Several months ago, we discussed Noridian’s announcement of an Oregon-specific probe review for inpatient rehabilitation facilities (IRFs). Earlier this week, Noridian presented the results of that probe along with provider education via webinar, and we will be reporting on the results in an upcoming article.
Meanwhile, on March 21, Noridian posted its final findings from a similar probe in Arizona, for claims reviewed from Dec. 21, 2015 through March 3, 2016. In this review, 100 claims were reviewed, with 71 accepted and 29 denied. The overall error rate – calculated by dividing the dollar amount of charges billed in error (minus any confirmed underbilled charges) by the total amount of charges for services medically reviewed – was 30 percent.
A Few Caveats
- For clarification, the error rates reported do not take into account any claims that were paid on appeal, and some appeals are likely still in progress. Therefore, the 30-percent error rate reported is likely higher than the actual.
- There is no indication in the report of the number of claims denied for specific reasons.
- The list still includes language reflecting that “medical necessity requirements for admission were not met” when Medicare’s clarification documents have focused on whether it is “reasonable and necessary” for care to be provided in an IRF.
- The reasons for denial are similar to what we have seen in similar probe reviews conducted throughout the country.
What Were the Common Reason for Denial?
Noridian provided the following list of reasons for denial of the 29 claims:
- Post-admission physician evaluation requirements for timeliness were not met.
- Interdisciplinary team conference requirements for attendees and/or frequency were not met.
- The rehabilitation physician did not complete the minimum requirements for the individualized overall plan of care within four days of the IRF admission.
- Minimum therapy intensity requirements were not met.
- A valid IRF admission order was not completed.
- An IRF-PAI (patient assessment instrument) was not documented for validation of claim coding.
- The minimum intensity requirements for the qualified rehabilitation physician face-to-face visits were not met.
- Medical necessity requirements for admission were not met.
- No medical records were received.
The denial reasons follow the pattern we have been seeing from Noridian and other Medicare Administrative Contractors (MACs) that have completed IRF reviews in recent years. This once again demonstrates that IRFs continue to have difficulty with ensuring that documentation demonstrates that each case meets the updated Medicare guidelines for reasonable and necessary care in an IRF.
What the Report Does NOT Say
Noridian appropriately reports only the factual information that was noted in the probe. What the report does not address, and what providers need to address within their own organizations, is that most of the reasons for denial are preventable.With the exception of denials related to whether the care was reasonable and medically necessary, the majority of the denials were due to technical requirements not being met. Noridian has provided a comprehensive table of educational topics and details along with the results of the probe.
What Do We Recommend that IRFs Do Now?
While we agree that in some rare cases, an IRF may admit a patient who does not meet the test for “reasonable and necessary,” we believe that IRFs are making every effort to accept appropriate patients to their settings – and the challenges noted in this and similar probe reviews result from inconsistencies in documentation and processes. The table below includes some strategies that IRFs can utilize to improve performance in areas noted in the results described above.
PROBE REVIEW DENIAL REASONS
Post-admission physician evaluation requirements for timeliness and completion by qualified staff were not met.
Establish checks and balances to ensure that the PAPE is completed on time – when physicians round at varying times each day, establish a notification system so that the rehabilitation physician is aware of the exact time of admission.
Establish a process that clearly identifies the admission time – organizations that “pre-admit” patients need a process to update the actual time of admission so that it reflects the time the patient is actually admitted rather than the time of the pre-admission.
Interdisciplinary team conference requirements for attendees and/or frequency were not met.
Establish a “standing” ITM day and time and when a patient arrives the same day as the meeting, include the patient in the team meeting agenda, and note that full information is not yet available.
Be certain attendees either sign an attendance roster or are noted as present by a recorder to demonstrate attendance.
Be certain that staffers understand that therapy assistants and LPN/LVNs can attend and contribute, but their attendance does not meet the requirements; the appropriate licensed therapist and an RN must be present to meet the requirements.
Watch out for SLP. In our chart reviews, we’ve identified inconsistent attendance in a number of settings due to staffing patterns.
Rehabilitation physician did not complete the minimum requirements for the individualized overall plan of care within four days of the IRF admission.
Review the content requirements, including specificity – there should be NO ranges in the POC.
Establish a method of notifying the rehab physician with a work list of when certain documents are required.
Minimum therapy intensity requirements were not met.
Develop a real-time method of monitoring minutes of therapy.
Retrain all therapy staff on the importance of documenting missed minutes and the reasons they are missed.
Valid IRF admission order was not completed.
Be certain that orders are present and signedat the time of admission to the IRF. While standing orders are acceptable, it is essential they be signed.
IRF-PAI (patient assessment instrument) was not documented for validation of claim coding.
At any time charts are requested, at least two staff members should review the documents for accuracy and completeness prior to sending to the reviewer.
Minimum intensity requirements for the qualified rehabilitation physician face-to-face visits were not met.
Be certain rehab physician notes are identified with a template or note header.
Encourage rehab physicians to separate their team meeting notes from their face-to-face notes for the day, as some reviewers will not accept a notation that the patient was seen face-to-face when it is included with the team note by the physician.
Medical necessity requirements for admission were not met.
While this is subjective, and the rehab physician is the person best qualified to make this statement, be certain that the PAS, PAPE, and ongoing documentation by the rehabilitation physician clearly outlines why the rehab physician believes it is reasonable and necessary for the patient to be seen in an IRF.
No medical records were received.
Be certain that whoever is responsible for receiving ADRs within the organization is aware of how IRF ADRs are received and shares this information with the appropriate staff.
The Bottom Line
The continued issues related to technical requirements, including the timing and content of certain documents, are frustrating for organizations. But they need to be addressed as system issues as well as performance issues. Establishing processes to monitor how and when information is documented and providing real-time feedback to staff is essential in meeting these requirements and reducing the risk of denials for appropriate services.
About the Author
Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has over 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.
Contact the Author
Comment on this article
More Articles from this Week's eNews