AHA asks CMS to Spike IRF Demonstration Audits

The proposed integrity audit on inpatient rehabilitation facilities in four states during the public health emergency raises a number of concerns for hospitals.

Stakeholders are asking the federal government to withdraw proposed model "integrity audits" of hospital inpatient rehabilitation facilities that are scheduled to launch in four states later this year.

In a letter this week to Elizabeth Richter, acting administrator for the Centers for Medicare & Medicaid Services, the American Hospital Association complained about the launch of a review choice demonstration (RCD) in the middle of a pandemic.

"One of our top concerns is the timing of these new audits, which would begin during the COVID-19 public health emergency and divert critical resources from the IRF field’s efforts in helping fight the pandemic," Thomas P. Nickels Executive Vice President Government Relations and Public Policy, said in the letter to Richter.

"During the pandemic, IRFs are treating patients with and recovering from COVID-19, as well as those transferred from overwhelmed general acute-care hospitals," Nickels said.

"These pandemic-driven IRF admissions often include patients who, as a result of the virus, face a longer-term and often complex recovery trajectory requiring specialized care to address pulmonary and other complexities and debilities – these patients have become known as “long-haul COVID patients.”

Under the five-year proposed model, which CMS says is designed "to improve methods for the identification, investigation, and prosecution of potential Medicare fraud," integrity audits would examine both pre-claim and post-payment Medicare fee-for-service admissions at IRFs in California, Texas, Pennsylvania, and Alabama.

Auditors in the four model states would examine all IRF claims until the facility hits an approval rate of at least 90%, after which it would be subject to spot checks for continued compliance.

Nickels said the AHA also has "numerous additional operational and design concerns about the RCD that justify its withdrawal," namely:

• The long-standing problem of Medicare auditors lacking adequate knowledge of IRF-specific coverage and payment guidelines would be perpetuated under this proposal.
   
• Administrative burden would materially and needlessly increase for IRFs in the target states.
   
• The across-the-board design of the proposed demonstration would place unwarranted burden on IRFs with no history of noncompliance.

Nickels noted that the PHE waivers gave IRFs flexibility to collaborate with acute-care hospital, including IRF units that were repurposed during surges to accommodate patients overflow.

"Given the rapid development of need in many COVID-19 hotspots, the varying resources across communities, and the complex needs of some COVID-19 patients, these waivers have been instrumental in enabling IRFs to help fight against the virus," Nickels said.

"However, despite the waivers, the pandemic has imposed numerous and unprecedented operational challenges, such as shifts in case-mix, inadequate testing supplies, personal protective equipment, fill-in personnel for infected staff, and, more recently, unsteady vaccine supply and distribution planning."

Nickels said the pandemic's strain on the nation's healthcare system is not taken into consideration in the IRF RCD notice.

"Indeed, there was not one mention of the PHE," Nickels said. "We urge CMS to refrain from implementing this burdensome new demonstration. IRFs need to remain focused on the full-court press required to slow and then stop the virus."