Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted a post-payment review of claims for Medicare Part A claims billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:

Background

Over the years, the IRF benefit was reviewed by the Office of the Inspector General (OIG) and continues to be a part of the work done by the OIG. In a 2018 OIG report, titled Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (A-01-15-00500), the OIG found for many IRF’s, the medical record documentation did not support IRF care was reasonable and necessary, in accordance with Medicare’s requirements.

CERT data from 2021 reflected improper payment error rates for Inpatient Rehabilitation Facilities and Inpatient Rehabilitation Facilities Units of 18.5% and 16.0% respectively.

In addition, between 2015 and 2019, the SMRC completed prior data analysis and medical review of IRF claims. Findings supported additional review and education on the IRF benefit was indicated.

Reason for Review

The SMRC was tasked with performing claim review on a sample of IRF claims from March 1, 2020, through December 31, 2020. The SMRC conducted medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the ADR
  • Internet-Only Manual Publication (Pub.) 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6) and Social Security Act Title XVIII, Sections 1815(a), 1833(e), and 1862(a)(1)(A). No medical record documentation was received. The Medicare Program Integrity Manual (PIM) Pub. 100-08, Chapter 3, Section 3.2.3.8 requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request for the dates of service under review. The documentation was not submitted from the provider.
• Supervision by the Rehabilitation Physician
  • 42 CFR 412.622(a)(3)(iv), Medicare Benefit Policy Manual Chapter 1, Section 110.2. The IRF physician supervision requirement is intended to ensure patients receive comprehensive assessments of their medical and functional status, and modification of the course of treatment, as needed, by a rehabilitation physician at least 3 times per week during the face-to-face visits. The documentation submitted did not support the IRF physician supervision.
• Reasonable and Necessary
  • 42 CFR 412.622(a)(3)(i), Medicare Benefit Policy Manual Chapter 1, Section 110.2. Within the Inpatient Rehabilitation Facility coverage criteria, the documentation did not support upon admission to the IRF the beneficiary generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs.

References

Social Security Act (SSA), Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• § 1814(2)(B), (6) Conditions of and Limitations on Payment for Services
• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1834(m)(4) (F) Special Payment Rules for Particular Items and Services
• § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• § 1886(j) Prospective Payment for Inpatient Rehabilitation Services

42 Code of Federal Regulations (CFR)

• § 400.200 General Definitions
• § 411.15(k)(1) Particular Services Excluded From Coverage
• § 412.29 Classification Criteria for Payment Under the Inpatient Rehabilitation Facility Prospective Payment System
• § 412 Subpart A Prospective Payment Systems for Inpatient Hospital Services. General Provisions
• § 412 Subpart P Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
• § 424.5(a)(6) Basic Conditions

Federal Register

• Final Rule Volume 85, No. 154. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2021. August 10, 2020. Retrieved from 2020-17209.pdf (govinfo.gov)
• Interim Final Rule with Comment Period. CMS 1744-IFC. Medicare and Medicaid Programs, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. March 26, 2020. Retrieved from CMS-1744-IFC
• Interim Final Rule with Comments (IFC), 5531. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. Effective March 1, 2020. Retrieved from CMS-5531-IFC .

Public Law

• Coronavirus Aid, Relief, and Economic Security Act. Title III- Supporting America’s Health Care System in the Fight Against the Coronavirus. Subtitle D-Finance Committee, §§ 3710. Medicare Hospital Inpatient Prospective Payment System add-on Payment for Covid-19 Patients During Emergency Period. § 3711. Increasing Access to Post-Acute Care During Emergency Period. January 3, 2020. Retrieved from BILLS-116hr748enr.pdf (congress.gov)
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). § 101. Telehealth Services During Certain Emergency Periods Act of 2020. Retrieved from PUBL123.PS (congress.gov)
• Public Health Service Act, 2021, § 319(e). Telehealth Enhancements for Emergency Response. Enacted June 25, 2022. Retrieved from COMPS-8773.pdf (govinfo.gov)
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. May 2021. Retrieved from Stafford Act, as Amended – FEMA P-592 vol. 1 May 2021

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Chapter (Ch) 1, § 110 Inpatient Rehabilitation Facility (IRF) Services

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 3, § 140.3 Billing Requirements Under IRF PPS

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, § 3.3.2.1 Documents on which to Base a Determination
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria

Other

• Office of Inspector General (OIG), Report A-01-15-00500. Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements. September 2018

Last Updated Dec 28, 2023