Medicare Compliance & Reimbursement

GAO charges providers with 'sloppy' admissions practices - and fallout is expected.

The long-awaited report from the Government Accountability Office on the 75 percent rule (which determines whether a facility qualifies as an IRF) came out in late April, and providers are reeling from what it says - and what it doesn't say.

"I was very disappointed by the GAO report," laments Karen Eyberger, rehab development manager for Genesis HealthCare System in Zanesville, OH.
 
Experts Cannot Comprehend Another Refinement In a move that left many providers shaking their heads, the GAO recommends that the Centers for Medicare and Medicaid Services further refine the rule to "describe more thoroughly the subgroups of patients within a condition that require IRF services."

The GAO called on the Institute of Medicine to convene an expert panel to discuss the 75 percent rule, including a discussion about whether CMS should add more diagnoses to the list of qualifying conditions.

The verdict: "The experts IOM convened questioned the strength of the evidence for adding conditions to the list, finding the evidence for certain orthopedic conditions particularly weak, and they called for further research to identify the types of patients that need inpatient rehabilitation and to understand the effectiveness of IRFs," the report says.

Panelists did agree that condition alone doesn't provide sufficient information about a patient, and that functional status also should figure into whether the patient qualifies, the report says.
 
Prediction: More Dx Restrictions The chances that CMS will broaden the list of 13 qualifying conditions is slim. In fact, it is more likely to place additional restrictions on those diagnoses that currently count toward the percentage threshold.