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The Centers for Medicare & Medicaid Services (CMS) is accepting requests from inpatient rehabilitation facilities (IRFs) to settle appeals that were filed for redetermination with their Medicare administrative contractor (MAC) no later than Aug. 31, 2018 — if the appeal is currently pending or eligible for further appeal at the MAC, quality improvement contractor, Office of Medicare Hearings and Appeals, and/or Medicare Appeals Council review level.
CMS indicates it will pay 69% of the net payable amount for most claims associated with pending IRF appeals. However, claims that were denied solely because justification for group therapy was not documented in the medical record, or because a threshold of therapy time was not met, will be settled at 100% of the net payable amount.
The higher payment rate for claims denied based on group therapy utilization is of particular significance to CHA member IRFs, several of which had previously reported inappropriate denials based on group therapy utilization. In response to these reports, CHA facilitated communication between CMS, Noridian, and facilities to express concerns over the change in interpretation and to request additional clarification and review.
Additional information, including eligibility and procedures, is available on the IRF Appeals Initiative page on the CMS website.
