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Auditing IRF Records is Essential – Are You at 90% Risk?

Written by: Mediware on Wednesday, August 13, 2014 Posted in: Inpatient Rehab

Does it take four years to ‘get it right?’

Per Strategic Health Solutions, “The Office of Inspector General (OIG) identified a deficiency in key documentation elements required by Medicare to substantiate payment. Based on the OIG findings, the Centers for Medicare & Medicaid Services (CMS) directed the SMRC to perform additional review of Medicare Part A IRF facility services for calendar years 2010, 2011, and 2012.”

CMS states that the purpose of this project was to determine whether IRF service claims were appropriately completed per Medicare regulations and guidelines. The findings were quite disappointing, leading one to believe that up to 90 percent of the time, all claims reviewed are NOT meeting the stringent criteria that is oulined for services/documentation provided at an IRF level of care.

SMRC sampled a total of 186 claims for 164 beneficiaries during calendar years 2010, 2011 and 2012. The 164 beneficiaries consisted of 22 beneficiaries with more than one claim sample selected (multiple admissions). Additional Development Request letters were sent to the billing providers and the charts were requested for review within 45 days of receipt of the letter.

If these results do not beg you to audit your own records and to determine if you too are at such significant risk, I am not sure what evidence you will need to understand that the present environment in Medicare Part A payment is somewhat ‘hostile’. If every item required is not present in your medical record, you could be unpaid. This is the most effective means of saving the Medicare Trust Fund; beneficiaries provided services and denial of payment for technical purposes or purposes they feel do not render medical necessity for a rehabilitation level of care. Time to stay out of these alarming statistics. Get your audits done and create your action plan in areas of weakness NOW!


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