Inpatient Rehabilitation Review Choice Demonstration Project: How Is It Going?

The Review Choice Demonstration (RCD) project for Inpatient Rehabilitation Facilities (IRF) seemed like a pipe dream when the Centers for Medicare & Medicaid Services (CMS) started talking about it even before the Pandemic. But, now it is in full swing in Alabama and Pennsylvania. Texas and California are slated to be next in the roll out. 

If you are listed and bill as an Inpatient Rehabilitation Facility (IRF) or an Inpatient Rehabilitation Unit (IRU) in Pennsylvania, you should have made your choice on either the Pre-Claim Review or the Postpayment Review by June 2, 2024.  If you missed making the selection, Novitas, the Medicare Administrative Contractor (MAC) in Pennsylvania will automatically sign you up for the Postpayment Review.

Novitas IRF RCD information provides all the specifics.

Choice 1 – Pre-claim review (PCR) is when 100% of claims are reviewed prior to final claim submission. PCR is a process through which a request for provisional affirmation of coverage is submitted for review before the final claims are submitted for payment. Pre-claim review provides reasonable assurance that applicable coverage, payment, and coding rules are met before the final claim is submitted.

Choice 2 – Postpayment review is when 100% of claims are reviewed after final claim submission. The IRF will follow the standard intake, service, and billing procedures, and the claims will pay according to normal claim processes. The claim will be processed and paid per CMS guidelines. Novitas will send an additional documentation request (ADR) letter following payment of the claim. The IRF will submit medical records for review. Novitas will follow normal post payment review processes. If a claim is denied, Novitas will follow the standard payment recoupment procedure. The IRF retains all appeal rights for denied claims.

If you have chosen the Pre-Claim Review you are hopefully getting approvals for each new admission as you submit initial paperwork to support the medical necessity of each admission. If you are admitting from home for specialized programs such as prosthetic training or Second-Chance Stroke Rehab, make sure you include adequate supporting documentation to show the efficacy of the inpatient admission.

If you chose the Postpayment Review or if you missed the choice deadline, be on the lookout for those ADRs. You WILL get an ADR for every admission! Once the ADRs come in, you will have a limited time to submit all the supporting documentation to demonstrate the medical necessity of the admission. The initial review is set for 6 months. If you would like an expert external review that is not CMS, LW Consulting, Inc. would be glad to provide feedback.  Contact Kay Hashagen, PT, MBA, RAC-CT, Senior Consultant at [email protected] or (410) 777-5999.

LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!