Frequent MAC audits indicate that Oasis Point has triggered one or more red flags in CMS's monitoring systems. MACs use predictive analytics and pattern recognition to identify facilities with higher-than-expected error rates.
Common Triggers:
- • Failed 60% Rule presumptive compliance
- • High rate of IRF-PAI corrections or resubmissions
- • Previous audit findings with denials
- • Statistical outliers in case mix or length of stay
- • Complaints or referrals from other sources
The Audit Cycle:
- 1. Initial audit finds errors
- 2. Facility is flagged for increased monitoring
- 3. More frequent audits occur
- 4. Additional errors are found
- 5. Cycle continues until zero errors achieved
Meticulous surveillance means implementing systematic quality control processes that catch and correct errors BEFORE IRF-PAI submission. This shifts the facility from reactive (responding to audits) to proactive (preventing errors).
1. Daily Surveillance Activities
- Morning Review (8:00 AM): Check all new admissions for PAS completion before admission
- Midday Check (12:00 PM): Monitor therapy minutes to ensure 3 hours/day target is met
- Afternoon Audit (4:00 PM): Review IPOC completion status for patients approaching day 4
- End-of-Day Verification: Confirm physician face-to-face visits are documented
2. Weekly Surveillance Activities
- Monday: Calculate 60% Rule compliance for current census
- Tuesday: Review all pending discharge IRF-PAIs for accuracy
- Wednesday: Conduct peer review of completed IRF-PAIs before submission
- Thursday: Audit therapy documentation for functional status alignment
- Friday: Generate weekly compliance report for leadership
3. Monthly Surveillance Activities
- Internal Audit: Random sample of 10 medical records with IRF-PAI cross-check
- Error Log Review: Analyze trends and implement corrective action plans
- Compliance Meeting: Review metrics with clinical team and identify training needs
- Policy Update: Revise procedures based on CMS guidance and internal findings
Every IRF-PAI must pass these checks before submission:
- ☐ Primary diagnosis matches physician documentation
- ☐ ICD-10 code is most specific available
- ☐ IGC code is correct per CMS-13 list
- ☐ All comorbidities are documented and counted correctly
- ☐ Functional scores match therapy notes
- ☐ All dates are accurate and within timelines
- ☐ PAS signed before admission
- ☐ IPOC completed within 4 days
- ☐ Peer review completed and signed
To exit the frequent audit cycle, Oasis Point must:
- • Achieve 100% accuracy on next 3 consecutive audits
- • Maintain 60% Rule compliance for 6+ months
- • Eliminate all IRF-PAI resubmissions and corrections
- • Document robust internal audit program
- • Show evidence of staff training and competency
- • Respond promptly and completely to all MAC requests
Goal: Zero audit findings for 12 consecutive months
Documentation Issues:
- • PAS signed after admission
- • IPOC completed late
- • Missing physician visits
- • Incomplete IDT notes
Coding Errors:
- • Unspecified ICD-10 codes
- • Wrong IGC assignment
- • Incorrect tier level
- • Mismatched diagnoses
Compliance Issues:
- • Failed 60% Rule
- • Insufficient therapy minutes
- • Inappropriate admissions
- • Pattern of similar errors
Immediate Actions (Week 1-2)
Implement daily surveillance checklist, conduct emergency training on common errors, establish peer review process
Short-Term Goals (Month 1-3)
Achieve 100% accuracy on internal audits, eliminate all IRF-PAI resubmissions, maintain 60% Rule compliance
Long-Term Success (Month 4-12)
Sustain zero-fault accuracy, pass all MAC audits with no findings, reduce audit frequency to standard levels
What is the PRIMARY reason facilities experience frequent MAC audits?