Jane Snecinski, FACHE Post Acute Advisors, LLC P.O. Box Atlanta, GA

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1 Jane Snecinski, FACHE P.O. Box Atlanta, GA

2 RAC Demonstration Project 3 year demonstration project Greatest impact to IRF from California Issue with greatest impact medical necessity $1.03 Billion identified in Overpayments Overpayments by Provider Type (1) Impact (in millions) Inpatient Rehabilitation Facility $59.7 Outpatient Hospital $44.0 Physician $19.9 Skilled Nursing Facility ++ $16.3 Ambulance/Lab/Other $5.4 Durable Medical Equipment $

3 Provider Appeals of RAC Initiated Overpayments: Cumulative through 8/31/08, Claim RACS only, Part A Claims Only % Total # Claims with # # # # appealed favorable Overpayment appealed appealed appealed appealed Total # (all to % favorable Determinations to FI to QIC to ALJ to DAB appealed levels) provider to provider % of all claims overturned on appeal Claim RAC Connolly 78, , % % 5.1% HDI 104,394 24,318 6, , % 11, % 11.2% PRG 91, , % % 2.7% Unknown na ,219 n/a % n/a All RACS 274,952 42,794 11,548 2, , % 18, % 6.8% Source: RAC invoice files, RAC Data Warehouse, and data reported by the Administrative Qualified Independent Contractor (AdQIC) and Medicare claims processing contractors Medicare Recovery Audit Contractor (RAC) Program: Update to the evaluation of the 3 Year Demonstration, January

4 High success rate of appeal process Significant scrutiny on orthopedic patients Skepticism re: impact of RAC January December, 2010 no complex medical record reviews reported Ongoing MAC probe audits for IRFs Continued confusion as to meaning of medical necessity 4

5 High success rate of appeal process Convincing appeals by IRFs at ALJ level Continued focus on medical necessity Significant recoupment for the Trust Fund prior to Appeal process Implementation of IRF Coverage Policies 5

6 Pre-admission Screen Physician Involvement Physician Involvement/Supervision Physician Orders Post Admission Physician Evaluation Physician Face-to-Face Visits Plan of Care Intensity of therapy Initiation of therapy Interdisciplinary Team Approach/ Team Conference PAI maintained within the medical record 6

7 Any non-compliance to coverage guidelines will result in denials COMPLIANCE TO THE COVERAGE GUIDELINES DOES NOT NECESSARILY DEEM MEDICAL NECESSITY 7

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11 The Pre-admission Screen should include and identify the specific reasons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary. 11

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13 The Post Admission Physician Evaluation confirms the patient s status upon admission and reiterates the patient needs that require admission to an inpatient rehabilitation program. 13

14 The daily progress notes should demonstrate ongoing supervision of the Plan of Care (correlate with other disciplines notes), ongoing progress and ongoing need for continued stay in an inpatient rehabilitation program. 14

15 The Plan of Care is the proactive and ongoing map of the treatment the patient will receive, how and why as well as the expected outcomes and timeframes. 15

16 A significant demonstration of the need for an inpatient rehabilitation stay is a patient s need, ability to benefit and receipt of intensive therapy (unique to inpatient rehabilitation). 16

17 The Interdisciplinary Team Approach (as exemplified in the Team Conference) is unique to an inpatient rehabilitation level of care. If a patient demonstrates the need for an interdisciplinary approach, there is no other level of care that is appropriate. 17

18 The patient has medical and rehab needs that can ONLY be treated in inpatient rehabilitation acute care hospital Pre-admission screening supports admission to IRF vs. any other level of care Post admission evaluation discusses the need for inpatient rehabilitation The Plan of Care demonstrates the need for, plan to provide and benefit from an inpatient rehabilitation level of care Daily progress notes are not repetitive and strongly support the need for inpatient rehabilitation Reflect/justify information, e.g. lack of participation in therapy The patient requires, can tolerate, receives and benefits from intensive therapy (makes progress) Discharge summary tells the whole story The documentation in the medical record is coordinated and collaborative 18

19 Inpatient care is required only if the beneficiary s medical condition, safety or health would be significantly and directly threatened if the care was provided in a less intensive setting Documentation that is not legible has a direct impact on RAC s ability to review and determine of medical necessity CMS encourages all provides to ensure all fields on documentation forms are complete RAC demonstration project entries in medical records were not consistent 19

20 The IRF Benefit is designed to provide intensive rehabilitation therapy in a resource intensive hospital environment for patients who, due to the complexity of their nursing, medical management and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care. (1) New coverage Policies for Inpatient Rehabilitation Services, CMS, November,

21 The greatest (financial) threat for IRF continues to be audits focusing on medical necessity (RAC, MAC, MIC, Medicaid RAC, etc.) It is in an IRF s best interest to proactively address the content of your medical records Compliance with the Coverage Policies is a must but not the final word 21

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23 Jane Snecinski, President (P) (F)