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.