AMRPA Takes Action on Proposed IRF Choice Review Demonstration
Kate Beller, JD, AMRPA Executive Vice President for Government Relations and Policy Development
In mid-December, AMRPA was concerned to learn of the Centers for Medicare and Medicaid Services (CMS) proposal to implement what it calls the “Review Choice Demonstration for IRF Services.” This five-year demonstration program is aimed at reducing what CMS says are high rates of improper payments and potential fraud in the inpatient rehabilitation facility (IRF) benefit in the Medicare fee-for-service program. As currently proposed, the demonstration would span five years. It would initially begin in Alabama, followed by expansion to Pennsylvania, Texas and California within two years. Beginning in the third year, the demonstration will expand to all providers in Medicare Administrative Contractor (MAC) jurisdictions JJ, JL, JH and JE, which includes 17 additional states and territories. The demonstration would subject all IRFs in these states and territories to review 100% of their Medicare claims. Providers will have the option of participating in either a 100% pre- or 100% post-claim review of their claims. A provider’s compliance percentage will be calculated every six months based on the outcomes of the reviews. If a provider achieves 90% or higher compliance, it will no longer be subjected to 100% reviews, and instead will only be subject to review of a small sampling of claims.
Jonathan Gold, JD, Director of Government Relations and Regulatory Counsel
According to CMS, those participating in the pre-claim review option will need to submit a pre-admissions screening, an individualized overall plan of care, and several other pieces of information about the patient. MACs will need to return a decision on the claim within five business days. However, CMS states that the provider need not wait to accept or begin treating the patient prior to receiving a determination. If the MAC requires additional information to reach an affirmative decision, it can request that from the hospital, and then return a subsequent decision within 10 business days. If a preclaim request is denied, but a claim is still submitted, that claim will be automatically denied but the provider may then appeal the denial following the usual appeals process. Under the post-claim review option, providers will follow the usual process for submitting claims for Medicare beneficiaries. At six-month intervals, MACs will send additional documentation requests for 100% of all claims submitted by the provider to conduct a review of those claims. According to CMS, these reviews will follow the same process typically required of post-claim audits by CMS contractors. Providers can then also follow the usual process for appealing any denied claims on a post-claim basis. CMS estimates the cost to IRFs will be $3,144,909 in the third year of the demonstration when it has been fully expanded to all participating jurisdictions. This calculation is based upon an hourly wage of $17.13, a “fully loaded” cost of $34.26/hour, an average
AMRPA Magazine / March 2021
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