Knowledge Base Article

Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments through medical reviews. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules. One such initiative is the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services.

On May 15, 2023, CMS announced a new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services.  CMS notes “this program reduces the number of Medicare appeals, improves provider compliance with Medicare program rules, does not alter the Medicare IRF benefit, and should not delay care to Medicare beneficiaries. This RCD protects our programs’ sustainability for future generations by serving as a responsible steward of public funds.”

About the Initiative

According to the CMS, this initiative provides flexibility and choice for IRFs, and a risk-based approach to reduce burden on providers that demonstrate compliance with the Medicare IRF rules.

Cycle 1 Choice Selection

The first milestone for IRF providers is to select between pre-claim or post-payment reviews. Following are the steps of each choice as outlined in a flow chart available on the RCD for IRF webpage.

Choice 1: 100% Pre-claim review

• IRF must request Pre-Claim review (PCR) for all stays.
• Claims submitted without PCR will undergo prepayment review.
• An affirmation rate to be calculated every 6 months.

   

  Choice 2: 100% Post-payment review (Initial Default)

• IRF submits claims for each stay.
• Each claim is processed and paid per CMS procedures.
• MAC sends Additional Documentation Requests (ADRs) and follows CMS’ post-payment review procedures.
• An approval rate is to be calculated every 6 months.

   

  The selection period will start on July 7, 2023 and end on August 6, 2023. Alabama IRF providers will need to go to the Palmetto GBA Provider Portal to make your selection.  If a choice is not selected, an IRF will automatically be assigned to participate in Choice 2: Post-payment Review.

   

  Cycle 1 Review Dates

  The first cycle of review dates for this demonstration is August 21, 2023 through February 29, 2024.

   

  IRFs with Full Affirmation Rate of Claim Approval

  Palmetto GBA notes in a related article that “IRFs will be evaluated for six months, if the full affirmation rate or claim approval meets the target rate or greater (based on a minimum of 10 submitted pre-claim review requests or claims) in the first cycle, the IRF may select one of three subsequent review choices:

• Choice 1: Pre-Claim Review;
• Choice 3: Selective Post-payment Review; or
• Choice 4: Spot Check Review.”

If an IRF does not actively choose one of the subsequent review options, it will automatically be assigned to participate in Choice 3: Selective Post-payment Review.

Note, IRFs with less than the target affirmation rate or who have not submitted at least 10 requests/claims must again choose from one of the initial two options.

What Can You Do?

Now is the time to make sure you are following the Medicare program rules for IRFs. You can read about prior Medicare IRF reviews and available education resources on Palmetto GBA’s website in a related article in this week’s newsletter.

Resources

CMS RCD for IRF Services webpage: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services