In their most recent Work Plan update, the OIG announced they will conduct a nationwide audit of inpatient rehabilitation facilities (IRFs) and reviews of Medicare payments for trauma claims.
Prior audits of IRF services by both the OIG and CMS have resulted in high error rates. The OIG indicated the medical record documentation often does not support the IRF care is reasonable and necessary. The types of errors noted in prior audits include:
- Inadequate documentation to support the patients had medical needs and functional rehabilitation goals that required the complexity and intensity of medical rehab.
- Inadequate documentation to support need for high level physician supervision.
- Admissions for patients who did not have the ability to participate in intense rehab.
- Continued admissions for patients with no measurable improvement.
Trauma Team Activation
The OIG also announced they will be conducting a review of Medicare payments for trauma activation. The OIG indicated they will be evaluating whether:
- Trauma activation was medically necessary
- Trauma activation was billed by a facility with an appropriate trauma center designation
- The documentation supports the coverage guidelines
We recommend you review all active Work Plan items to identify known risk areas that may affect your organization. Identified risk areas applicable to your organization should be incorporated into your auditing and monitoring efforts to evaluate your compliance with the regulations and guidelines.
HBE’s team of experts is available to assist you with risk assessments, routine auditing and monitoring, policy and procedure development as well as customized education and training for your clinical and administrative staff.
The OIG Work Plan is located here: http://https://oig.hhs.gov/reports-and-publications/workplan/updates.asp
The prior OIG Report for IRF: https://oig.hhs.gov/oas/reports/region1/11500500.pdf
The trauma activation guidelines are location in the Medicare Claims Processing Manual, Ch. 4, Section 160.1 Critical Care Services: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c04.pdf