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CMS Supplemental Review Contractor Targets Outpatient Therapy Stopped BeforeTherapy Caps

August 13, 2013 3 Comments

Kleiner DetektivOutpatient therapy providers have been subject to CMS data mining and analysis to identify provision of therapy services that either stopped or delayed just under the therapy cap.  Over 350 therapy providers have received a letter from Strategic Health Solutions, a CMS Supplemental Review Contractor to submit selected claims for post payment review from the review period of August 2012 through March, 2013.  Strategic has a number of other review projects underway based upon a TDL (Technical Direction Letter) from CMS, including review of power mobility devices, inpatient rehabilitation facilities, hyperbaric oxygen and E & M codes.

While a generic sample ADR letter is available on the CMS website, the specific text of therapy is not included.  Here is how the outpatient therapy letter reads:

Analysis of Medicare claims data between August 2012 and March 2013 identified provision and billing for therapy services that either stopped or delayed just under the allowed therapy cap.  This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.908(b).  StrategicHealthSolutions, LLC is requesting additional documentation for these claims for Supplemental Medical Review of Outpatient Therapy Services authorized by CMS.

If you received a ADR request letter from Strategic Health Solutions, carefully review the letter and follow all their instructions for submitting data.  A couple of tips to assist you in this endeavor:

  1. Ensure compliance with all CMS signature requirements, and then double check to ensure compliance with signature requirements
  2. Submit all requested documentation, and additional documentation to support the claim
  3. Prepare a summary cover letter of the key clinical findings: medical necessity for skilled care, previous level of function, and therapy outcomes (goals)
  4. Ensure timely certification of the plan of care (signed and dated) – and submit reason for late certification per CMS guidelines as needed
  5. Submit your records using esMD, rather than faxing (faxing only guarantees delays and problems)
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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (3)

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  1. KristinV says:

    Lucky me, I got one of the 350 letters. This was on a patient that had been previously reviewed while I was on prepayment review by my MAC. Some of her visits had also gone through redetermination and to the QIC appeal. I sent numerous requests and talked to them by phone regarding the apparent redundancy of this action. Although they indicated it should not be reviewed again, I had to send in all of the requested records within the 45 day time period. I know my documentation is top notch after being on prepayment review for 5 months, but this seems like “double jeopardy”. How can I be “tried” multiple times by different agencies on the same record?

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