Looking Ahead in 2021: What IRFs Can Expect

IFR providers expect that the pandemic as well as new regulatory issues will impact their services.

2020 was certainly a historical year, punctuated by the COVID-19 pandemic and an overwhelming number of waivers and flexibilities for healthcare providers attempting to provide care amid chaos.

Those same providers were also required to maintain compliance with any existing and “un-waived” payer requirements, adding to provider stress. As we enter 2021, inpatient rehabilitation facilities (IRFs), along with all other healthcare providers, will be dealing with ongoing fallout from COVID-19, as well as the myriad of documentation and practice requirements that drive payment.

Recovery Audits

Recovery Audit Contractor (RAC) audits have resumed for IRFs, and while the number of charts requested is small, the impact can be significant. Despite prescribed limits to the number of charts that can be requested in any 45-day cycle and an annual limit of half of one percent, those limits may be adjusted upward based on low compliance rates. While all IRFs need to be prepared for these requests, small providers are at greater risk for high rates of non-compliance due to sample size, and they need to be certain they are responding promptly to these requests, and appealing denials if they occur.

COVID Impact

COVID continues to have an impact on IRFs, as well as all sectors of the health delivery system, with no real end in sight. We have seen impacts on staffing – related to the U.S. Census, staff burnout, and staff illness – as well as bed capacity and throughput, and we expect those issues to continue. 

The federal public health emergency (PHE) was recently extended for 90 days, from Jan. 21 until April 21, 2021. This means that the blanket waivers that impact providers will remain in place for this period, unless the Secretary of the U.S. Department of Health and Human Services (HHS) decides to end the PHE prior to that time. The waivers most pertinent to IRFs are the blanket waivers allowing for lower intensity of therapy services during the PHE, and those that allow for physicians to provide the required face-to-face visits via telehealth. Providers may continue to use these waivers. We advise our readers, however, to clearly document services to ensure that the record can be defended in future audits.

Additionally, IRFs continue to have the ability to utilize IRF beds for acute patients (and acute beds for IRF cases, when necessary) to meet surge demand. The waivers provide some relief for IRFs as they address the shift in IRF volumes that result from fluctuations in acute care and the need for post-COVID-19 rehabilitation for patients with significant debility. The ability to provide rehab in a safe and effective way, based on these shifts, is important for patient care and organizational success. We believe that IRFs should continue to explore opportunities for the provision of post-COVID-19 rehabilitation services as part of the solution to moving patients from acute care through the health continuum and on to home with improved functional abilities. Focused COVID-19 rehab programs have been shown to be big wins on all fronts: patients get much-needed care focused on functional recovery, IRFs maintain volume needed to remain open, and acute organizations are able to manage throughput by transferring patients to post-acute beds, effectively opening more acute beds for incoming patients.

Use of Non-Physician Practitioners (NPPs)

Effective Oct. 1, 2020, the Centers for Medicare & Medicaid Services (CMS) allows the use of NPPs to provide one of the three required face-to-face visits in the second and later weeks of a patient’s stay. In audits for our clients, we have seen two separate issues:

• Difficulty tracking and managing the face-to-face visits to ensure that the rehabilitation physician completes at least three face-to-face visits during week one, as well as ensuring that during week two and forward, an NPP does not provide more than one of the required face-to-face visits. Note that the NPP can provide additional patient visits, but these visits will not count toward the required three face-to-face visits for the week.
• Developing policies, procedures, and practices that demonstrate that the organization has established a mechanism to ensure that when a NPP provides face-to-face visits in lieu of the rehabilitation physician, he or she has the appropriate training, experience, and competencies to do so.

Exposure Under OIG Reviews

The HHS Office of Inspector General (OIG) continues to review hospital claims based on four claim areas considered to be high risk for billing non-compliance, based on prior OIG findings. Those areas include inpatient claims billed with high-severity-level DRG codes, inpatient claims paid in excess of charges, IRF claims, and outpatient medical device claims. Large health systems appear to be more likely to be audited, based on the types of claims being targeted. Feedback from the field suggests that these reviews continue to have very high determinations of non-compliance.

Quality Initiatives and Social Determinants of Health

Social determinants of health (SDoH) are likely to be of increasing importance in measurement of quality indicators, and IRFs should be preparing not only to be collecting data on SDoH, but planning for how they will mitigate the impact of these factors on ongoing success of the rehabilitation program and the consistency of rehabilitation outcomes. While implementation of the updated IRF-PAI components have been delayed, the focus on this area continues to grow, and IRFs’ responsiveness now may well be reflected in later success.