Medicare vs Commercial
          • Medicare:
                –Must be “reasonable and necessary”
                –Does not say that “if the patient can be treated in SNF, they 
                    cannot be seen in an IRF”
          • Commercial:
                –Totally up to the payer
                       • The only MC rule that applies to the commercial patient is that we must 
                          count them in our CMS-13 calculations
                –So, if functional loss and belief that IRF is the best discharge 
                    disposition, refer and we will attempt to get prior authorization
                       • Worker’s Comp will often approve rehab in spite of patient’s inability to 
                          participate at the high level of therapy intensity that Medicare requires
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                                        Medicare: Reasonable and Necessary
           •     Significant functional loss
                   –     Needs assist in several one or areas of function
                            •   Gait, transfers, bowel and bladder, dressing, eating
                   –     Potential for gain (as assessed by the IRF and IRF physician)
           •     Need for intensive therapy
                   –     2 therapies
                   –     3 hrs. per day, 5 days per week or 15 hours per week 
                            •   Includes activities of daily living (feeding, grooming, bathing, dressing)
                            •   Not all  about time in the gym
                            •   let the IRU decide if patient can tolerate
           •     Rehab Nursing 24/7
                   –     To reinforce skills from therapy and to teach and coach
                   –     To address medical issues and treatment as well as functional issues
           •     Interdisciplinary Care
                   –     Rehab nursing to reinforce skills from therapy and to teach and coach
                   –     Social work/Case Management to address discharge planning and resource needs
                   –     Therapy services
                   –     Rehab physician
           •     Rehab physician supervision
                   –     To coordinate the entire team
                   –     To work with consulting medical staf
                   –     To lead the team in addressing function in spite of or along with medical management
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                 Commercial Insurance Issues
     •  Not governed by Medicare requirements except that the CMS-13 
        diagnostic compliance is calculated on the entire population
     •  Each payer may have their own pre-cert requirements
         – Admissions Coordinator will facilitate this step
     •  Significant push to send patients to SNF
         – Less expensive on the surface; not necessarily so
         – May need to have physician advocate for patient with insurer’s Medical 
            Director; but…..
     •  Commercial Payers can and do approve cases that would not meet MC 
        payment requirements; and
         – It is appropriate for us to take those patients
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                                                  Commercial Patients
          • Does the patient have an IRF benefit?
          • Does the patient have functional loss?
          • Do you believe the patient would benefit from an 
                interdisciplinary treatment plan to help them achieve 
                higher levels of independence?
          • If yes, refer to IRF.   Let our clinical assessment staf 
                review the case and make a recommendation.
           This presentation prepared for client use by Images & Associates.  2014 All Rights Reserved.                                              5
                               Reasonable Criteria 
                                    for Admission
     •  The CMS-13 Diagnostic Categories (to some extent)
     •  Prior Level of Community Activity
     •  Significant Functional Loss
     •  Potential for Significant Practical Improvement
     •  Intensive Therapy Services 
     •  Rehab Nursing Requirements
     •  Requirement for Medical Supervision
         – Comorbid Conditions
         – Face-to-face physician visit 3 x per week
     •  Requirement for Coordination of Care
     •  Approved funding (yes, this is legal)
     This presentation prepared for client use by Images & Associates.  2014 All Rights Reserved.
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