On June 17, 2019, CMS announced a voluntary settlement program for Inpatient Rehabilitation Facility (IRF) appeals pending at the Medicare Administrative Contractor (MAC), the Qualified Independent Contractor, the Office of Medicare Hearings and Appeals and/or Medicare Appeals Council levels of review.

CMS will pay 69 percent of the net payable amount for all claims associated with pending IRF appeals, and will pay 100 percent of the net payable amount for all IRF appeals in two cases: (1) claims denied based solely on a threshold of therapy time not being met where the claim did not undergo more comprehensive review for medical necessity of the intensive rehabilitation therapy program based on the individual facts of the case; and (2) claims denied solely because justification for group therapy was not documented in the medical record.

To be eligible, the IRF appellant must have filed an appeal at the MAC for redetermination no later than August 31, 2018. Notably, claims that were part of an extrapolation and claims that were dismissed are not eligible for the settlement. In addition, providers involved in False Claims Act litigation or investigations, or that otherwise have program integrity concerns, may not be eligible.

If an IRF provider is approved for participation in the settlement process, the resulting settlement will apply to all eligible appeals from that appellant. As such, a provider cannot choose to settle some eligible IRF appeals and continue to appeal others.

Providers that would like to participate should submit an Expression of Interest to CMS by September 17, 2019. Additional details and complete eligibility criteria are available here.