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 website 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 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 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 including verifying 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).
4.8.2.3.2.1 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.
4.8.2.3.2.2 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.
4.8.2.3.2.3 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 needed to support military contingency mission requirements.
4.8.2.3.4 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 needed to
maintain this continued network adequacy.
4.8.2.3.4.1 Number of IRFs and IRF beds
in the network locality;
4.8.2.3.4.2 Efforts that have been made
to create an adequate network;
4.8.2.3.4.3 Availability of IRF services
in the locations or nearby; and
4.8.2.3.4.4 Other cost effective alternatives
and other relevant factors.
4.8.2.3.5 The contractor shall submit
all documentation in
paragraphs 4.8.2.2 and
4.8.2.3.3 to
the Government Designated Authority (GDA), if the contractor’s independent
analysis shows that:
4.8.2.3.5.1 The IRF met the disproportionate
share criteria; and
4.8.2.3.5.2 The IRF is essential for continued
network adequacy.
4.8.2.3.6 The contractor shall notify
the GDA of their findings if the IRF fails to meet the disproportionate share
criteria or is not essential for continued network adequacy, but
shall not submit the full request for a GTMCPA payment to the GDA
unless requested by the GDA.
4.8.3 The GDA
will perform a thorough review and analysis of the IRF’s submission
and the contractor’s review, utilizing any DHA data deemed 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).
4.8.3.1 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 geographic area of responsibility during the
relevant period, if a freestanding TRICARE IRF does not have a Medicare
IRF-specific CCR in the PSF.
4.8.3.2 The contractor shall use the
Medicare CCR for the co-located acute care hospital to determine
the IRF’s TRICARE costs if a specialty IRF unit in an acute care
hospital does not have a Medicare IRF unit-specific CCR. An IRF
shall not be approved for a GTMCPA if the payment would result in
the IRF’s PCR exceeding 1.15. The GDA will forward their recommendation
for approval of the GTMCPA payment and the recommended percentage adjustment
to the Director, DHA. Disapprovals by the GDA 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 DHA.
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 or 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, the GDA 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, Contract Resource Management (CRM).
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 GDA 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 The contractor shall process
the claim using Type Of Institution 46 for IRFs.
4.9.4 The contractor 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.