Medicare's recovery audit contractor program: inpatient rehabilitation facilities are taking back takebacks, but enough?

A perfect storm had been brewing in the last decade: Medicare payment mistakes; Medicare waste, fraud, and abuse; fuzzy medical necessity definitions; erroneous coding; and a strained national budget. The United States Congress responded by inserting Section 306 into the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Section 306 called for the correction of Medicare payment problems by establishing the Recovery Audit Contractor program as the vehicle for the Centers for Medicare & Medicaid Services to recoup Medicare overpayments as far back as 3 yrs from its healthcare providers and to return underpayments to them. The legislation allowed for Medicare to contract with private firms to follow the money and earn a cut. Caught in the eye of the storm, Medicare providers combined are giving back more than they get back. Inpatient Rehabilitation Facilities are taking back takebacks-but enough to remain viable?

Rasch-derived latent trait measurement of outcomes: insightful use leads to precision case management and evidence-based practices in functional healthcare.

The use of Rasch-derived latent trait measurement of outcomes for persons with chronic disease and disablement evolved from other fields, particularly education. Person-metrics is the measurement of how much chronic disease and disablement affects an individual's daily activities physically, cognitively, and through vocational and social role participation. The ability of the Rasch model to assume that the probability of a given person/item interaction is governed by the difficulty of the item and the ability of the person is invaluable to disability measurement. The difference between raw scores and true measures is illustrated by an example of a patient whose physical difficulty is rated on rising from a wheelchair and walking 100m (known to be more difficult), and then walking an additional 200m. Though number ratings of 0-1-2 are assigned to these tasks, they are not equidistant, and only a true measure shows the actual levels of physical difficulty.

Medical necessity: is current documentation practice and payment denial limiting access to inpatient rehabilitation?

Medical necessity is a legal, not medical, term. Depending on the stakeholder's point of view, it may seem less about human need and dispensing medical care and more about a web of rules, rulings, regulations, and manuals, especially for Medicare patients, who use the lion's share of rehabilitation services. In other words, the term medical necessity seems, to some stakeholders, to refer more to what determines payment by Medicare instead of what should be done to determine optimal patient health. Such a perspective on medical necessity has major implications, considering that Medicare pays for most of the rehabilitation treatment in some 1200 inpatient rehabilitation facilities and that its policies determine which patients qualify for admission to an inpatient rehabilitation facility. Medicare's medical necessity policies are often described by inpatient rehabilitation facility administrators and physiatrists as complicated and unfair, as well as being demeaning to the standing of physicians. Ask some physiatrists about their patients meeting Medicare guidelines for medical necessity, and they might bark, "Medical necessity?! That's what I was taught to know!"