Physician Advisory

Dr. Ronald HirschNovember 4, 2020

RACmonitor: IRF Care Again in Audit Crosshairs

healthcare team reviewing patient chart

Last week, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an audit of OSF Saint Francis Medical Center in Peoria, Ill. In this audit, the majority of the errors were once again due to admissions to inpatient rehab that the OIG’s contracted auditor determined were not appropriate for inpatient rehabilitation facility (IRF) care. And as expected, the hospital adamantly disagreed with the auditor’s findings.


Now, you have heard here before about the high denial rate of inpatient rehab admissions in multiple OIG audits, and the objections from the hospitals about the result. While the definition of medical necessity for IRFs seems clear to providers, the general theme of the rebuttals is that the auditors are misinterpreting the Centers for Medicare & Medicaid Services (CMS) rules. At some point, IRFs are going to start denying admissions to worthy patients, fearing these denials, and then Medicare beneficiaries will be the ones paying the price, with loss of optimal recovery.


Last week, CMS released another COVID-related rule. In this one, it discussed coverage of the COVID vaccine by Medicare. In a strange twist, the costs of vaccines given to Medicare Advantage (MA) patients have to be billed directly to Medicare, and will be covered by Medicare and not the MA plan. Logistically, this is going to be challenging for providers and patients who are used to the MA plan covering all necessary care, exclusive of hospice.


This rule also extended the Comprehensive Care for Joint Replacement (CJR) bundle payment program to the new DRGs for hip replacement after hip fracture. This change is retroactive to Oct. 1, which makes it doubly distressing to providers; not only was there no opportunity to comment on this, but then it was enacted retroactively, after doctors thought these patients were out of the program. CMS also released data on CJR patients during the pandemic, and compared to April 2019, there was an 87-percent drop in volume. I am wondering where in the midst of a pandemic those 13 percent were able to have surgery.


Moving on, as you know, it is always the responsibility of the billing provider to submit records when a claim is audited. That’s easy for office-based doctors; they just send the chart. It’s trickier for hospital-based doctors, whose billing staff must be able to access the hospital electronic medical record (EMR).


But think about the radiologist submitting a claim for reading an imaging study that was ordered for a non-hospital patient. The medical records supporting that study are at the ordering physician’s office. Well, last week, CMS announced that it is starting a pilot project, through which some Medicare Administrative Contractors (MACs) will be requesting these medical records directly from the ordering physician office when they are auditing the radiologist claim. This should simplify things for everyone, but only if the MACs explain to the ordering physician office why they are requesting the records.


It will be interesting to see how everything unfolds.  

Author Bio: Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.