Medicare Compliance & Reimbursement

Last summer, the Centers for Medicare and Medicaid Services (CMS) commenced a short-term voluntary initiative for Medicare Parts A and B providers to cut down on its appeals junket. Now, the agency is offering a similar program that targets Inpatient Rehabilitation Facility (IRF) appeals.

Details: On June 17, CMS began accepting “Expressions of Interest (EOIs) for a settlement option” from IRF appellants with outstanding appeals with their Medicare Administrative Contractors (MACs), “the Qualified Independent Contractor (QIC), the Office of Medicare Hearings and Appeals (OMHA) and/or Medicare Appeals Council (Council) levels of review,” relates a brief on the IRF Appeals Initiative.

IRF appellants have the option to settle their appeals and receive 69 percent of their net Medicare pay — with two exceptions. For “Intensity of Therapy Appeals, CMS will pay 100 percent of the net payable amount” if  “the claim was denied based solely on a threshold of therapy time not being met,” and there was a lack of a thorough review of the medical necessity outlined in the case’s facts, online guidance suggests. Secondly, IRF appellants will receive full payments for  “all IRF appeals in which the claim was denied solely because justification for group therapy was not documented in the medical record,” CMS indicates.

Caveat: Only IRFs with appeals pending and redeterminations filed with their MACs no later than August 31, 2018 can submit an EOI.

Deadline: CMS will accept EOIs from eligible IRFs through Sept. 17, 2019, at MedicareAppealsSettlement@cms.hhs.gov.

Resource: Review the IRF Appeals Initiative and check your eligibility at www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Appeals-Settlement-Initiatives/Inpatient-Rehabilitation-Facility-Appeals-Initiative.html.