Medicare Audits for Services Exceeding $3700 to Begin

StrategicHealthSolutions (SHS), LLC was awarded as the Supplemental Medical Review Contractor (SMRC), a Specialty Medical Review Contractor, supporting the Centers for Medicare and Medicaid Services (CMS). The SMRC will perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the outpatient therapy cap exception process until December 31, 2017 and modified the requirement for manual medical review for services over the $3700 therapy thresholds. One of the tasks SMRC has been assigned will be conducting medical reviews of outpatient therapy services that have exceeded $3700 in a calendar year for physical therapy and speech therapy combined and a separate $3700 for occupational therapy. MACRA eliminated the requirement for manual medical review of all claims exceeding the $3700 threshold and instead allows a targeted review process.

As directed by CMS, SHS will begin to conduct post payment medical review of outpatient rehabilitation therapy services.

In this article, I will discuss:

• The process of how claims will be selected
• How providers will be notified to submit medical record documentation
• How many claims can be requested from a provider
• Time process for the review to be completed
• How the provider will be notified of the decision of the medical review
• The options the provider has if claims are denied.

The SMRC will be selecting claims for review based on: