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When it Comes to Medicare Dollars, Compliance Trumps Innovation

Written by: Mediware on Tuesday, June 30, 2015 Posted in: Inpatient Rehab

Healthcare quality and performance improvement work is not sexy .1

It is expensive, painfully time consuming and highly detailed with focus upon improving service in meeting the needs of patients. And, it usually occurs long after the patient encounter. Technology exists to acquire the information needed to accomplish quality and performance objectives but healthcare infrastructures and behaviors are not prepared to take advantage. When costs are excessive and money is limited, the investment decisions in improving quality and performance will always favor short term dollars.

Last month, a draft appropriations bill to provide funding for the Agency for Healthcare Research and Quality (AHRQ) may have been cut off by politicians. AHRQ supports the studies and systematic reviews that objectively evaluate how well clinical procedures, quality approaches and consumer satisfaction work. The House and Senate must pass funding legislation by September 30th. Will those duties be absorbed and funding stay at zero dollars?

AHRQ captures research data on many issues, including cost and quality of services, medical practice patterns, access to care and treatment outcomes; then translates those data into information to help inform decision-making and improve health care delivery. And, more specifically, AHRQ addresses what has been missing in American health care; what treatments work best for whom, and how errors can be prevented.

Money just does not exist to get all the quality and performance improvement work done. Now we must look elsewhere to shoulder this burden. CMS is sufficiently taxed with protecting tax payers’ Medicare dollars, and the backlog of audit recovery activities still looks for additional resources to get caught up with the work at hand.

Interestingly, the Office of Inspector General (OIG) has released a mid-year update to its 2015 Work Plan .11 Therein are many new items on the agency’s agenda, most of which are scheduled for 2016.

The OIG’s oversight extends to other programs under the U.S. Department of Health & Human Services (HHS), but the majority of its resources go toward combating fraud, waste, and abuse in Medicare and Medicaid.

For rehabilitation hospitals, the OIG has added documentation required in support of the claims paid by Medicare to its watch items.

For IRFs, it may feel like 2010 all over again as the “2010 Rules” are scrutinized by yet another enforcement agency. Did you know the OIG agents are authorized to carry guns? And you thought RAC auditors were tough!

It is good advice to make sure that your inpatient rehabilitation facility is in compliance with the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). In 2016, the OIG will determine whether IRF claims are being paid in accordance with federal laws and regulations.

By now most IRFs know what is required, but at a minimum, it is time to review:

• Pre-admission screening
• Post-admission physician evaluation of the patient within 24 hours of the admission
• Timely submission of the plan of care (must be completed within the first four days)
• Physician generated admission orders for the patient’s IRF care
• Documentation of medical necessity:
o  The patient must require the active and ongoing therapeutic intervention of multiple therapy
disciplines, one of which must be physical or occupational therapy.
o The patient must generally require an intensive rehabilitation therapy program.
o The patient must reasonably be expected to actively participate in, and benefit significantly from,the intensive rehabilitation therapy program.
o The patient must require physician supervision by a rehabilitation physician.
o The patient must require an intensive and coordinated interdisciplinary approach to providing
• Documentation to indicate both the nature and degree of expected improvement and the expected length of time to achieve the improvement.
• Discharge planning must begin upon the patient’s admission, and not exceed a reasonable period to achieve a patient’s established goals or the determination that further progress is unlikely.

During most IRF stays, therefore, the emphasis of therapies would generally shift from traditional, patient-centered therapeutic services to patient/caregiver education, durable medical equipment training, and other similar therapies that prepare the patient for a safe discharge to the home or community-based environment.

These are the expectations required of all IRF providers. We will expect another branch of government to scrutinize and enforce the quality and performance of same. Dollars available for innovation and improvement have been withdrawn in favor of enforcement of compliance with the 2010 rules of engagement. This work may not be sexy, but it will draw a lot of attention.

Eliminating AHRQ sends the message that funding innovation and quality improvement in healthcare is too expensive when we aren’t getting our money’s worth from current care delivery infrastructures.



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