As we’ve noted in prior articles, while inpatient rehabilitation facilities (IRFs) have had some relief from Recovery Auditors (RACs), inpatient rehabilitation claims are still under scrutiny from a wide range of auditors, including Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) contractors, Zone Program Integrity Contractors (ZPICs), and Supplemental Medical Review Contractors (SMRCs). And what’s even more disconcerting is that the results of these audits do not seem to be showing much improvement over time.

While there has been some minimal easing on denials related to small variations in timeframes as they pertain to some of the required elements, there continues to be a lot of focus on both the technical requirements and on documentation that supports treatment as “reasonable and necessary” in an IRF.

What Are the Current Issues Noted by the MACs?

Noridian recently announced a service-specific targeted review for claims billed on or after Oct. 7, 2014. This review is based on a recent probe review of 100 claims filed between May 15 and Sept. 5; 70 out of the 100 claims reviewed were denied based on a variety of reasons (many of them due to the technical requirements of the preadmission assessment, post-admission physician evaluation, individualized plan of care, physician supervision, and intensity of therapy services. Due to the high error rate, Noridian now is moving forward with the announced targeted review.

Earlier this year, Noridian completed a similar probe review in Nevada with an overall 75-percent error rate; this resulted in a targeted review there as well.

Cahaba Government Administrators continues to conduct ongoing prepayment reviews in Alabama, Georgia, and Tennessee. Claims being reviewed involve those filed for lower extremity joint replacements, lower extremity fractures, and debility for cases in which there are no tier-level comorbidities reported (Tier A CMGs). These issues are posted through November 2014 and are likely to continue based on the results of those reviews, which show very high error rates.

On Oct. 23, 2014, Cahaba also posted review results from a widespread targeted review in Alabama that addressed the neurological CMGs A0601-A0604 and D0601-D0604. The review included 26 providers and yielded a 100-percent error rate, with the majority of denials due to documentation not justifying the medical necessity of the services. In this review, the identified reasons were slightly different from those previously noted. The review results indicated that CMGs were not validated in the documentation and that documentation did not establish an expectation that the patient would require an IRF. There also was no documentation of the medical management by the rehabilitative physician, and the units of therapy services billed were not supported in the documentation.

The last reported targeted results we found from Novitas included a November 2013 review that included  47 cases over a seven-state area, resulting in error rates ranging from 20-100 percent. The reasons for denial were related to key technical components previously mentioned, but also included errors in timing of key documents and failure of therapy staff to meet the time requirements for intensive therapy.

CERT reviews completed by Novitas for April through June 2014 indicated common errors in documentation to support IRF services, missing overall plans of care, and missing IRF-PAI documents.

In September 2014, Palmetto GBA posted the top denial codes for IRF services under medical review for July-September 2014. The top three reasons were: a) no orders for inpatient admission; b) no indication services were medically and reasonably necessary; and c) records not submitted.

Palmetto recently performed a service-specific prepayment targeted medical review on IRF case mix group (CMG) stroke codes A0101 through A0110 for facilities in North Carolina, South Carolina, Virginia, and West Virginia.   

Understanding the Ongoing Compliance Issues

While IRFs have been working under the refined and clarified technical requirements since January 2010, achieving compliance with these requirements still can be challenging due to the complexity of the rules, the need for specific processes and procedures to meet the time and content elements, and the multitude of competing requirements from accreditation and regulatory agencies. The majority of IRFs are units within hospitals, with each unit subject to many of the same policies and procedures as the primary hospital – yet they are also required to meet the same regulatory requirements (with the exception of the hours required of the medical director) as a free-standing rehabilitation hospital. Creating policies, processes and structures to ensure that the key technical components are addressed in a timely, accurate, and complete fashion can be challenging for smaller units. Furthermore, because compliance is highly dependent on the rehabilitation physician (who often practices in multiple locations), it is difficult to manage the processes that meet the time requirements.

Tips for Compliance

Based on our experiences with a large number of IRFs across the nation, we suggest that organizations consider the following to improve compliance with the technical requirements:

Key Documents: PAS, PAPE, IPOC

  • Create templates that include all of the key components that are required for these documents.
  • If you are a subscriber to one of the vendors (eRehabdata, UDSmr) that support the IRF-PAI, utilize the tools provided by your vendor for initiating the PAS, which will be web-based and available online for rehab physician review and signature. You have the added benefit of having this information automatically populate certain sections of the IRF-PAI at the time of admission.
  • Train, train, train: Ensure that all of your staff understands the time and content requirements of each of these specific tasks or documents.
  • Self-audit: Audit routinely and in real time. Share the results of your audits with key stakeholders and work collaboratively for improvement.

Get Help!

  • The impact of failure to meet these technical requirements is significant. If you feel you cannot develop and implement systems for compliance, consider support for that process.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has over 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

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