Inpatient rehabilitation facility audits for Medicare Plus Blue^SM PPO claims start Oct. 1

HMS (formerly Health Data Insights), an independent company working for Blue Cross Blue Shield of Michigan, will start auditing Medicare Plus Blue PPO inpatient rehabilitation facility claims on Oct. 1, 2017. The audit will:

• Include a two-year look-back at claims.
• Check patient-met criteria for admission to an inpatient rehabilitation facility.
• Confirm billed case mix group codes.
• Detect, prevent and correct waste and abuse.
• Facilitate correct claim payment.

Be ready to share medical charts. After an audit, HMS will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

Medical criteria information
Inpatient rehabilitation facility level of care is reasonable and necessary if the patient meets all requirements (see Medicare Benefit Policy Manual, Chapter 1, Section 110 and Prospective Payment System rule 42 CFR 412.622(a)(3), (4) and (5)).

HMS will confirm that you’ve properly documented requirements for inpatient rehabilitation facility level of care, such as:

• The physician order
• Patient supervision by a rehabilitation physician
• Physician visits
• The patient needed active and ongoing therapeutic intervention of multiple therapy disciplines

Questions?

• Call your Blue Cross provider consultant.
• During the audit, if you need to speak to an HMS representative, call 1-866-875-1749.