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By Chelsey Jonason and Katie Ilten

The deadline to join the Centers for Medicare & Medicaid Services' (CMS) proposed settlement for inpatient rehabilitation facility (IRF) appeals is September 17, 2019. If you appealed an IRF overpayment decision, you may be eligible to join this settlement. Instructions for submission are below and can be found on the CMS website.

On June 17, 2019, CMS announced a voluntary appeals settlement option for IRFs. An IRF can participate in the settlement if the IRF appeal is still pending and the appeal was filed at the redetermination level on or before August 31, 2018.

Under the settlement, CMS will make the following payments for eligible claims:

  • Intensity of Therapy Appeals: CMS will pay 100 percent of the net payable amount for all appealed claims denied solely on the basis that a threshold of therapy time was not met and where the claim did not undergo further review for medical necessity of the intensive rehabilitation therapy program.
  • Documentation of Group Therapy Appeals: CMS will pay 100 percent of the net payable amount for appealed claims denied solely on the basis that the justification for group therapy was not documented in the medical record.
  • Other Appeals: CMS will pay 69 percent of the net payable amount for appealed claims that do not otherwise meet the criteria for “Intensity of Therapy Appeals” or “Documentation of Group Therapy Appeals.”

The settlement terms are favorable to providers. Contact Fredrikson & Byron’s Health Care attorneys for support to determine whether you should participate in the settlement. If you elect not to participate, you can still appeal the claims.

To participate, submit an Expression of Interest to CMS no later than September 17, 2019. This is a very short, easy form to complete, requiring only the name of the appellant and the NPI for the facility. The Expression of Interest form is available on the CMS website.

Within 30 days of submitting the Expression of Interest, you should receive a spreadsheet from CMS that identifies the eligible claims. You will have 15 days to review the spreadsheet and submit an Eligibility Determination Request if you want to add or remove claims. Our attorneys can help you work with CMS to reach consensus on claim eligibility.

You should receive payment within 180 days of CMS signing the Eligibility Determination Request.

Learn more about Fredrikson & Byron’s Health Care Law practice.


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