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CMS Announces a New Demonstration Project for IRF Claim Review

For inpatient facility leaders, directors of reimbursement, compliance officers, health information managers

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The Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new demonstration project for payment review for inpatient rehabilitation facilities (IRFs).  

The Review Choice Demonstration (RCD) will initially be implemented in Alabama and then expanded to Pennsylvania, Texas, and California. Under the RCD, participating IRFs will be able to choose between a pre-claim or a post-payment review process. Pre-claim review will require IRFs to submit a pre-claim review and required documentation before the final claim is submitted for payment. Under the post-payment process, IRFs will submit claims following normal processes and then submit required documentation for medical review. The IRF RCD does not create any new documentation requirements.   

If the IRF provider reaches the target claim approval rate (90%, based on a minimum of 10 pre-claim requests or claims submitted), they will be able to elect to opt out of future claim reviews, except for a spot check of 5% of their claims to ensure continued compliance. The IRF provider may also instead choose to continue or start participating in pre-claim review, or choose to participate in selective post-payment review based on a statistically valid random sample. 

Additional information is available in the Federal Register. CMS has also provided a supporting statement and a summary of the documentation that will be required in the reviews. Comments on the proposed collection of information for the IRF RCD demonstration will be accepted until Feb. 16, 2021.