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According to AARP, “virtually all of us benefit from Medicare, directly or indirectly. Medicare is a lifeline that puts health care in reach of millions of older Americans. But it does much more: By helping older Americans stay healthy and independent, Medicare eases a potential responsibility for younger family members. Before Medicare, almost 1 in 2 older Americans had no health insurance and faced a bleak future if they got seriously ill. Their choices often included wiping out their savings, taking money from their children, seeking welfare or doing without care".

The Medicare trust fund finances health services for beneficiaries of Medicare. The Medicare trust fund comprises two separate funds. The hospital insurance trust fund is financed mainly through payroll taxes on earnings and income taxes on Social Security benefits. The Supplemental Medical Insurance trust fund is financed by general tax revenue and the premiums enrollees pay.

The practice of auditing medical records for compliance with Medicare coverage, payment, coding and billing rules is aimed a protecting the Medicare trust fund and its future viability. CMS developed the Comprehensive Error Rate Testing (CERT) Program to randomly select statistically valid samples of Medicare Fee for Service (FFS) claims and related medical records and perform compliance reviews.

One component of the audit or review is the principle of “reasonable and necessary”. Medical records must justify why it is reasonable and necessary to admit individual patients for the specialized programs provided by inpatient medical rehabilitation.

Why is it reasonable?   Reasonable means sensible, rational, fitting, proper well-grounded, plausible and credible. An admission decision for inpatient rehabilitation is well-grounded when we believe that: 1.) an individual’s impairments and disabilities are complex and require intensive services; 2.) they have the capacity to actively participate in the program; 3.) their prior level of functioning is diminished and they have the potential to improve; 4.) their comorbid conditions in combination with current impairments require medical management and 5.) there is an expected length of time to achieve improvement and an anticipated discharge setting.

Why is it necessary?   Necessary means essential, called for, required and unavoidable. An admission decision for inpatient rehabilitation is requisite when we believe that the ability to meet their most basic needs, physiological and safety needs are threatened by their current condition. Through the admission and program participation, we are helping the patient to avoiding harm.

This discussion brings us back to the pre-admission process. Is the pre-admission screening process narrative as opposed to a check-list? Pre-admission screeners must have clinical skills, but also excellent writing and communication skills. A check-list can be used as a reminder to cover relevant aspects in the narrative, but rich descriptions are key. For more information, contact Dr. Pam Smith at This email address is being protected from spambots. You need JavaScript enabled to view it.  

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