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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, November 20, 2012 Posted in: Inpatient Rehab

I’ve always felt that inpatient rehabilitation, with its specialty dedication to fairly focused results in meeting discharge demands for complex patients to return to the community, was a no-brained clear winner for all patients with functional impairment. A level of care so special that it would always have its place in healthcare and would be revered in the line of medical management for the many miracle-like outcomes achieved. I thought IRFs would always have a niche and that niche would be filled by the professionals I worked alongside for more than 20 years; those who call themselves inpatient rehabilitation specialists. Yet here we are today, defending medical necessity not based on the outcomes achieved, but on timeliness, content and prescriptive, detailed standards called “2010 guidelines.”

An entire level of very specialized care is being defrauded of importance because a very prescriptive set of expectations of highly stressed contingency may not be taken seriously by the rehabilitation physician. If the rehabilitation physician (even one within the team), is not on board with the expectations set to defend the coverage criteria, you are in for a tumultuous experience when medically necessary audits are performed.

If more than two years later your rehab physician(s) cannot detail each expectation to the rigor of the interpretations themselves, then you may be in jeopardy. These laws hold significant weight in an audit frenzy environment where the payment-neutral healthcare benefit called Medicare Part A is attempting to care for significantly more covered lives at your expense for being foolhardy. Don’t take this wrong, we should be defending the Medicare Trust Fund; that is the RIGHT thing to do and rules help guide right from wrong.

Leadership must audit and guide to appropriate expectations as many facilities operate with higher than 50 percent Medicare populations and they have a lot to lose. If your rehabilitation physician is not detailing the expected documentation and demonstrating they are in charge of the directed care and plan then you are at risk for denial.

Have you determined if your charts defend the 2010 ‘coverage criteria’ seriously? If not, you are headed toward financial reclaim at a level that might sink your ship. No margin, no mission and margins are already tight.  If you don’t believe me, talk to the many facilities now experiencing record level take-backs because rigor and intent can seem gray if documentation isn’t super pristine.

These 2010 requirements take time to master. Defensible documentation must clearly demonstrate that the Inpatient Rehabilitation Facility level of care is truly reasonable and necessary as part of each of the demanded criteria, not just one part. Forget simple check boxes and generic arguments; the pre-admission due diligence must be followed by thorough data and information that aligns with the expectations and risks presented, and the level of detail around individual patient recovery.

ANY physician that calls themselves to serve the special population of IRF patients can not  ‘be ‘rushed’ into doing so. It must be evident in the documentation that the rehabilitation physician is leading, concurring with and guiding the plan of care from the moment a pre-admission candidate is selected, to the 24 hour defense of continued appropriateness. Given input from the team, the baseline plan of care must be confirmed within the first four days and then reassessed for functional and medical management to the discharge barriers no less than 3 times per week. Given all this involvement, they then must physically attend and guide the collaborated plan in a weekly team meeting that focuses on the realistic and achievable outcomes toward expected. That’s a lot of work – the livelihood of  a rehabilitation level of care is in their hands.  It ‘s our future.  The final question will be determined by auditors if not guided by you!  It’s time to be sure your rehabilitation physicians are on board – it’s actually two years too late if they are not!

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