The Comprehensive Outpatient Rehabilitation Facility (CORF) is something of an orphan rehab program. A CORF is a Part A provider, and a sister to a rehab agency, sometimes known as an ORF. The CORF and rehab agency join the other outpatient therapy programs billing Part B: outpatient hospital therapy departments, private-practice therapy programs, and physicians billing for therapy under the incident-to rules.
The CORF originally was envisioned 20 years ago as something of an inpatient rehab program without the beds. The regulations never fully evolved to make that happen, and a CORF over the years has become an outpatient therapy program that became more complicated with the move from cost-based reimbursement to HCPCS coding - and, more recently, with the confusing conflicts in not only the Conditions of Participation and Interpretive Guidelines but also the inconsistencies in the Medicare Benefits Policy Manual, the Medicare Claims Processing Manual and various MLM articles.
Some of these inconsistencies have led several CORF providers to report that they have received denials based on this conflicting set of regulations. Others have reported having all their claims subject to ADR, with an ultra-high percentage unpaid due to regulatory variances and interpretations - in one case, for example, the transposition of two words tumbled one small outpatient therapy provider to the tune of $300,000 during the past 7-8 months. The words "respiratory" and "rehabilitation" don't sound much alike, but when "rehabilitation" inadvertently was used in a mandatory requirement that only applied to "respiratory," it was only the lonely providers who screamed as their claims went unpaid - and their sounds fell on deaf ears, as often is the case for orphan programs. Denials were fruitless as the error was embedded in various CMS publications, only there for those to see if they had a historical list of applicable regulations.
Well, where there's smoke, there's bound to be fire, and for providers it is likely that issues found to be "easy" recoupments for one CMS contractor are likely to be investigated and copied by other CMS contractors (think RACs). The whole story of the curious CORF won't be told; I'll save that for my rehab compliance blog. However, the lesson harkens back to a story on scrapbooking that appeared in RACMonitor last Sept. 16. In Local Coverage Determinations: Scrapping Your Way to Success in A RAC World, the concept of creating a book (or books) of key regulatory requirements, including national coverage and local coverage determinations, plus policy guidance for specific programs, was presented.
The curious case of the CORF very well may represent the first written testament to the positive effect of having coverage and policy decisions in order when the red pen of a Medicare reviewer is in hand and the check is NOT in the mail. By having direct reference to the inconsistency in the documents and a historical record of the various versions of the same numbered CMS document, it was possible to see that reviewers were denying claims based on the interpretation of the program materials they were referencing while the provider was documenting according to the program materials they were using.
While it is distressing that those providers were caught in the middle of this wordsmith mix-up (they had to spend the resources, time and effort to get through the appeals process), the bleeding on the matter of respiratory vs. rehabilitation has been stopped. These providers now have in place a credible defense should the issue of plan of treatment in a CORF be approved as a RAC issue.
As the RAC program continues to gear up for medical necessity reviews, take a look at your facility's key risk programs, diagnoses and vulnerability areas, then begin scrapbooking your way to success. It's been proven to work!
Now, for those orphan CORFs out there, CMS has reissued MM6005-CORFs with up-to-date language, although the MLM article is not clear in stating exactly what they are clarifying. They also have updated the JA6005 - Job Aid - CORFs. This is the article that the CSR folks read through when you call them to ask if a physician must write the rehabilitation plan of treatment in its entirety. STOP - the correct statement is that the physician must write the respiratory plan of treatment! Whew! Take a deep breath on that one, and call me if you're a CORF that is still curious.
About the Author
Nancy Beckley is a co-founder and president of Bloomingdale Consulting Group, Inc., providing consulting services to the rehab professional. Nancy is certified in healthcare compliance by the Healthcare Compliance Board, and serves on the Part A and Part B Provider Outreach Education and Advisory Panel for First Coast Services Options (Florida Medicare). She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities.