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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, June 14, 2012 Posted in: Inpatient Rehab

How many charts can be requested for review every 45 days?  The Recovery Audit Contractors released an educational flyer earlier this year for requests beginning March 15, 2012 and after that answers this question.

If you are a free standing rehabilitation facility, it is quite obvious that based on the Tax Identification Number (TIN) of your facility, you have a limit of ADRs that may be requested  based on your prior calendar year ofMedicare claims volume. It is a pure math equation on what your risk of audit may be for any given 45 day request as a freestanding IRF. You know the number of Medicare discharges and you apply the math. The baseline facts are as follows:

-The  maximum number of requests per 45 days is 400

-The limit is based on claims volume only.

-The type of claims do not factor into the limit.

-A provider’s limit will be applied across all claim types including professional services.

The limit is equal to 2 percent of all claims submitted for the prior calendar year divided by eight.

It’s pretty simple math if you are a freestanding facility and billed, let’s say,  1,200 claims last year.  The math is 1,200 x .02% = 24/8 =  3  claims in any 45 day period. Pretty manageable to prepare as a provider.

However, if you are a unit within a very large medical center that generates hundreds of thousands Medicare claims per year, you may find yourself in a very different predicament. The maximum amount is ‘per campus’.  The definition of campus is ‘one or more facilities under the same TIN’.

Let us look at this scenario. Consider you are a 25 bed unit within this TIN. Your Medicare volume happens to be 360 discharges for a prior year. Using the example in the education flyer, we will say that your entire facility TIN is large enough to generate 156,253 claims in the prior year. Two percent of that claim volume is 3,125.  The limit is calculated by dividing by eight. In this example, the provider’s limit is no more than 390 requestsevery 45 days for this particular facility under the same TIN. Your IRF may be a small unit within that TIN. Surely they cannot request an entire 45 day limit from just one area, this could be every Medicare discharge in the prior year. Can they request every patient in the same 45 days?

Considering that the request is made at the TIN level, and the above scenario happens to be similar to what your situation might be; this could result in an ADR request asking for all 360 of your discharges in one 45 day period. Seems impossible, but it is probable. Imagine just half that number;  whereas you request that your own staff be involved in the preparation of all ADRs specific to an IRF level of care. Wow, you just got slammed. I am writing this blog because I am aware of a particularly similar occurrence. It can happen and it may happen to you! It led me to read the Audit Program flyer and sure enough, it not only can happen, it is happening.

After reading the guiding education document several times, it became apparent that the present rule permits this type of scenario to occur.  I also asked an CMS representative and received a prompt detailed response from one of their Senior Health Insurance Specialists in Baltimore.

The response stated that,  ”although they are aware that Recovery Auditors have not conducted many IRF-specific reviews until recently, we have not heard of instances where there was undue hardship placed on any particular provider.

My response to YOU as IRF providers is:  ”has this happened to you?” If as a provider you have been one of those cases in which your small unit received an abundant of request within 45 days, you most likely obligated as required.   Did you also share this hardship at the government level as to  how that particular interpretation of the rule is a hardship? As an excluded unit within the TIN, it may be more fair across all provider types of IRF care to apply the standard calculation at the CMS Certification Number (CCN) level, rather than all claims submitted from a prior year at the TIN level.

If you do not voice these hardships, you run the risk of status quo. Our government often listens when we raise our voices to provide logic based on personal hardships. Testimony is key. Without testimony, your expectation to respond to ADR rests in the present interpretation.

Here is further discussion from the  CMS Senior Health Insurance Specialist that change will not happen unless you voice your concerns.  He responded, ”Recovery Auditor reviews are approved by CMS for a particular provider type, in this case IRF. As you mentioned, the size of any specific unit that generates those claims is not part of the ADR limit calculation. Therefore, if a recovery auditor chooses to use the majority of a facilities ADR limit on IRF claims, that would mean there would be very few ADRs for other claim types from that facility. Therefore, because the facilities fall under the same TIN, we would expect that the administration/management of the related facilities would coordinate and take the necessary steps to manage the process of responding to ADRs in a manner that makes the most sense for their organization.  The methodology used to determine ADR limits for facilities has been in place for some time now. CMS believes that this method is a fair and accurate way of calculating the ADR limits, and there is currently no plan to change this methodology.”

If you agree that this is a sensible method, sit still— there is nothing more to do.  If you believe this rationale would and will create undue hardship in ADRs  for IRF units within large hospital systemsthan you need to comment BEFORE it happens. Voice your concerns to an individual in the Provider Compliance Group of the Office of Financial Management. Before a flurry of ADRs begin to mount for small units within hospitals, you need to make CMS aware that selecting all records in one 45 day period that is nearly equivalent to an annual discharge volume is not reasonable, particularly when very specific items must be tagged to validate compliance toward the 100-02 Chapter 1:110 guidelines.

Ultimately it’s our government; they are waiting to hear from you. Medically necessary audits have just begun and the government is searching for ways to achieve budget neutral. It’s your dime! Be a leader!

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