CMS Takes Next Steps on Proposed Inpatient Rehabilitation Facility Review Choice Demonstration


By AMRPA Headquarters posted 09-27-2021 09:27

Remy Kerr, MPHBy Remy Kerr, MPH, AMRPA Health Policy and Research Manager

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) issued a second Information Collection Request (ICR) with a 30-day public comment period related to the inpatient rehabilitation facility (IRF) Review Choice Demonstration. This demonstration was initially proposed in December 2020 under the Trump Administration. The proposal seeks to require IRFs in selected areas to choose between either 100 percent pre-claim or 100 percent post-payment review for all Medicare Part A fee-for-service (FFS) claims. Under the pre-claim review choice, IRFs could initiate and continue services prior to the submission of a pre-claim review request, but the IRF must submit the request along with required documentation and have the review completed prior to the final claim for payment being submitted. Under the post-payment review, an IRF would provide services and submit all claims following standard procedures, and then submit the documentation for a medical review to determine medical necessity. The demonstration would begin first in Alabama, and then expand to IRFs in California, Texas, and Pennsylvania. At the time of the initial proposal, CMS asserted this demonstration was proposed “due to the potential for high rates of improper payments” in IRFs and stated that the selected states were chosen due to particularly high rates of improper payments.

In this second ICR, the notice is nearly identical to the first notice. There are, however, some revisions to the proposal within the supplemental materials. In the second notice’s supplemental information, CMS revised the language related to claim reviewers. Instead of “trained nurse reviewers,” CMS has expanded the definition to include “registered nurses, therapists or physician reviewers.” CMS also removed some language included in the initial notice related to documentation requirements. Lastly, CMS revised the pre-claim subsequent review decision timeline from 10 days, as initially proposed, to 5 days.

CMS also responded to public comments received on the initial ICR. Many of the comments CMS acknowledged included those raised by AMRPA. While CMS has not provided an anticipated start date for the demonstration, the agency states it will take the public health emergency (PHE) into account and “continue to monitor the status of the PHE for potential impact on proposed dates.” CMS also asserted, as it did at the time of the initial proposal, that the agency believes such a demonstration will not create significant burdens on patients or providers as the demonstration does not require any documentation an IRF does not already maintain for Medicare payment.

AMRPA’s comment letter on the first notice is available here. The Association is currently developing our response to the second notice, as well as other advocacy strategies, and will keep members apprised of any developments via this blog, Off the Record newsletter, and other member alerts. AMRPA will also discuss the demonstration during our upcoming 2021 Virtual Fall Educational Conference & Expo. If you have any questions, please contact Kate Beller.