claims subject to review are submitted throughout 2013.

To read the full 31 page GAO report on the implementation of the 2012 manual medical review process, click

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