Reimbursement Updates

February 15, 2016

Medicare News - Medical Manual Review for 2016

Background:  Medicare Access and CHIP Reauthorization Act (MACRA), passed in April 2015, extended the Medicare Therapy Cap extensions through December 31, 2017, and eliminated the requirement for automatic manual medical review (MMR) of claims exceeding the $3,700 extension and prohibited recovery auditors (RAs) from conducting MMR. In new clarifications issued by CMS on Feb. 9, 2016,CMS has hired Strategic Health Solutions as a “Supplemental Medical Review Contractor” (SMRC) to begin performing targeted claim reviews focusing on the following areas:

  • Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA.
  • Therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers, therapy provided in skilled nursing facilities (SNFs)

Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day.


December 7, 2015

Medicare Beneficiary Rates 2016

Medicare has released deductible and coinsurance rates for beneficiaries beginning January 1, 2016:

PART A - HOSPITAL INSURANCE (HI)

  • Deductible: $1,288
  • Coinsurance:
    • $322 a day for 61st-90th day
    • $644 a day for 91st-150th day (lifetime reserve days)
    • $161 a day for 21st-100th day (Skilled Nursing Facility coinsurance)
  • Base Premium (BP): $411 a month

PART B - SUPPLEMENTARY MEDICAL INSURANCE (SMI)

  • Standard Premium: $121.80 a month
  • Deductible: $166 a year
  • Coinsurance: 20 percent

Please visit the Noridian Healthcare Solutions website for more information.