False Claims for Inpatient Rehabilitation Facilty Services

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False Claims for Inpatient Rehabilitation Facility Services

Inpatient rehabilitation facilities (IRF) provide specialized care for patients recovering from conditions requiring intensive inpatient rehabilitation therapy. According to the “Medicare Benefit Policy Manual,” Pub. No. 100-02 (the Manual), Medicare covers inpatient hospital rehabilitation for beneficiaries who require a more coordinated, intensive program of multiple services than is generally provided in a skilled nursing facility or on an outpatient basis. Among other criteria for inpatient hospital rehabilitation, Medicare requirements also state that the beneficiary must be expected to show significant practical improvement within a reasonable period of time.

Two basic requirements must be met for Medicare to cover inpatient hospital rehabilitative care:

1. The efficacy, duration, frequency, and amount of service must be reasonable and necessary for the treatment of the patient’s condition;

2. Furnishing the care on an inpatient hospital basis, rather than in a less intensive facility such as a skilled nursing home or on an outpatient basis, must be reasonable and necessary.

Inappropriate billing or false claims would include admitting patients who merely require pain management and straight-forward therapies, or those that would not be able to engage in any meaningful therapy.

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