4.0 Policy
4.1 Statutory
Background
Under Title 10, United States
Code (USC), Section 1079(i)(2), the amount to be paid to hospitals, Skilled
Nursing Facilities (SNFs), and other institutional providers under
the TRICARE program, “shall be determined to the extent practicable
in accordance with the same reimbursement rules as apply to payments
to providers of services of the same type under Medicare.” Based
on this statutory provision, DHA has adopted Medicare’s Prospective
Payment System (PPS) for reimbursement of IRFs currently in effect
for the Medicare program as required under Section 4421 of the Balanced
Budget Act (BBA) of 1997 (Public Law (PL) 105-33) by creating Section
1886(j) of the Social Security Act (the Act). Section 1886(j) of
the Act authorized the implementation of a per-discharge PPS for
IRFs. The IRF PPS payment for each patient is based on information
found in the IRF-Patient Assessment Instrument (PAI). The IRF-PAI
contains patient clinical, demographic and other information about
the patient, which classifies the patient into distinct groups based
on clinical characteristic and expected resource needs. Separate payments
are calculated for each group, including the application of case
and facility-level adjustments.
4.2 Applicability And Scope Of
Coverage
All IRFs that meet the classification
criteria for payment under the IRF PPS under Title 42 CFR Part 412,
subpart B, are considered authorized IRFs under the TRICARE program.
4.3 Payment On
A Per Discharge Basis.
Under the PPS, IRFs
receive a pre-determined amount per discharge for inpatient services furnished
to TRICARE beneficiaries.
4.3.1 Payment in full. The payment
made under the IRF PPS represents payment in full (subject to applicable
deductibles, cost-shares, and copayments) for inpatient operating
and capital-related costs associated with furnishing TRICARE covered
services in an IRF, but not for the cost of direct graduate medical
education.
4.3.2 In addition to payments based on prospective
payment rates, IRFs receive payments for the following:
4.3.2.1 Bad debt
expenses, as provided in 42 CFR 412.622(b)(2)(i).
4.3.2.2 A payment
amount per unit for blood clotting factor provided to TRICARE inpatients
who have hemophilia.
4.4 Elements of the TRICARE IRF
PPS
4.4.1 Rates
4.4.1.1 As required
by the Act, the Federal rates reflect all costs of furnishing IRF
services (routine, ancillary, and capital related) other than costs
associated with operating approved education activities as defined
in 42 CFR Parts 413.75 and 413.85, bad debts, and other costs not
covered under the PPS. Federal rates are adjusted to reflect:
4.4.1.1.1 Patient
case-mix, which is the relative resource intensity typically associated
with each patient’s clinical condition as identified through the
patient assessment process:
4.4.1.1.1.1 Cases are
grouped into Rehabilitation Impairment Categories, according to
the primary condition for which the patient was admitted to the
IRF.
4.4.1.1.1.2 Cases are further grouped into case-mix groups
(CMGs), which group similar cases according to their functional
motor and cognitive scores and age.
4.4.1.1.1.3 Finally,
cases are grouped into one of four tiers within each CMG, according
to patients’ comorbidities (conditions that are secondary to the
principal diagnosis or reason for the inpatient stay). Each tier
adds a successively higher payment amount to the case depending
on whether the costs of the comorbidity are significantly higher
than other cases in the same CMG (low, medium, or high).
4.4.1.1.1.4 Additional
adjustments are made for interrupted stays, short stays of less
than three days, short stay transfers, and high-cost outlier cases.
4.4.1.1.2 Facility
Level Adjustment Factors:
4.4.1.1.2.1 Rates are
adjusted to reflect geographic differences in wage rates, using
the hospital wage index.
4.4.1.1.2.2 Rates are
further adjusted to account for a facility’s proportion of low-income
patients, teaching status, and rural area location.
4.4.1.2 Federal
rates are updated annually:
4.4.1.2.1 To reflect
inflation in the cost of goods and services used to produce IRF
services using a market basket index calculated for freestanding
and hospital-based IRFs.
4.4.1.2.2 To reflect
changes in local wage rates, using the hospital wage index.
4.4.2 Classification
Criterion
4.4.2.1 To be excluded from the TRICARE Diagnosis Related
Group (DRG)-based payment system and instead be paid under the IRF
PPS, an inpatient rehabilitation hospital or rehabilitation unit
of an acute care hospital (or CAH) must meet the requirements for
classification as an IRF stipulated in Subpart B of 42 CFR Part
412.
4.4.2.2 One criterion specified at 42 CFR 412.29(b)
that Medicare uses for classifying a hospital or unit of a hospital
as an IRF is that a minimum percentage of a facility’s total inpatient
population must require treatment in an IRF for one or more of 13
medical conditions listed in 42 CFR 412.20(b)(2). This minimum percentage
is known as the compliance threshold, or the 60% rule. DHA is adopting Medicare’s
60% requirement for IRFs.
4.4.3 Patient Assessments
4.4.3.1 Admission
Orders
At the time that each patient is admitted,
the IRF shall have physician orders for the patient’s care during
the time the patient is hospitalized.
4.4.3.2 PAI
Payment
for services is contingent on the requirement that IRFs complete
a PAI upon admission and discharge. IRFs shall use the CMS IRF-PAI
as specified in 42 CFR 412.606 that covers a time period that is
in accordance with the assessment schedule in 42 CFR 412.610.
4.4.3.3 Comprehensive
Assessments
A clinician of the IRF shall
perform a comprehensive, accurate, standardized, and reproducible
assessment of each TRICARE inpatient as specified in 42 CFR 412.606(c).
4.4.3.4 Coordination
of the Collection of Patient Assessment Data
A
clinician of an IRF who has participated in performing the patient
assessment shall accept responsibility for the data as specified
in 42 CFR 412.612.
4.4.3.5 Transmission of Patient Assessment
Data
The IRF shall encode, i.e., enter data
items into the fields of the computerized patient assessment software
program, and transmit the patient assessment data for each inpatient
based on the data requirements in 42 CFR 412.614. The IRF shall
transmit the patient assessment data:
4.4.3.5.1 Using the
computerized version of the PAI available from CMS; or
4.4.3.5.2 Using a
computer program(s) that conforms to CMS’ standard electronic record
layout, data specifications, and data dictionary, includes the required
PAI data set, and meets CMS’ other specifications.
4.4.3.6 Data Collection
Software
The Inpatient Rehabilitation Validation
and Entry System (jIRVEN) was developed by CMS. jIRVEN is a free
Java-based software application which provides an option for IRFs
to collect and maintain PAI information. Facilities are able to
enter and subsequently export their data from the application for
submission to the appropriate national data repository.
4.4.3.7 The IRF
shall:
4.4.3.7.1 Electronically encode all required data into
a CMS approved IRF-PAI software product. This may include jIRVEN,
which is provided to IRFs for free on the CMS web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Software.html. jIRVEN
provides an option for IRFs to collect and maintain IRF-PAI information
on any IRF patients. The jIRVEN software product allows the IRF
to enter data for each patient into the program and create an electronic
IRF-PAI for each patient. The IRF would import the IRF-PAI data
for the TRICARE patient into the jIRVEN system to produce a report
that includes a distinct five-character CMG number for the patient
which accounts for the existence of any relevant comorbidities.
The first character of the CMG number is an alphabetic character
that indicates the comorbidity tier. The last four characters of
the CMG number are numeric characters that represent the distinct
CMG number. The IRFs shall indicate this CMG reported for the TRICARE
patient IRF-PAI report on the TRICARE claim.
4.4.3.7.2 For TRICARE
Medicare-eligible patients, electronically transmit complete, accurate,
and encoded data from the PAI for each TRICARE patient to the national
data repository. An IRF may also attempt to electronically submit
the PAI to CMS data repository for non-Medicare-eligible TRICARE patients,
however, this data may or may not be accepted. Transmittal of the
TRICARE patient’s IRF-PAI does not affect TRICARE payment.
4.4.3.8 Once a
TRICARE IRF patient is discharged, the IRF submits a Healthcare
Insurance Portability and Accountability Act (HIPAA) compliant electronic
claim, or a paper claim (UB-04) using the five-character CMG number
assigned by the jIRVEN Grouper software when submitting claims for processing.
4.4.3.9 Assessment
Process for Interrupted Stays
The IRF shall
follow the assessment process for interrupted stays as specified
in 42 CFR 412.614.
4.4.4 Reasonable and Necessary Criteria
In order for an IRF claim to be considered
reasonable and necessary, there shall be a reasonable expectation
that the patient meets all of the requirements in 42 CFR 412.622(3)(i)
through (iv) at the time of the patient’s admission to the IRF.
4.4.4.1 Documentation.
To document that each patient for whom the
IRF seeks payment is reasonably expected to meet all of the requirements
in
paragraph 4.5.3 at the time of admission,
the patient’s medical record at the IRF shall contain the documentation
outlined in 42 CFR 412.622(4)(i) through (iii).
4.4.4.2 Interdisciplinary
Team Approach To Care
In order for an IRF
claim to be considered reasonable and necessary, the patient must require
an interdisciplinary team approach to care, as evidenced by documentation
in the patient’s medical record of weekly interdisciplinary team
meetings that meet the requirements in 42 CFR 412.622 (A) through
(C).
4.5 Basis of Payment
4.5.1 For admissions
prior to October 1, 2018, IRFs shall be reimbursed based on billed
charges or negotiated rates.
4.5.2 For admissions on or after
October 1, 2018, inpatient services provided in IRFs shall be reimbursed
in accordance with Medicare’s IRF PPS as found in Title 42 CFR,
Part 412, Subpart P. IRF PPS payments shall be made on the basis
of prospectively determined rates and applied on a per discharge basis.
4.5.3 To the extent practicable, in accordance with
10 USC 1079(i)(2), DHA will adopt Medicare’s IRF PPS methodology,
to include Medicare’s relative weights, payment rates, adjustments
for the 60% compliance threshold, and high cost-outlier payments.
4.5.4 DHA is
adopting Medicare’s IRF adjustments for interrupted stays, short
stays of less than three days, short-stay transfers, teaching adjustments,
rural adjustments, and the Low Income Payment (LIP) adjustment.
4.5.5 DHA is
also adopting Medicare’s IRF Quality Reporting Program (IRFQRP)
payment adjustments for TRICARE-authorized IRFs that reflect Medicare’s
annual payment update for that facility. DHA is not establishing
a separate reporting requirement for IRFs, but will utilize Medicare’s payment
adjustments resulting from their IRFQRP that are included in the
IRF-PPS Pricer.
4.5.6 IRF PPS Pricer Software. CMS
has developed an IRF Pricer Program that calculates the IRF payment
rate for each case. The Pricer software uses the CMG number, along
with other specific claim data elements and provider-specific data,
to adjust the IRF’s prospective payment for interrupted stays, transfers,
short stays, and deaths, and then applies the applicable adjustments
to account for the IRF’s wage index, percentage of low-income patients,
rural location, outlier payments, and the teaching status adjustment.
4.6 QRP
DHA will
apply the same QRP reductions as Medicare.
4.7 Transition
Period
In the Final Rule (FR) published in
the Federal Register on December 29, 2017, DHA created
a multi-year transition period to buffer the impact from any potential
decrease in revenue that rehabilitation facilities may experience
during the implementation of a revised IRF inpatient payment system.
This transition period provides IRFs with sufficient time to adjust
and budget for potential revenue reductions. The transition is as
follows:
4.7.1 For the first 12 months following implementation,
the TRICARE IRF PPS allowable cost will be 135% of Medicare IRF
PPS amounts.
4.7.2 For the second 12 months following implementation,
the TRICARE IRF PPS allowable cost will be 115% of the Medicare
IRF PPS amounts.
4.7.3 For the third 12 months following
implementation, and subsequent years, the TRICARE IRF PPS allowable
cost will be 100% of the Medicare IRF PPS amounts.
4.8 General Temporary
Military Contingency Payment Adjustment (GTMCPA) Payments
4.8.1 The Director, DHA, or designee,
may approve a GTMCPA payment based on all of the following criteria:
4.8.1.1 The IRF serves a disproportionate share of
Active Duty Service Members (ADSMs) and Active Duty Dependents (ADDs),
i.e., 10% or more of an IRF’s total inpatient admissions are for
ADSMs and ADDs.
4.8.1.2 The IRF
is a TRICARE network hospital.
4.8.1.3 The IRF’s actual costs for TRICARE inpatient
services exceed TRICARE payments for those services or other extraordinary
economic circumstance exists; and
4.8.1.4 Without the GTMCPA payment, the Department
of Defense’s (DoD’s) ability to meet military contingency mission
requirements will be significantly compromised.
4.8.2 Following is the GTMCPA Payment Process for
TRICARE IRFs.
4.8.2.1 The IRF
shall submit a request for a discretionary GTMCPA payment to their
regional Managed Care Support Contractor (MCSC). The request shall
be made to the contractor within 12 months of the end of the IRF
year (October 1 through September 30) for which the IRF is requesting
a GTMCPA payment. For example, an IRF shall submit a request for
a GTMCPA payment for the IRF year ending September 30, 2019, by
September 30, 2020. Late submissions or requests for extensions
shall not be considered.
4.8.2.2 The IRF shall submit the following information
to the contractor for review and consideration:
• Their IRF-specific
Medicare provider number.
• The
total number of IRF admissions (from all payers) during the 12-month
period in the previous TRICARE IRF year and the total number of
TRICARE ADSM and ADD admissions in this same period. An IRF shall
not include TRICARE Non-Active Duty Service Member (NADSM) or Non-Active
Duty Family Member (NADFM) admissions (i.e., TRICARE retiree or
TRICARE retiree dependents), TRICARE for Life (TFL) beneficiary
admissions, overseas beneficiary admissions, or TRICARE beneficiary
admissions with Other Health Insurance (OHI). TRICARE Uniformed
Services Family Health Plan (USFHP) ADSM and ADD IRF admissions
may be included in the IRF’s submission if the stays were paid utilizing
the IRF-PPS Reimbursement System, however, these admissions shall
be separately identified as TRICARE USFHP admissions by the IRF.
• The
total billed and paid amounts for all TRICARE IRF admissions paid
by the IRF PPS at the IRF during the 12-month period, excluding
TRICARE OHI and TRICARE USFHP admissions. This includes non-OHI
claims for ADSMs, ADDs, and retirees and their dependents.
4.8.2.3 The contractor shall perform a thorough evaluation
of the IRF’s request in
paragraph 4.8.2.2. The evaluation shall consist
of the following:
4.8.2.3.1 The contractor
shall evaluate the IRF’s package for completeness. The contractor
shall verify the IRF has provided all components in
paragraph 4.8.2.2.
4.8.2.3.2 The contractor shall perform a validation that
the IRF meets the disproportionate share criteria (as stated in
paragraph 4.8.1).
The contractor shall independently calculate the number of TRICARE
ADD/ADSM IRF admissions, utilizing the contractor’s data systems,
and divide it by the total number of IRF admissions (from all payers)
reported by the IRF in
paragraph 4.8.2.2. The contractor shall compare
this result to the IRF’s submission in
paragraph 4.8.2.2 to ensure
the hospital met the disproportionate share criteria in
paragraph 4.8.1.
The contractor shall work with the IRF to resolve discrepancies
in the reported data prior to submission of the request to DHA if
the IRF’s data show that they qualify, but the contractor’s data
show that they do not.
4.8.2.3.3 The contractor shall perform an evaluation
to determine if the IRF is essential for continued network adequacy
and is necessary to support military contingency mission requirements. The
contractor shall report the following data elements for the prior
IRF year, i.e., the year prior to the requested GTMCPA, as well
as provide a brief narrative with supporting rationale, describing
why the IRF is essential for continued network adequacy and why
a GTMCPA payment is necessary to maintain this continued network
adequacy.
4.8.2.3.3.1 Number
of IRFs and IRF beds in the network locality;
4.8.2.3.3.2 Efforts that have been made to create an adequate
network;
4.8.2.3.3.3 Availability
of IRF services in the locations or nearby; and
4.8.2.3.3.4 Other cost effective alternatives and other
relevant factors.
4.8.2.3.4 If the
contractor’s independent analysis shows that: (1) the IRF met the disproportionate
share criteria; and (2) the IRF is essential for continued network
adequacy, the contractor shall submit all documentation in
paragraphs 4.8.2.2 and
4.8.2.3.3 to
the Chief, MCSC Program. If the IRF fails to meet the disproportionate
share criteria or is not essential for continued network adequacy,
the contractor shall notify the Chief, MCSC Program of their findings,
but shall not submit the full request for a GTMCPA payment to the
Chief, MCSC Program unless requested by the Chief, MCSC Program.
4.8.3 The Chief, MCSC Program will
perform a thorough review and analysis of the IRF’s submission and
the contractor’s review, utilizing any DHA data the Chief, MCSC
Program deems necessary, to determine if the IRF meets the four
criteria listed in
paragraph 4.8.1 and qualifies for a GTMCPA
payment. If the IRF qualifies, the GTMCPA payment shall be set by
the contractor utilizing DHA and CMS data so that the IRF’s Payment-to-Cost
Ratio (PCR) for TRICARE IRF services does not exceed a ratio of
1.15. The TRICARE IRF PCR shall be calculated using the IRF’s Medicare
Cost-To-Charge Ratio (CCR) in the most recent version of the CMS
IRF Provider Specific File (PSF). If a freestanding TRICARE IRF does
not have a Medicare IRF-specific CCR in the PSF, the contractor
shall calculate an average CCR based on the Medicare IRF CCRs in
the most recent PSF file, weighted by total number of TRICARE cases in
each IRF in the contractor’s region during the relevant period.
If a specialty IRF unit in an acute care hospital does not have
a Medicare IRF unit-specific CCR, then the contractor shall use
the Medicare CCR for the co-located acute care hospital to determine
the IRF’s TRICARE costs. An IRF shall not be approved for a GTMCPA
if the payment would result in the IRF’s PCR exceeding 1.15. The
Chief, MCSC Program will forward their recommendation for approval
of the GTMCPA payment and the recommended percentage adjustment
to the Director, DHA. Disapprovals by the DTRO will not be forwarded
to the Director, DHA, for review and approval. The PCR shall be
calculated as follows:
Step 1: Determine the IRF’s total
TRICARE payments in the 12-month period, excluding TRICARE OHI and
USFHP claims. The IRF GTMCPA payment is specific to the IRF PPS reimbursement
system and there is no authority to include non-IRF PPS paid amounts in
the PCR calculation.
Step 2: Determine
the IRF’s estimated TRICARE costs by identifying the TRICARE billed
charges for all non-OHI, non-USFHP TRICARE IRF admissions. The contractor
shall then multiply the IRF’s total TRICARE billed charges for these
beneficiaries during the 12-month period by the Medicare IRF-specific
CCR (as determined in
paragraph 4.8.3).
Step 3: Divide Step 1 (total TRICARE
non-OHI, non-USFHP IRF payments in the 12-month period) by Step
2 (total TRICARE non-OHI, non-USFHP IRF estimated costs in the 12-month
period).
Step 4: If
the amount in Step 3 is lower than 1.15 the IRF may receive a GTMCPA
payment so that the IRF’s total TRICARE payments in the 12-month
period are equal to or less than 115% of their TRICARE costs in
the same period. The percentage used is at the discretion of the
Director, DHA, or designee.
4.8.4 TRICARE IRF payments (non-OHI, non-USFHP) for
the qualifying IRF will be increased by the Director, DHA, or designee,
at his/her discretion by way of an additional GTMCPA payment after
the end of the TRICARE IRF year (October 1 through September 30).
Subsequent adjustments to the GTMCPA payment will be issued to the
qualifying IRF for the prior IRF year, when requested by the IRF,
to ensure claims that were paid-to-completion the previous year
are adjusted. These adjustments are separate from the applicable
GTMCPA payment approved for the current IRF year.
4.8.5 Upon approval of the GTMCPA payment request
by the Director, DHA, or designee, the Chief, MCSC Program will
notify the Contracting Officer (CO) who will send a letter to the
contractor notifying them of the GTMCPA payment approval.
4.8.6 The contractor shall process the GTMCPA payments
per the instructions in Section G of their contracts under Invoice
and Payment Non-Underwritten - Non-TRICARE Encounter Data (TEDs), Demonstrations.
No GTMCPA payments shall be sent out without approval from DHA-Aurora
(DHA-A), Contract Resource Management (CRM), budget.
4.8.7 DHA will send an approval to the contractors
to issue GTMCPA payments out of the non-financially underwritten
bank account based on fund availability.
4.8.8 GTMCPA payments will be reviewed and approved
on an annual basis; i.e., they will have to be evaluated on a yearly
basis by the Chief, MCSC Program in order to determine if the IRF
continues to serve a disproportionate share of ADSMs and ADDs and
whether there are any other special circumstances significantly
affecting military contingency capabilities.
4.8.9 The Director, DHA, or designee is the final
approval authority for GTMCPA payments. A decision by the Director,
DHA, or designee to approve, reject, adopt, modify, or extend GTMCPA payments
is not subject to the appeal and hearing procedures in
32 CFR 199.10.
4.8.10 DHA, upon request, will provide the detailed
IRF claims data and Medicare CCR used to calculate the IRF’s PCR
and maximum GTMCPA payment, if any, to the requesting IRF through
the contractor.
4.8.11 GTMCPAs
may be extended to IRF facilities that have changed their network
status during the IRF GTMCPA year. If an IRF network facility changes
their status during the IRF year, and the facility was and remained
a network facility that is essential for military readiness, contingency
operations, and network adequacy and the facility served a disproportionate
share of ADSMs and ADDs during the period of the year it was subject
to IRF reimbursement, then a prorated IRF GTMCPA may be authorized. Any
IRF adjustment will only apply to IRF payments.
4.9 Billing and
Coding Requirements
4.9.1 Once an IRF patient is discharged, the IRF
shall submit a HIPAA compliant electronic claim, or a paper claim
(UB-04) using the five-character CMG number when submitting claims
for processing. In addition to all entries previously required on
a claim, the following additional instructions shall be followed
to accurately price and pay a claim under the IRF PPS.
4.9.2 The IRF
shall bill using Bill Type 11X along with Revenue Code 0024.
4.9.3 Contractors
shall process the claim using Type Of Institution 46 for
IRFs.
4.9.4 The contractors shall use Pricing Rate Code
(PRC) CI for CAH IRF reimbursement and RF for all
other IRF reimbursement.
4.10 Direct
Medical Education
DHA will reimburse IRFs
who file a request for their direct medical education costs in a
timely manner, as outlined in
Chapter 6, Section 8.
Although the procedures listed in
Chapter 6, Section 8 pertain
to DRGs, those same procedures are to be used to reimburse IRFs
for direct medical education costs.