Knowledge base

Inpatient Psychiatric Facilities (IPF) Fraud

CMS pays for mental health services provided to Medicare Part A eligible patients under the Inpatient Psychiatric Facility Prospective Payment System, which has been phased- in since 2005. This process incorporates the age of the patient, the diagnosis related group (DRG) for the mental illness of the patient, the geographic location of the hospital (urban vs. rural), the wage area of the hospital, the number of days the patient is hospitalized and any other health concerns of the patient (co-morbidities). Questions to ask include, is the patient care provided under an individual treatment or diagnostic plan? Is it reasonably expected to improve the patient’s condition or for the purpose of diagnosis? Is the claimed DRG upcoded? Are the outlier payments, and payments made for interrupted stays appropriate? Do the patient admissions meet medical necessity requirements. Has the facility masqueraded as a nursing facility to obtain nursing home certification?

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