Medicare Compliance & Reimbursement

Zero in on problem areas through routine checks to protect your facility.

The HHS Office of Inspector General's 2005 Work Plan leaves no stone unturned as it probes inpatient rehab facilities' payment practices. But watching documentation p's and q's will put IRFs ahead of the game if auditors land on their doorstep.
 
Admissions top the list of the OIG's IRF targets, so providers will need to show that patients meet Medicare's specific requirements for IRFs, including appropriate preadmission screening and assessment testing.
 
Behind this admissions scrutiny is CMS' perception that many IRFs aren't complying with medical necessity guidelines - an issue brought into focus this year by the 75 percent rule.
 
Don't assume that a referring physician's orders for IRF services will suffice for CMS. "Even if a physician orders the care, it's the job of the provider to evaluate medical necessity," stresses Burtonsville, MD-based attorney Elizabeth Hogue.
 
And IRFs should focus on patient outcomes. The OIG is examining whether IRFs are admitting patients who don't really need IRF-specific services, comments attorney David Glaser with Fredrickson & Byron in Minneapolis.

Providers should ensure that they're measuring and documenting progress to show that patients benefited from the IRF's intensive therapy programs, Hogue advises.

Heads up: IRFs should perform routine spot checks on their documentation to make sure it's complete and clinically appropriate, advises Linda Baumann, an attorney with Reed Smith in Washington, DC. For instance, every Friday, the rehab manager could pull a certain number of charts and review the therapists' notes, identifying omissions or problems, she suggests.

Expect Outlier Cash To Raise Red Flags

Outlier payments to IRFs also loom large on the OIG's radar screen. "In CMS' view, if reimbursement is calculated accurately, there should be very few outliers," Baumann observes.
 
Outliers are "easy pickings" for the OIG because they clearly indicate that the facility received extra money based on the claim that a patient needed more intensive services than the norm, Hogue cautions.
 
If you have an adversely high number of outlier payments, look closer to ensure you can justify them, Glaser says.
 
Strategy: IRFs should assign someone the job of reviewing how many outliers the facility has had in a given period and monitor the percentage in overall reimbursement, Baumann recommends to providers.

Don't Be Late With Assessments

Turning in admission and discharge assessments late to an FI could also raise OIG eyebrows.
 
The OIG's emphasis on late assessments is linked to the increased focus on documentation in IRFs, Baumann remarks.
 
Often, providers want to make sure their assessment documentation is accurate and will make late entries to fix it, missing the FI deadline, Baumann explains.
 
Tip: IRFs should develop a tracking system with reminders so that it doesn't miss assessment deadlines, recommends Hogue.
 
Editor's Note: To see the Medicare section of the Work Plan, go to www.oig.hhs.gov/publications/docs/workplan.html. To read Medicare's admission guidelines for IRFs, see www.cms.hhs.gov/manuals/102_policy/bp102c01.pdf.