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