The 60% Rule is a Medicare facility criterion that requires each IRF to discharge at least 60 percent of its patients with one of 13 qualifying conditions. Inpatient rehabilitation hospitals or units that do not comply with the 60% Rule will lose the IRF payment classification and will instead be categorized as general acute care hospitals.
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What is the 60% rule for inpatient rehabilitation hospitals?
Jan 13, 2021 · Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule”: CMS is waiving requirements to allow IRFs to exclude patients from the IRF freestanding hospital’s or unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the …
What is the 60% rule for IRF?
May 03, 2020 · What is the 60 rule in rehab? The 60% Rule is a Medicare facility criterion that requires each IRF to discharge at least 60 percent of its patients with one of …
What are the requirements to receive inpatient rehab?
Specifications for Determining IRF “60% Rule” Compliance CMS has established procedures whereby Regional Offices and Medicare Administrative Contractors (MACs) determine whether facilities qualify as Inpatient Rehabilitation Facilities (IRFs).
What is the 60% rule cut in the 2016 budget?
Oct 15, 2021 · What is the rule of 60 in rehab? The 60% rule is a Medicare policy setting that requires each IRF to discharge at least 60% of patients with one of …
What is site neutral payment policy?
Under a so-called “site-neutral” payment policy, the payment for a service provided to a patient is the same regardless of the setting where the service is provided. FAH and its member hospitals agree with the goal of ensuring patients receive the right care, at the right time, in the right setting. However, blunt site-neutral payment policies between IRFs and other settings, especially Skilled Nursing Facilities (SNFs), will not achieve this goal and may risk jeopardizing access to medical rehabilitation crucial for the high acuity patients cared for by IRFs.
Why do IRFs need prior authorization?
Instead, prior authorization of IRF care undermines medical judgment and leads to improper denials, reduced access to care, referrals to less effective care settings that can compromise patient outcomes and lengthy delays that cause irreversible harm to beneficiaries. Given the critical nature of IRF’s intensive, ongoing care, rigorous patient admission and coverage criteria have already been established and rigorously applied specifically for this level of care.
What is the 60 percent rule for Medicare?
The current “60% rule” stipulates that in order for an IRF to be considered for Medicare rei mbursement purposes, 60% of the IRF’s patients must have a qualifying condition. There are currently 13 such conditions, including, stroke, spinal cord or brain injury and hip fracture, among others.
Does CMS have a PAC?
CMS continues to develop and implement bundled payment programs which place financial risk on acute care hospitals for post-acute care (PAC) spending. Options for acute care hospitals to reduce PAC spending, however, are currently limited to encouraging patients to receive PAC in settings that receive lower Medicare payments or encouraging PAC providers that have the ability to reduce payments to do so. However, IRFs are unable to reduce their Medicare payments to help hospitals because episode target prices and performance period are based on Medicare’s per-discharge payment to IRFs.
Can a site neutral payment policy be implemented?
Site-neutral payment policies cannot be effectively implemented unless and until there is adoption of major changes in the regulatory requirements of post-acute care (PAC) providers to level the playing field across PAC settings.
What is the 60% rule?
The 60% Rule is a Medicare facility criterion that requires each IRF to discharge at least 60 percent of its patients with one of 13 qualifying conditions. Inpatient rehabilitation hospitals or units that do not comply with the 60% Rule will lose the IRF payment classification and will instead be categorized as general acute care hospitals. ...
What is an IRF?
Inpatient rehabilitation facilities (IRFs) have faced significant scrutiny from Congress and the Centers for Medicare & Medicaid Services (CMS) in recent years, which has led to multiple interventions, including strict criteria for IRF patients, multiple payment cuts and other policy restrictions.
What is 412.23(b)(2)?
Under revised §412.23(b)(2), a specific compliance percentage threshold of an IRF’s total patient population must require intensive rehabilitation services for the treatment of one or more of the specified conditions. Based on the final rule, CMS issued a Joint Signature Memorandum including instructions related to Regional Office (RO) and Medicare fiscal intermediary (FI) responsibilities regarding the performance of reviews to verify compliance with §412.23(b)(2) as detailed in CRs 3334 and 3503, which revised Medicare Claims Processing Manual Chapter 3, sections 140.1 to 140.1.8. (CR 3503 corrected some errors or clarified the instructions in CR 3334 and presented additional instructions to implement revised §412.23(b)(2).
What is Medicare certified hospital?
Section 1886(d)(1)(B) of the Social Security Act (the Act) and Part 412 of the Medicare regulations define a Medicare certified hospital that is paid under the inpatient (acute care hospital) prospective payment system (IPPS). However, the statute and regulations also provide for the classification of special types of Medicare certified hospitals that are excluded from payment under the IPPS. These special types of hospitals must meet the criteria specified at subpart B of Part 412 of the Medicare regulations. Failure to meet any of these criteria results in the termination of the special classification, and the facility reverts to an acute care inpatient hospital or unit that is paid under the IPPS in accordance with all applicable Medicare certification and State licensing requirements. In general, however, under §§ 412.23(i) and 412.25(c), changes to the classification status of an excluded hospital or unit of a hospital are made only at the beginning of a cost reporting period.
What is Medicare IRF?
All hospitals or units of a hospital that are classified under subpart B of part 412 of the Medicare regulations as inpatient rehabilitation facilities (IRFs). Medicare payments to IRFs are based on the IRF prospective payment system (PPS) under subpart P of part 412.
When was the CMS rule for major multiple traumas?
In the proposed rule dated September 9, 2003 (FR 68, 53272) CMS clarified which patients should be counted in the category of major multiple traumas to include patients in diagnosis-related groups 484, 485, 486 or 487 used under the IPPS.
When was the 412.23(b)(2) review suspended?
On June 7 , 2002, CMS notified all ROs and FIs of its concerns regarding the effectiveness and consistency of the review to determine compliance with §412.23(b)(2). As a result of these concerns, CMS initiated a comprehensive assessment of the procedures used by the FIs to verify compliance with the compliance percentage threshold requirement and suspended enforcement of the compliance percentage threshold requirement for existing IRFs. The suspension of enforcement did not apply to a facility that was first seeking classification as an IRF in accordance with §412.23(b)(8) or §412.30(b)(2). In such cases, all current regulations and procedures, including §412.23(b)(2), continued to be required.
What to do if you have a sudden illness?
Though you don’t always have advance notice with a sudden illness or injury, it’s always a good idea to talk with your healthcare team about Medicare coverage before a procedure or inpatient stay, if you can.
How long does Medicare require for rehabilitation?
In some situations, Medicare requires a 3-day hospital stay before covering rehabilitation. Medicare Advantage plans also cover inpatient rehabilitation, but the coverage guidelines and costs vary by plan. Recovery from some injuries, illnesses, and surgeries can require a period of closely supervised rehabilitation.
How long does it take for a skilled nursing facility to be approved by Medicare?
Confirm your initial hospital stay meets the 3-day rule. Medicare covers inpatient rehabilitation care in a skilled nursing facility only after a 3-day inpatient stay at a Medicare-approved hospital. It’s important that your doctor write an order admitting you to the hospital.
What are the conditions that require inpatient rehabilitation?
Inpatient rehabilitation is often necessary if you’ve experienced one of these injuries or conditions: brain injury. cancer. heart attack. orthopedic surgery. spinal cord injury. stroke.
How many hours of therapy per day for rehabilitation?
access to a registered nurse with a specialty in rehabilitation services. therapy for at least 3 hours per day, 5 days per week (although there is some flexibility here) a multidisciplinary team to care for you, including a doctor, rehabilitation nurse, and at least one therapist.
How many days do you have to stay in the hospital for observation?
If you’ve spent the night in the hospital for observation or testing, that won’t count toward the 3-day requirement. These 3 days must be consecutive, and any time you spent in the emergency room before your admission isn’t included in the total number of days.
Does Medicare pay for inpatient rehabilitation?
Original Medicare and Medicare Advantage plans pay for inpatient rehabilitation if your doctor certifies that you need intensive, specialized care to help you recover from an illness, injury, or surgical procedure.
What is the 75% rule for rehabilitation?
The Centers for Medicare and Medicaid Services (CMS) has recently published a new set of reimbursement criteria for acute inpatient rehabilitation facilities (IRF). [ 1] Commonly referred to as the "75% rule," IRFs must prove that 75% of their patients have 1 of only 13 diagnoses. Otherwise, the facility risks losing all reimbursement from Medicare, for all hospital admissions to the IRF in that fiscal year.
How long does it take for IRFs to become compliant?
Because only 13% of IRFs are treating the patient population suggested by the CMS and the other 87% will have only 3 years to become "compliant," there is going to be aggressive competition for patients who have one of the 13 diagnoses.
How many diagnoses are there in Medicare?
Not only is Medicare's rule dangerous for a large number of the population of which they serve, but it sets a bizarre precedent; an entire medical specialty, namely, physical medicine and rehabilitation, is being restricted to treating, nearly exclusively, 13 diagnoses in the inpatient setting.