Rac ‘n Rehab Series© In the last post we described manual medical review of outpatient therapy claims that exceed one of the $3700 thresholds. It is likely that outpatient therapy providers will be submitting therapy documentation in support of December claims though out January, and perhaps into February, in response to therapy in December. When submitting requests three things are important in this process to ensure that your therapy documentation is assembled correctly, submitted correctly, submitted timely, and submitted to the right location
Tip #1: Read the Letter Carefully – Note the Timelines
The ADR letter for submitting therapy documentation will come from the Recovery Auditor (RAC) in post-payment review states, and from your MAC in pre-payment review state. It will identify the timeline you have for records submission that is based upon the date at the top of the letter (the date the letter was generated). If you do not meet the deadline for submitting records to the RAC for manual medical review of therapy claims, your Medicare Contractor (MAC) will notify you that payment is not allowed for failure to submit documentation. If you have already received payment, recoupment will begin if you don’t file a timely appeal. If you are in a prepayment state, you will not receive payment, and you will have to exercise your timely rights to appeal in order to begin the process. Ensure that someone at your practice is responsible for meeting this deadline, which means that work in assembling the requested documents should begin immediately. Review your records to ensure that you have all required elements, including the signed (certified) plan of care. All is not lost if the plan of care is not certified, as there are provisions for late certification. Have the referring physician certify the plan of care, and note as to the reason for the delay. If you have made multiple fax requests for certification include this in your ADR submission.
Tip #2: Attach Summary Cover Letter
When submitting therapy documentation use a cover summary letter which will help the reviewer travel through the records. Identify all the documents that you have attached, and indicate the page number, if documents were requested that are not applicable (such as surgical records), indicate as such. Since the record is being reviewed based on the $3700 therapy limit, indicate the reason for the extensive therapy, (such as a single complicated episode of care, or multiple unrelated episodes of care), and the nature and progression of this episode of care. Be sure to identify patient progress toward goals as well as response to treatment.
Tip #3: Send Records Electronically via esMD
Providers have told long and sad tales of faxes not being received, or certified mail not being received. Often the provider finds this out too late and is forced into an appeal, despite having a fax receipt or the little green card from the US Postal Service. Electronic submission of medical documentation by an approved CMS vendor will require a bit of front end work on your part to setup your account, but will ensure that HIPAA compliant transmission with a guarantee arrival that generally cannot be disputed (as in faxed or mailed documentation). I reviewed the esMD program in this post, and mentioned MEA for their small provider discount program.
Moral of the Story
CMS contractors, both the MAC and the RAC follow strict calendar guidelines for ADR guidelines, and enforce these on the provider community. However, the contractors themselves have had trouble keeping within the timeframe of reviewing rehab documentation under manual medical review in the mandated 10 days. Some providers are reporting communication that lags past 45-60 days. Don’t let that lull you into a sense of complacency, as once a provider has missed a time-based deadline, there is no going back. See our next post in which we discuss the only penalty phase in which providers can benefit under pre-payment review of therapy claims over the $3700 threshold. In submitting therapy documentation ensure that your documents have a fair chance of being appropriately reviewed and that you will obtain/retain payment: know the deadlines, submit a summary cover page, and ensure submission through a CMS approved esMD vendor.