Did you know Medicare is auditing PT, SLP, and OT services exceeding $3,700?

Please note that this article contains information that is only relevant to our American clients.


Did you know that the Centers for Medicare and Medicaid Services (CMS) recently contracted StrategicHealthSolutions (SHS) to conduct audits on their behalf? Neither did I until I read a recent article on the Gawenda Seminars and Consulting website.


SHS is what’s known and a Supplemental Medical Review Contractor. This means that they were hired by the CMS to help them perform a certain task. In this case, they’ve been charged with the task of tracking down improper payment rates while simultaneously increasing the efficiency of the medical review functions of both Medicare and Medicaid. Sounds like a big job, eh?


But to understand the role of the SHS, we’ll have to briefly revisit the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Essentially, this act extended the outpatient therapy cap exception process until the end of 2017, and made changes for the review process of services exceeding $3,700.


Previously, the CMS deemed that all services exceeding $3,700 were to be audited; however, under the new rules outlined by MACRA, only PT and SLP services (combined) that exceed $3,700 and OT services (separate) that exceed $3,700 within one calendar year will be audited. In essence, they’ve created a targeted review system that focuses on outpatient rehabilitation services.


But how will the SHS prioritize the claims that they’re investigating? They’ll be selecting their reviews based on providers who have a high percentage of patients who’ve exceeded the $3,700 threshold during the calendar year of 2015.


The SHS will be limiting their reviews to 40 claims per provider. At which point, providers will be evaluated based on the number of units and hours of therapy provided in a day. This evaluation is formally known as an Additional Development Request (ADR).


Click here to see an example of an ADR.


Once the SHS receives the provider’s response, they have 45 days to render a decision. Afterwards, the SHS will send the provider a Review Results Letter containing information about their findings.


If the provider decides that they want to learn more about the decision that was rendered, or if they want to learn more about how they can avoid these types of audits in the future, they can submit a request for a discussion and education period in writing. However, it must be submitted within 30 days of the date on the Review Results Letter.


In sum, please don’t assume that you’ll be selected for an audit simply because your treatment for a patient exceeded the $3,700 threshold. Remember: this inquiry will primarily be targeting providers with a high percentage of patients surpassing the threshold.

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