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Written by: Darlene D'Altorio-Jones (1959-2015) on Wednesday, November 28, 2012 Posted in: Inpatient Rehab

There is so much weighing on the rehabilitation physicians due diligence to truly meet all the coverage criteria. From nuts to bolts in timeliness, to content and full documentation in order to meet the more than 40 items in the 2010 IRF regulations for the Medicare part A beneficiary; is it a growing trend that physician contracts have shared risk clauses?

When I attend national conferences for rehabilitation, I listen for ‘new talk’ on what is happening in the inpatient rehabilitation facility network. More than ever this fall, with the resurgence of chart audits and denials, was the discussion that perhaps the only way to get documentation done correctly is to create ownership of the financial viability for the patient. That when ‘clearly’ (not certain who or how that is defined), the record cannot meet baseline requirements for coverage that not only would the facility have payment rescinded but the responsible physician receives less compensation then a full compliment as outlined by contract. With so much resting on the critical minutia and required elements of charting, the question of who holds financial responsibility is often questioned. Is it all one sided?

How do you make documentation more foolproof? Are templates, checklists and reminders to staff sufficient enough to be sure a medical record holds up to scrutiny? When the final result is often FULL denial and not just portioned lack of payment, any denials are costly. This is particularly true because payment audits often come months after a patient is discharged and all resources have been expended and paid for. The patient could have been wholly successful in meeting the goals outlined by the rehab team and yet payment is never guaranteed and hinges on retrospective review of a detailed record of care.

Did your utilization review process (a process defined in conditions of participation for all inpatient hospitals) provide real-time guidance to be certain all risks were met?

If not, given the new capabilities of a very integrated CMS payment system – if the inpatient bill is declined, will all part B care attending to that denial also be up for recoupment? That too could be a future reality. In the past I have heard talk on this topic but it seems to me the talk is taking on greater proportions and persons are now asking one another how they can get full accountability.

I don’t know why it always has to be a punitive type approach, except that history tells us these types of measures get noticed. Maybe just talk will be enough this time, and the seriousness of non-payment will force us to work together without contract language or regulatory threats so that the obligations of charting specific to the requirements will be done because it’s our professional obligation. If tools are needed to support full compliance, provide the appropriate tools. Shared risk sounds scary because it is. Professionally, it shouldn’t come to threats to understand the importance of protecting the bottom line and resources for all future patients. However, given the conversations around this topic recently, it seems feasible that it may.



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