Raising the Bar ... And the Stakes

CMS has increased medical claims and program integrity reviews ...

  • CERTS – Comprehensive Error Rate Testing
  • Special Fiscal Intermediary probes
  • Post discharge review and payment denials
  • Prepayment reviews – ‘Request for Additional Information’  prior to processing

... identified significant weaknesses in documentation ... 

  • Physician documentation
    • Little to no recorded medical intervention/support
    • Limited or no recorded reasoning for IRF stay/level of care
    • Few to no recorded goals for stay
  • Nursing documentation
    • Little to no recorded rehab nursing
    • Little to no recorded nursing intervention other than passing meds
    • Little to no recorded support for IRF level of care
  • Therapy documentation
    • Status report
    • Little to no recorded evidence of required three hours of therapy
    • Little to no recorded ‘skilled therapy’

... concluded that current levels of documentation ... 

  • did not support the Patient Assessment Instrument (PAI)
  • did not demonstrate medical or rehabilitation necessity at IRF level-of-care
  • did not indicate involvement of required ‘multidisciplinary team’ in treatment plan or team conferences
  • did not provide evidence to support Functional Independence Measure (FIM) scores

... and is taking action.

  • Recouping payment
  • Placing IRFs on ‘Medical Review’
  • Closing IRFs
  • Involving Office of the Inspector General (fines)
  • Denying payment (multi-million dollars)

What's At Stake

 ... for CMS

... for IRF 

Related Documentation 

75% Rule

Determinate Medicare IRF provider status

Presumptive Designation:
Patient Assessemnt Instrument

Definitive Designation:
IFR Classification Criteria Summary Sheet

Medical Necessity Verify appropriateness
of service and setting
Show appropriateness
of service and setting

Patient Assessemnt Instrument

IFR Classification Criteria Summary Sheet

Reimbursement Fiscally responsible
Fair and adequate
 Casemix and comobidity data
Coverage Determinations Define covered benefits Define needed benefits  Medical Record - all documentation

Dispute Resolution

 Medical Record - all documentation




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