Expert Conversation: Strategies For Navigating New IRF Policies-Session Recording

Video Transcription

Video Summary

The webinar reviewed current Medicare policy and reimbursement challenges for inpatient rehabilitation facilities (IRFs), with a focus on documentation, medical necessity, audits, and Medicare Advantage (MA).<br /><br />Presenters discussed a recent Office of Inspector General (OIG) audit that found documentation concerns in many sampled IRF claims, but no fraud. After reviewing 19 disputed examples with stakeholders, CMS agreed with the stakeholders in 14 cases and said the OIG’s findings and perceived risks may have been overstated. Speakers recommended clearer documentation of team conferences, plans of care, medical complexity, and the rehabilitation physician’s role.<br /><br />New rules effective October 2026 require all ordered therapies to begin within 36 hours of admission and an interdisciplinary team conference within four days. Physicians reported that the conference deadline may increase administrative burden and disrupt care; CMS has temporarily exercised enforcement discretion through March 31, 2027.<br /><br />The discussion also covered the IRF Review Choice Demonstration, which subjects participating facilities in selected states to review of every claim, and proposed changes to IRF payment methodology. Clinicians raised concerns that proposed diagnosis and comorbidity models do not adequately reflect the complexity of IRF patients.<br /><br />Finally, OIG reports showed wide variation in MA prior-authorization denials and high reversal rates on appeal. Speakers emphasized that MA plans must follow traditional Medicare coverage criteria, encouraged providers and families to appeal inappropriate denials, and highlighted the importance of documenting the need for intensive, interdisciplinary rehabilitation and physician management.

Keywords

Medicare

inpatient rehabilitation facilities

IRF

documentation

medical necessity

OIG audit

Medicare Advantage

prior authorization denials

review choice demonstration

reimbursement challenges