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Ask the payment expert
What should our facility do to minimize our risk of medical review?

Recently, we have seen more evidence of medical review activity. Medical review can be prepayment or post payment review by your Fiscal Intermediary, requested review based on a Medicare appeal or, as we recently saw, review initiated by the Office of Inspector General (OIG). 

A facility in Florida was targeted for medical review based on a high percentage of RUGs days in the Rehab Ultra High category. As a result of reviewing 100 claims, 19 were denied because the OIG determined that they were not medically necessary. 

Although medical necessity is a subjective determination, we can learn some lessons from this review. In this case, the finding was that the level of therapy was not appropriate. It is important not to bring in everyone in at the highest level; keep them at that level throughout their stay and then send them back home. 

Residents are more successful at home when we build up the therapy, maintain the highest practicable level as needed and then ramp them down to a lower level as discharge approaches. You can also integrate restorative nursing at this time to allow the resident to adjust to not having as much therapy at home.

Another way that facilities can be held accountable for paying back dollars is when appropriate notices are not given. Recently, a facility in Wisconsin was ordered by its fiscal intermediary to pay back more than $40,000 to a resident. Although the Fiscal Intermediary had found in favor of the facility's decision to stop Medicare A coverage, it stated that the facility failed to provide the appropriate notice to the resident and therefore was responsible for the charges. 

It is essential that a comprehensive process be in place whenever medical review activity occurs so that correct documentation and forms are sent to the Fiscal Intermediary. 