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

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` 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 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


Claim  RAC Claims with  Overpayment  Determinations appealed  to FI appealed  to QIC appealed  to ALJ appealed  to DAB Total #  appealed appealed  (all  levels) Total #  favorable  to  provider % favorable  to provider % of all  claims  overturned  on appeal Connolly 78,698 6608 1067 73 18 7,766 9.9% 4007 51.60% 5.1% HDI 104,394 24,318 6,053 556 7 30,934 29.6% 11,658 37.69% 11.2% PRG 91,860 11868 3410 1380 172 16,830 18.3% 2478 14.72% 2.7% Unknown na 1018 201 0 1,219 n/a 443 36.34% n/a All RACS 274,952 42,794 11,548 2,210 197 56,749 20.6% 18,586 32.75% 6.8%

Provider Appeals of RAC‐Initiated Overpayments:  Cumulative through 8/31/08, Claim RACS only, Part A Claims Only

Source:  RAC invoice files, RAC Data Warehouse, and data reported by the Administrative Qualified Independent Contractor (AdQIC)

and Medicare claims processing contractors


` 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


` 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


` Pre-admission Screen

Physician Involvement

` Physician Involvement/Supervision

Post Admission Physician EvaluationPhysician Face-to-Face Visits

Plan of Care

` Intensity of therapy

Initiation of therapy

` Interdisciplinary Team Approach/


Any non-compliance to

coverage guidelines will result in




“The Pre-admission Screen should

include and identify the specific reasons that led the IRF clinical staff to conclude that the


“The Post Admission Physician Evaluation confirms the patient’s status upon admission


“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


“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


“A significant demonstration of the need for an inpatient rehabilitation stay is a patient’s need,


“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


` 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


“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”


“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.”


` 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


Jane Snecinski, President






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