Retaining your inpatient rehab dollars
How to prevent RAC recoupments in rehabilitation services
Inpatient rehabilitation services are already a big target area for recovery audit contractors (RACs), and there will likely be more denials as audits ramp back up. According to the American Hospital Association (AHA), this is already happening.
“The Centers for Medicare & Medicaid Services (CMS) will allow current RACs to restart a limited number of claim reviews beginning this month,” reads the AHA’s August 2014 newsletter. “The agency said most reviews will be done on an automated basis. However, a limited number will be complex reviews on certain claims… CMS said it hopes that the new RAC contracts will be awarded later this year.”
Why inpatient rehab?
RACs apply to any inpatient admitted from a hospital to a designated rehab center (or the designated rehab unit of a hospital) for physical therapy (PT) or occupational therapy (OC). Inpatient rehabilitation services are an easy RAC target because they meet the criteria for an auditor trifecta. They are:
- High dollar;
- High volume; and
- Have myriad rules and regulations.
Furthermore, there are specific forms and documentation requirements to support medical necessity of inpatient rehab services. Providers must submit this information in a timely fashion, or face possible denial of all or part of the claim.
Two keys for revenue retention: Collaboration and documentation
Just as location is key in real estate, documentation is of utmost importance when it comes to successfully retaining your inpatient rehab revenue. Inpatient rehab services must be deemed as a medical necessity in order for organizations to get reimbursed. This is especially true when multiple organizations are involved.
If the inpatient rehab facility is managed by and/or contracted with another source, it is imperative that you have all of the components of that patient’s record, and that all of those components properly align.
For example: A rehab facility in a hospital might be managed by a separate rehab company with its own EHR system and doctors. Hospital staffers must be sure they get all prior treatment history and current therapy documentation from the rehab firm and its partner(s), in order to prove medical necessity when the RAC request comes in. Auditors will carefully review your documentation to make sure all regulations are followed to the letter.
RAC criteria include:
- Inpatient Rehab Facility Patient Assessment Instrument (IRF PAI) form must be completed within 15 days of admission;
- Physician signatures;
- Specific timelines and measurable progress for treatments;
- Care plan for rehab (must match PT/OT notes with diagnosis); and
- Amount of face time with physician.
If one criterion is not met, RACs can deny a significant part of admission or even the patient’s entire stay. The rehab provider has to show progress to be justified for inpatient status.
Timeliness, consistency of prime importance
Timelines for sharing this documentation must be met, and all pieces must be pulled together to establish medical necessity and appeal RACs. Most providers now are aware of the deadlines, but if you can’t provide the proof it was sent on a certain date, auditors can still deny the claim.
In summary, recommendations for providers include:
- Gather more specific documentation on why the patient is going to rehab from all parties involved, including prior treatment history.
- Educate inpatient rehab staff, coders and billers on the specific rules and regulations associated with these patients and services.
- Secure all the necessary signatures on documentation and forms.
- Ensure care plan is followed and improvement is shown.
- Make certain the physician is monitoring the patient’s progress.
- Know the rules of inpatient rehab care and have good controls around them.
- And last, but certainly not least, document, document, document!
Inconsistencies around patient care are what RACs will most closely watch, because where there are inconsistencies, there is more room for error. Remaining consistent, proactive and vigilant are the best ways to keep your inpatient rehab dollars from the RACs.
