fy 2014 final rule and mds 3.0 updates

FY2014 and More

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:Keri Hart, MS CCC-SLP, RAC-CT, CHHRP-QTDirector of Rehabilitation & Reimbursement

Education

Speaker Bio

Nearly 30 Years Experience in Long-term Care

Corporate Director of Clinical Reimbursement ServicesMDS Corporate Rehab DirectorRehab DirectorSLP

Cognition (Dementia and Head Injury)Head and Neck (Dysphagia and Voice)

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

“It is not the strongest of the species that

survives, nor the most intelligent that

survives. It is the one that is the most

adaptable to change.”

Charles Darwin


FY 2014 Final Rule: Impact on Providers

Final Rule

On August 1, 2013, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2014Effective October 1st, 2013 for FY 2014


New SNF Rates

The Final rule provides for a net market basket increase for SNFs of 1.3% beginning October 1, 2013

Full market basket increase of 2.3 percentage points Less a 0.5 percentage point multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA)Less 0.5 percentage point reduction to correct for an error in forecasting the market basket in FY 2012


Impact on Providers

CMS estimates that the net market basket update would increase Medicare SNF payments by approximately $500 million in FY 2014

Nationally projected $7 per Medicare patient day


Therapy Co-treatment

RAI User's Manual reporting requirement for coding co-treatment minutes on the MDS

Will not impact RUG calculation at this time


Therapy Co-treatment

Indicator that CMS is concerned about over utilization Applies to Medicare Part A onlyWhen two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in fullCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9

Impact on Provider

MDS Software Update requiredRehab Software Update requiredRehabilitation Staff reporting required on therapy logsRehab reporting to MDSEnsure clearly defined


Distinct Days of Therapy

Add MDS Item 00420 (Calendar Days of Therapy)

Distinct calendar days of therapyClarify that classification criteria for the Rehabilitation Medium RUG categories require that the resident receive 5 distinct calendar days of therapyClarify that classification criteria for the Rehabilitation Low RUG categories require that the resident receive 3 distinct calendar days of therapyIf not achieved the RUG would reduce to a Nursing RUGApplies to COT review and ARD Management



Current RUG classification allows classification criteria for the Medium Rehab category without 5 distinct days of therapy

Combination of 5 therapy visits

Current RUG classification allows classification criteria for the Low Rehab category without 3 distinct days of therapy

Combination of 3 Therapy visits plus 6 Days restorative in 2 areas



Safety Net for missed therapy days

Potential Nursing RUG despite significant therapy involvementOnly 4 Distinct Calendar Days:


PT 4 X 240OT 4 X 240ST 4 X 240

720

Distinct Days of Therapy-Daily Basis

The daily basis requirement can be met by furnishing multiple therapy types on different days of the week that collectively add up to "daily" skilled services CMS clarified that to meet this requirement the patient must actually need skilled rehabilitation services to be furnished on different days"It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required”


RAI Manual Updates

Released September 2013Section O: Skilled Procedures

Distinct Days of TherapyReporting Co-Treatment Minutes

Section K: Nutrition% Intake Artificial RouteWhile NOT a resident, While a Resident and “During Entire 7 Days”


Impact on Provider

MDS Software Update requiredRehab Software Update requiredAnother factor in ARD ManagementIncrease in Change of Therapy (COTs)

Rate reduction retroactive 7 daysIncrease Lower 14 Nursing RUGs

Increase audits and denialsIncrease in use of Short Stay Policy

Providers still struggle with thisPotential for Rehabilitation Medium patients to not meet Rehab skilled criteria


SNF Therapy Research Project

“Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a patient during the 7-day look-back period, regardless of the specific patient characteristics”



“As an initial step, the project will review past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services received”CMS has contracted with Acumen, LLC and the Brookings Institution to identify alternatives to the existing methodology used to pay for therapy services received under the SNF PPS CMS invites comments and ideas on the existing methodology



CMS will “regularly” update the public on the progress of this project on the project Web site: http://www.cms.gov/Medicare/Medicare-Fee-forServicePayment/SNFPPS/therapyresearch.html


http://www.cms.gov/Medicare/Medicare-Fee-forServicePayment/SNFPPS/therapyresearch.html



Impact on Providers

SNF Therapy Research Project could significantly change the reimbursement model for therapy services provided under Medicare Part ADiagnosis may factor in


Presumption of Coverage

“The establishment of the SNF PPS did not change Medicare’s fundamental requirements for SNF coverage”CMS proposes to continue presumption of coverage for beneficiaries correctly assigned to one of the upper 52 groups

Automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day assessment


Presumption of Coverage

“We note that this administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG–IV groups (which, in turn, serves to trigger the administrative presumption) are themselves medically necessary”


Impact on Providers

Warning by CMS to ensure documentation of skilled coverage criteria in the first days of a Patient’s stayPotential increase in audits


Consolidated Billing

Consolidated billing requirements are unchanged

Acknowledged certain chemotherapy items, chemotherapy administration services, radioisotope services and customized prosthetic representing recent advances that might meet its criteria for exclusion from SNF


Consolidated Billing

Corrections of error to the annual pricer exclusion files will show that HCPCS codes 11042, 11043, and 11044 (surgical debridement codes) will be corrected to ensure that they are excluded from consolidated billing“Flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice)’’ (65 FR 46791)


Consolidated Billing-Reminder

April 2013The annual update file contains the complete list of HCPCS codes that are excluded from SNF CB for claims submitted to Fiscal Intermediaries/A/B MACS for payment Effective for claims with dates of service on or after 1/01/2013 unless otherwise noted belowCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26

Swing Beds FYI

CMS notes that critical access hospitals (CAHs) will continue to be paid on a reasonable cost basis for SNF level services furnished under a swing bed agreement and that all non CAH swing bed rural hospitals continue to be paid under the SNF PPS


AIDS Add On

128 percent for SNF residents with Acquired Immune Deficiency Syndrome (AIDS) remains Transition from ICD-9-CM coding system to the ICD-10-CM coding system starting October 1, 2014

ICD-10-CM diagnosis code of B20 for purposes of defining AIDS Add-On. Includes AIDS, AIDS related complex (ARC) and HIV infection, symptomaticCurrent code 042 also includes AIDS like syndrome and new Final code B20 does not

Impact On ProvidersMay exclude some patients from meeting criteria


Physician Assistants-Certification

CMS finalized revisions to the regulation related to the SNF level of care certification and re-certifications by including Physician Assistants in the provision authorizing nurse practitioners and clinical nurse specialists to sign SNF level of care certifications and re-certificationsImpact On Providers

Allows additional Physician Extenders to sign Physician Certification


CMS Review Impact FY2012 Changes

CMS concludes that it has found no evidence of possible negative impacts that had been anticipated by SNF providers in comments on the FY 2012 Final Rule, particularly the potential for a “double hit” from the combined impact of the recalibration of the FY 2011 SNF parity adjustment and the FY 2012 policy change

Recalibration of the FY 2011 SNF parity adjustment to align with RUG-IIIAllocation of group therapyImplementation of changes to the MDS 3.0 patient assessment instrument, most notably adding the COT OMRA requirementsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30

Distribution of MDS Assessments

MDS FY2011 % FY2012 %

Scheduled PPS 95 84

SOT 2 2

EOT 3 3

EOT/SOT Combined

0 0

EOT-R N/A 0

Combined SOT and EOT-R

N/A 0

COT N/A 11


FY2014 Transition Memo

FY2014

Transition Memo released September 20th

Prior to RAI Manual Release


FY 2014 Transition

An MDS may generate a RUG that bills for days in September 2013 (FY2013) and October 2013 (FY2013) The CMS transition policy dictates payment for these scenarios In short, MDSs with an ARD from October 1st through October 13th will generate a “FY2013 RUG” that will be communicated to billers through the MDS validation report process


FY 2014 Transition

Facilities must ensure MDS/PPS Coordinators communicate with the Business Office to provide the MDS transmission validation reports to accurately bill The FY2013 transition RUG will be based on FY2013 RUG qualifications and the FY2014 will require the new requirements


Distinct Calendar Days of Therapy

MDS Change: For all assessments with an ARD on or after 10/1/2013 must include Item O0420 (Distinct Calendar days) must be coded with the number of distinct calendar days that the resident received therapy services



RUG IV: Extensive Rehabilitation and Rehabilitation Medium and Low Categories Extensive Rehabilitation and Rehabilitation Medium and Low Categories Criteria Change: Rehabilitation Medium must have greater than 5 Distinct Calendar Days and 150 Minutes of Therapy; Rehabilitation Low must have 3 distinct calendar days and 45 minutes of therapy with 2 rehabilitation/restorative nursing for 6 days



COT reviews completed on or after October 1st follow FY2014 requirements of Distinct Calendar Days to meet Rehab Medium and Low Criteria


Swallowing and Nutritional Status Items

MDS Change: For all assessments with an ARD on or after 10/1/2013 must include K0710A and item K0710B with the proportion of total calories the resident received through parental or tube feeding and the average fluid intake per day by IV or tube feeding, respectively RUG IV: Special Care High (fever) / Low and Clinically Complex (ADL=0-1) K0710A and item K0710B3 must be codedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39

FY2013 Transition RUG

September Days Billed October Days Billed

ARD on or before 9/30/13

Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013

Bill actual RUG for all days of service associated with that assessment even if some of those days of service are on or after 10/1/2013

ARD 10/1/2013 through 10/13/2013

FY2013 transition RUG should be used to bill any days of service before 10/1/2013 which are associated with that assessment

Bill actual RUG for FY2014 for days on or after October 1st 2013

ARD date after 10/13/2013

Not Applicable Bill actual RUG for FY2014 for days on or after October 1st 2013


FY2013 RUG

An MDS with an ARD after 10/13/13 will not report a transitional RUG as there is not a scenario when a MDS with an ARD on or after 10/14/13 will pay for days both in September and October 2013


FY2014

Harmony Healthcare (HHI) recommends implementing FY2014 RUG requirements for ARD planning prior to the implementation date of October 1st


Co treatment

Facilities are also reminded that effective ARD 10/1/13, MDSs must also include of Co-Treatment Minutes Item to MDS 3.0 (items O0400A3A, O0400B3A, and O0400C3A)Co-treatment must also be included in individual minutes to calculate RUG There is no change to the Rehabilitation RUG categorization requirements for co-treatment; therefore, there is no transitional RUG requiredCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43

PEPPER: Program for Evaluating

Payment Patterns Electronic Report

PEPPER

This report will the SNFs detailed Medicare claims data in certain targeted areas and compare he SNF to other SNFs nationallySkilled Nursing Facilities (SNFs) should have received via mail on or about August 30, 2013Envelope with red print on the outside containing your facility specific PEPPER


PEPPER

PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper paymentsAllows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction. PEPPER data is also shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs).


PEPPER

Targeted areas were derived from two recent Office of Inspector General (OIG) Reports:

“Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012)“Questionable Billing by Skilled Nursing Facilities” (December 2010)


Claims Data

The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years

FY 2012 (October 1 2011 through September 30th )is displayed on the first tableWhen the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48

Target Areas

Therapy RUGs with High ADLsNontherapy RUGs with High ADLs

Change of Therapy AssessmentUltra High RUGs Therapy RUGs90+ Day Episodes of Care


Episode of Care

Based on episodes of careDefined as a series of claims for a patient where the difference between the “Through Date” of one claim and the “From Date” of the subsequent claim is less than or equal to thirty days

Admission through DischargeConsidered same Episode of Care if readmission to SNF (billed again) within 30 Days of discharge Data includes episodes of care that end in period reported


Therapy RUGs with High ADLs

Numerator : Count of days billed within episodes of care ending in the report period for Rehabilitation and Rehabilitation Extensive RUGs

All Rehab “C” or “X” DaysAlso includes RLB

Denominator : Count of days billed within episodes of care ending in the report period for all Rehabiliattion RUGs


Nontherapy RUGs with High ADLs

Numerator : Count of days billed within episodes of care ending in the report period for Nursing RUGs

All Non Therapy “E”DaysAlso includes BB1 and BB2 (Low ADL)

Denominator : Count of days billed within episodes of care ending in the report period for all Nursing RUGs


Change of Therapy Assessment

Numerator: Count of assessments with AI second digit equal to “D” within episodes of care ending in the report period

“D” is a Change in Therapy Assessment (COT)

Denominator: Count of all assessments within episodes of care ending in the report period

COT initiated October 1st 2011 (FY2012)Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53

Ultrahigh Therapy RUGs

Numerator: Count of days billed within episodes of care ending in the report period with RUG equal Rehabilitation Ultra High or Ultra High Extensive (RUC,RUB,RUA,RUX,RUL)Denominator: count of days billed within episodes of care ending in the report period for all Rehabilitation RUGs

Not Total RUGsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54

Therapy RUGs

Numerator: Count of days billed within episodes of care ending in the report period for Rehabilitation RUGsDenominator: Count of days billed within episodes of care ending in the report period for all RUGs


90+ Day Episodes of Care

Numerator: Count of episodes of care ending in the report period with a length of stay of 90+ days Denominator: Count of all episodes of care ending in the report period


Compare Target Report

Page 1 (after introduction)FY2012 onlyWhen the SNF’s percent is at or above the national 80th percentile for a target area, the SNF’s percent is printed in red boldWhen the SNF’s percent is at or below the national 20th percentile for a target area the SNF percent is printed in green italics When the SNF is not an outlier, the SNF’s percent is printed in blackBlank if Less than 11 SNFs in group


Target Count

Number of Episodes of CareShows Volume of CareThe “Target Count” can also be used to help prioritize areas for review Areas in which a provider is at/above the 80th percentile that have a large target count may be given higher priority than target areas for which a provider is at/above the 80th percentile that have a smaller target count


Percentiles

Percentiles are calculated for each of the three comparison groups

StateMedicare Audit Contractor (MAC/FI) jurisdictionNation

SNF are to focus on National DataGiven the MAC may potentially use data for Additional Documentation Requests (ADR) reviews, all data is important

SNFs whose target percents are at or above the 80th percentile (i.e., in the top 20 percent) are considered at risk for improper Medicare payments with areas at risk for overcoding SNFs whose target percents are at or below the 20th percentile (i.e., in the bottom 20 percent) are considered at risk for improper Medicare payments with areas at risk for undercoding


Target Area Reports

Target area graph provides a visual representation of the SNF’s target area percent over three yearsTarget Area SNF Data Table titled “Your SNF” includes total number of episodes of care for the target area (numerator) and total (denominator)

Roughly correlates to Patients EpisodesBased on the definition of the target area

Comparative Data for National, State and Jurisdiction

Some include 80th and 20th PercentileSome only include 80th percentile

Average Length of Stay for the numerator and for the denominator


Target Area Reports

CMS has developed “suggested interventions” that SNFs may consider when assessing their risk for improper Medicare paymentsThese are “generalized suggestions and will not apply to all situations”


Suggested Interventions

Therapy or Non-Therapy RUGs with High ADLs greater than 80th Percentile

“This could indicate a risk of potential over coding of beneficiaries’ activities of daily living (ADL) status. The SNF should determine whether the amount of assistance beneficiaries need with ADLs as reported on the MDS is supported and consistent with medical record documentation.”



Therapy or NonTherapy RUGs with High ADLs less than 20th Percentile

“This could indicate a risk of potential undercoding of beneficiaries’ ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADLs as reported on the MDS is supported and consistent with medical record documentation.”



Ultrahigh Therapy RUGs greater than 80th Percentile

“This could indicate that the SNF is improperly billing for therapy services. The SNF should determine whether therapy provided was reasonable and medically necessary, and that the amount of therapy reported on the MDS is supported by documentation in the medical record.”


RUG Reports

SNF Top RUGs Report for all episodes of care lists the top RUGs by number of days SNF Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of daysJurisdiction-wide Top RUGs Reports Report for all episodes of care lists the top RUGs by number of daysJurisdiction-wide Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of days


RUG Reports

Each RUG Report IncludesTotal episodes of care in the report periodRUG code and description Number of RUG days billed Percent of RUG days to total days Percent of episodes of care with the RUG billed total episodes of care Average length of stay for the RUG


PEPPER

Impact on Providers:Potential targeted audits in the areas listed on the PEPPEROpportunity to identify risk areas of over utilization to ensure documentation supports Opportunity to Identify areas of underutilization that to ensure facility is properly reimbursed for care provided and ensuring patients have access to Medicare benefits


Audit Environment: More Changes

Increase in Medicare Documentation Reviews

Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs)

Medicare Part A and BBilling inconsistenciesICD-9 Coding triggers

Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's

Number of "Help Letters“ was astoundingly highInvestigations into potential fraudulent billing practices increasedCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 70

Zone Program Integrity Contractor (ZPIC)

Goal is to identify Fraud

CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital auditsSoutheast, South Central, Midwest, Northeast and West Coast regions of the U.S. are seeing the most ZPIC audits at this time

Unified Program Integrity Contractor (UPIC)

CMS is developing a new integrity contractor called a Unified Program Integrity Contractor (UPIC). The previous Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) will comprise the new contractor, though MACs will not disappear entirely, they will simply be absorbed by the UPIC. This contractor will focus on both Medicare and Medicaid integrity issues. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71

Medicare Recovery Auditors (RAs)

Recovery Audit Contractors (RACs) are now known as The Medicare Recovery Auditors (RAs)The RAs post what area they are targeting on the web. Providers are able to review their jurisdiction’s website for an update on what the RAs are finding in their data collection.


Medicare Recovery Auditors (RAs)

RAs review claims on a post-payment basis There are three types of review:

Automated (no medical record needed)Semi-Automated (claims review using data and potential human review of a medical record or other documentation)Complex (medical record required)

Look back up to three years from the date the claim was paid Required to employ nurses, therapists, certified coders and a physician CMD


Be Prepared

Give Clinically Appropriate CareUnderstand Medicare Coverage requirements

TechnicalClinical

Accurately document care providedBill accuratelyRespond to documentation requests timely and completely

Communicate trends and audit outcomes to staff

Get back to Basics !!Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74

Medicare Part B: Things are Getting

Complicated

Overview of the Functional Reporting

Medicare Part BImplemented Functional Reporting with a 6-month testing period January 1 through June 30, 2013 Claims will be returned/rejected without applicable G-codes and modifiers for dates of services on or after July 1st 2013 G-Code FAQ released clarifying clinical coding



Q6) Can therapists use any of the G-Code sets or are they limited to those corresponding to their discipline?A6) The category G-Codes sets are not discipline specific. The G-code set that best describes the functional limitation being treated should be used, regardless of your discipline.



Q10) When I begin reporting on my patient’s second functional limitation, how do I report the severity of its current status? Do I use the severity modifier that reflected the current status at the time of the initial evaluation or the one from the time I began reporting? A10) The severity modifier used to indicate the beneficiary’s current status, reflects the severity of the functional limitation at the time of the visit for which Functional Reporting occurred



Q12) How do I report the functional information when I provide an evaluation only and determine that the patient does not need further therapy services? A12) For one-time visits, you report all three G-Codes for the functional limitation being evaluated, along with the corresponding severity modifiers for each



Q14) How do I report an evaluative procedure when it is for a different functional limitation than I am currently reporting? A14) You should report the evaluative procedure furnished for a second/different functional limitation other than the primary functional limitation for which ongoing reporting is occurring as a one-time visit (i.e., report all three (3) G-Codes in the code set for the functional limitation that most closely matches that for which the evaluative procedure was furnished)



A14 (Cont.)The ongoing reporting of a primary functional limitation is not affected by the reporting of a one-time visit with s all three (3) G-Codes in a code set are reported for the secondary functional limitation



Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act to require a claims-based data collection system for outpatient therapy services The system will collect clinical data on beneficiaries function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures. This data will be used in developing an improved payment system.



Implementation will not directly impact reimbursement at this time

No actual payment for G Codes billed

Data collection process that likely will be used at a later date to reform Medicare Part B Therapy billing and caps


Impact on Provider

Complicates Medicare Part B BillingComplicates documentation requirements for clinicians. Potential denials if documentation requirements to support G Code reporting are not met Increased Medicare Part B billing rejectionsData may be used for auditsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84

Manual Medical Review for Medicare Part B-April 2013

Similar to the therapy cap, there is a threshold of $3,700 for PT and SLP services combined and another threshold of $3,700 for OT services. Such requests for exceptions will be manually medically reviewed.

85Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved

Manual Medicare Reviews for Medicare Part B-April 2013

April 2013: No longer required to submit requests for exceptions to the threshold in advance of furnishing therapy services above the $3700Recovery Auditors (RAC) will now conduct prepayment review for all claims processed on or after April 1, 2013. The specific process for Manual Medical reviews is based on what state services are provided.

86Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved


Pre-Payment Review: Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis

These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri



Post-payment Review: In the remaining states, the Recovery Auditors will conduct “immediate post-payment review.” The MAC will flag the claims that meet the criteria, request additional documentation and pay the claim.



The MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor The Recovery Auditor will conduct post payment review and will notify the MAC of the payment decision. The facility’s MAC will then notify the therapy provider of the outcome of the decision.


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