MUNSTER - The U.S. Department of Health and Human Services, Office of the Inspector General (OIG) has been conducting a nation-wide review of claims submitted to the Medicare program related to certain rehabilitation services provided by hospitals. In general, inpatient rehabilitation facilities (IRFs) provide rehabilitation services to patients who require a hospital level of care, including an intense rehabilitation program and an interdisciplinary, coordinated team approach to improve their ability to function.
IRF claims submitted by Community Hospital for services provided in 2015 and 2016 were part of an OIG audit conducted between June 2017 and March 2018.
Community Hospital vehemently disagrees with OIG's assertion that 63 of 90 IRF claims reviewed were not payable as being “inappropriate admissions” for rehabilitation services, and will immediately appeal these findings.
Community Hospital has a rigorous process for admitting IRF patients. Community Hospital evaluated all of these patients using a demanding, three-tiered pre-admission screening process. Less than half of the patients referred for services were admitted to Community Hospital’s IRF, demonstrating the careful scrutiny of the physician decision makers, the Clinical Liaisons, and IRF staff to ensure that patients are only admitted to Community Hospital’s IRF unit when it is medically necessary.
Community Hospital underwent an external audit in late November 2016 conducted by the Medicare contractor Strategic Health Solutions (“SHS”) – also reviewing IRF records from 2015 and 2016. Under that audit, SHS determined that 97.5% of the cases were in compliance with the acute inpatient rehabilitation level of care. In addition, Community Hospital is awaiting final appellate results from an additional Medicare Supplemental Review Contractor audit for IRF claims from this same time frame and expects a compliance rate greater than 94%.
Community Hospital is in full compliance with federal Medicare regulations regarding IRF admissions. The OIG applied the wrong audit standards to the IRF claims when the OIG relied solely on non-binding guidance from a benefit policy manual when reviewing the patient records. Federal courts and the Attorney General have both concluded that such guidance does not have the force of law. Therefore, the OIG erred in its denial of claims. All of the claims audited by OIG meet the Medicare coverage requirements as determined by an independent outside expert.
Community Hospital is committed to complying with all statutes, regulations, and other standards governing participation in federal health care programs, including Medicare.
We strongly disagree with the OIG’s audit findings, its flawed methodology, incorrect application of the standards for review, its failure to consider Community Hospital’s comprehensive response and independent analysis, and the OIG’s statistically defective extrapolation approach --- again, we will immediately appeal these findings and stand ready to defend the outstanding patient care services provided through our rehabilitation programs.