Poster 3: Reasons for Medical Necessity Based Denials of Coverage by Medicare for Inpatient Rehabilitation Hospital and Unit (IRH/U) Admissions: Expert Assessment of the Clinical Reasons Cited and Their Appropriateness

Article Outline

• Disclosures
• Objective
• Design
• Setting
• Participants
• Interventions
• Main Outcome Measures
• Results
• Conclusions
• Copyright

Keywords: Rehabilitation, Medicare, Insurance, Medical necessity

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Disclosures 

B. M. Gans, Kessler Institute for Rehabilitation, Employment; Select Medical Corporation, Employment; Five Star Quality Care, Inc, Consulting fees or other remuneration; Hospitality Properties Trust, Consulting fees or other remuneration; Chair, AMRPA Board of Directors, Non-remunerative positions of influence President Foundation for PM&R, Non-remunerative positions of influence; Director, ThinkFirst Foundation, Non-remunerative positions of influence Director, APEC, Non-remunerative positions of influence Professor, UMDNJ-NJMS, Other.

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Objective 

To examine a sample of IRH/U admissions for which coverage was retroactively denied by Medicare to determine what factors contributed to the denials, and to compare the determinations with professional standards and expert medical opinion.

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Design 

Reviews of medical records by expert physiatrists in a group setting.

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Setting 

24 medical records from a variety of IRH/U in the United States. Each case was denied for coverage both by a Fiscal Intermediary (FI) and also on appeal to the Qualified Independent Contractor (QIC). All cases were then appealed to an ALJ.

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Participants 

Eight expert physiatrists highly experienced as medical directors of inpatient rehabilitation hospitals or units.

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Interventions 

Not applicable.

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Main Outcome Measures 

Survey score sheets using primarily dichotomous response options. For each item of each case, the presence of a specific factor being cited as a reason for denial was determined if at least 6 of the 8 independent reviewers identified it as so. Similarly, concurrence or disagreement with the judgment of the Medicare Contractor was determined.

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Results 

Of the 24 cases reviewed, 14 claims were paid because of the judgments of the ALJ, 2 were paid in part, and 8 continued to be denied for coverage. The majority of cases involved patients with orthopedic diagnoses (87%). Need for either close medical supervision or intense therapy services were the 2 reasons most commonly cited by the FI, QIC and ALJ for denial of coverage. Diagnosis was not explicitly cited as a reason for denial. The experts achieved consensus in 21 of 24 cases that the decisions of the FIs and QICs to deny payment did not meet the Academy's Standards. Experts disagreed with the ALJs in 5 of 8 cases ruled unfavorably.

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Conclusions 

This study showed how varied the expert opinions of experienced physiatrists may be regarding the application of expert judgment or the Academy's Standards. It also showed how inconsistent the determinations by FIs, QICs, or ALJs may be with either expert judgment or the Academy's standards. Other means of achieving resolution to the ongoing conflicts between physicians, Medicare contractors and IRH/U will need to be developed.