Rehab Review Findings Sample Clauses

Rehab Review Findings a. Narrative Results.‌‌ i. A narrative explanation of the IRO’s findings regarding factors noted Section A.4 above and supporting rationale (including adequacy of documentation, patterns noted, etc.) regarding whether the Rehab Therapy Services in each Patient Stay reviewed by the IRO were medically necessary and appropriate. ii. A narrative explanation of the IRO’s findings and supporting rationale (including reasons for errors, patterns noted, etc.) regarding the identification of Overpayments. iii. For each Paid Claim in any Rehab Review Sample that resulted in an Overpayment, the IRO shall describe and review the system(s) and process(es) that generated the Paid Claim (including the identification, by position description, of the personnel involved in coding and billing) and identify any problems or weaknesses that may have resulted in the identified Overpayments. b. Quantitative Results.‌‌ i. Total number and percentage of Paid Claims reviewed in each Rehab Review Sample that the IRO determined Rehab Therapy Services that were: 1. Not medically necessary and appropriate;‌ 2. Not medically necessary and appropriate and resulted in an Overpayment;‌ 3. Not supported by sufficient documentation;‌ 4. Not supported by sufficient documentation and resulted in an Overpayment;‌ 5. Not coded correctly on the MDS form; and‌ 6. Not coded correctly on the MDS form and resulted in an Overpayment.‌ ii. Total dollar amount of Paid Claims in each Rehab Review Sample.‌ iii. Total dollar amount of all Overpayments in each Rehab Review Sample. iv. Error Rate in the each Rehab Review Sample. The Error Rate shall be calculated by dividing the Overpayment in each Rehab Review Sample by the total dollar amount associated with the Paid Claims in the Rehab Review Sample.‌ v. An estimate of the Overpayment at the mean point estimate for the Population in each Rehab Review Sample.‌ vi. A spreadsheet of the Rehab Review results that includes the following information for each Paid Claim that included a Rehab Therapy Service that the IRO determined was not medically necessary and appropriate: A. Subject Facility;‌ B. Beneficiary health insurance claim number; C. Dates of service; D. RUG code submitted; E. Initial amount reimbursed; F. Revised RUG code as determined by the IRO; G. Revised amount that should have been reimbursed as determined by the IRO; and H. Dollar difference between initial amount reimbursed and revised amount that should have been reimbursed as determined by th...

Rehab Review Findings a. A narrative explanation of the IRO’s findings and supporting rationale (including adequacy of documentation, patterns noted, etc.) regarding whether each Rehabilitation Therapy Service reviewed by the IRO was medically necessary and appropriate. b. Total number and percentage of Rehabilitation Therapy Services reviewed that the IRO determined were not supported by the medical record and not medically necessary and appropriate. c. A listing Rehab Therapy Patients and Rehabilitation Therapy Services at each Service Location for which the IRO has made a determination that the Rehabilitation Therapy Services were not supported by the medical record and not medically necessary and appropriate. d. The IRO’s report shall include any recommendations for improvements to Encore’s services and processes for determining the appropriate rehabilitation services to be provided and for documenting such services, based on the findings of the Rehab Review.