Sec. 202. Extension of therapy cap exceptions process
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Section 1833(g) of the Social Security Act ( 42 U.S.C. 1395l(g) ) is amended— in paragraph (5)(A), in the first sentence, by striking March 31, 2015 and inserting December 31, 2017 ; and in paragraph (6)(A)— by striking March 31, 2015 and inserting December 31, 2017 ; and by striking 2012, 2013, 2014, or the first three months of 2015 and inserting 2012 through 2017 . Section 1833(g)(5) of the Social Security Act ( 42 U.S.C. 1395l(g)(5) ) is amended— in subparagraph (C)(i), by inserting , subject to subparagraph (E), after manual medical review process that ; and by adding at the end the following new subparagraph:
In place of the manual medical review process under subparagraph (C)(i), the Secretary shall implement a process for medical review under this subparagraph under which the Secretary shall identify and conduct medical review for services described in subparagraph (C)(i) furnished by a provider of services or supplier (in this subparagraph referred to as a therapy provider ) using such factors as the Secretary determines to be appropriate. Such factors may include the following:
The therapy provider has had a high claims denial percentage for therapy services under this part or is less compliant with applicable requirements under this title. The therapy provider has a pattern of billing for therapy services under this part that is aberrant compared to peers or otherwise has questionable billing practices for such services, such as billing medically unlikely units of services in a day. The therapy provider is newly enrolled under this title or has not previously furnished therapy services under this part.
The services are furnished to treat a type of medical condition. The therapy provider is part of group that includes another therapy provider identified using the factors determined under this subparagraph. For purposes of carrying out this subparagraph, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $5,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for fiscal years 2015 and 2016, to remain available until expended.
Such funds may not be used by a contractor under section 1893(h) for medical reviews under this subparagraph. The targeted review process under this subparagraph shall not apply to services for which expenses are incurred beyond the period for which the exceptions process under subparagraph
(A)is implemented. . The amendments made by this subsection shall apply with respect to requests described in section 1833(g)(5)(C)(i) of the Social Security Act ( 42 U.S.C. 1395l(g)(5)(C)(i) ) with respect to which the Secretary of Health and Human Services has not conducted medical review under such section by a date (not later than 90 days after the date of the enactment of this Act) specified by the Secretary.
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Sec. 202
Extension of therapy cap exceptions process
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