Medical Review of Touro Rehabilitation Center's Services for Medicare Outlier Claims for 2002

EXECUTIVE SUMMARY:

Our objective was to determine whether Touro Rehabilitation Center (Touro) submitted inpatient rehabilitation facility (IRF) outlier claims that met Medicare requirements. Touro submitted numerous IRF outlier claims during calendar year 2002 that did not meet Medicare requirements. For 69 of the 100 outlier claims in our sample, the services were not medically necessary (44 claims), were not reasonable (21 claims), or were not adequately documented (4 claims). As a result, Touro received $1,586,305 in unallowable Medicare payments on 69 claims. Based on the sample results, we estimate that Medicare overpaid Touro $3,309,699 for IRF outlier claims for 2002.

We recommended that Touro: (1) refund $3,309,699 to the Medicare program; (2) work with its fiscal intermediary to identify and refund overpayments for subsequent years' IRF outlier claims that did not meet Medicare requirements; and (3) ensure that its preadmission screening and admitting procedures provide reasonable assurance that beneficiaries who are admitted for IRF services require treatment at the IRF level of care, are capable of significant practical improvement, are able to participate in intensive rehabilitation, and are medically stable. Touro disagreed with the results of the medical determinations and took issue with many aspects of the review. Touro did not provide any additional documentation with its response nor did its comments warrant any revisions to the results of our review or to our recommendations.