IRF-PAI Accuracy Training Platform

Critical: Do Not Panic - Be Responsive

Receiving a MAC audit request is stressful, but it is NOT an accusation of wrongdoing. The most important thing you can do is respond promptly and professionally with complete, organized, and legible medical records.

Do NOT miss the deadline - Typically 30-45 days from the date of the MAC letter
Do NOT submit incomplete records - Missing documentation = automatic denial
Do NOT submit illegible records - If the reviewer can't read it, it doesn't exist

Step-by-Step Audit Response Process

Follow these steps immediately upon receiving a MAC audit request

Cover Letter Template

Professional response letter to accompany your medical record submission

[Facility Letterhead]

Oasis Point Rehabilitation Hospital
[Address]
[City, State ZIP]
[Phone Number]

[Date]

[MAC Name]
[MAC Address]
[City, State ZIP]

Re: Medical Review Request - Provider Number: [Your Provider Number]

Dear [MAC Representative Name]:

This letter is in response to your medical review request dated [Date of MAC Letter], requesting medical records for [Number] Medicare beneficiaries treated at Oasis Point Rehabilitation Hospital during [Time Period].

We have enclosed complete and legible medical records for each of the requested claims. Each patient's medical record is organized with a cover sheet that includes:

1. Patient name and Medicare Health Insurance Claim (HIC) number
2. Dates of service
3. Primary diagnosis and ICD-10 code
4. Brief summary of why the case meets IRF medical necessity criteria
5. Index of enclosed documentation

**Organization of Submitted Records:**

Each medical record package includes the following documentation in the order listed:

• Cover sheet with case summary
• Pre-Admission Screening (PAS) - completed and signed by rehabilitation physician BEFORE admission
• Individualized Plan of Care (IPOC) - completed within 4 days of admission
• Physician orders and progress notes
• Interdisciplinary Team (IDT) meeting notes with physician participation documented
• Therapy evaluations and daily treatment notes (PT, OT, ST as applicable)
• Nursing assessments and daily notes
• Discharge summary
• IRF-PAI admission and discharge assessments

**Compliance Statement:**

Oasis Point Rehabilitation Hospital is committed to full compliance with all Medicare Conditions of Participation for Inpatient Rehabilitation Facilities. We believe that each of the enclosed cases meets the medical necessity criteria for IRF-level care, including:

• Appropriate diagnosis requiring intensive rehabilitation
• Active and ongoing intervention of multiple therapy disciplines
• Ability to participate in and benefit from 3 hours of therapy per day, 5 days per week
• Physician oversight with required face-to-face visits
• Expectation of measurable improvement within a reasonable timeframe

If you require any additional information or clarification regarding these cases, please do not hesitate to contact me directly at [Phone] or [Email].

We respectfully request that you review these records in their entirety and consider all documentation when making your coverage determination.

Sincerely,

[Your Name]
[Your Title]
Oasis Point Rehabilitation Hospital

Enclosures: [Number] complete medical record packages

Claim Cover Sheet Template

Use one cover sheet for each patient's medical record

Oasis Point Rehabilitation Hospital
MEDICAL REVIEW CLAIM COVER SHEET

PATIENT INFORMATION:
Patient Name: _________________________________
Medicare HIC Number: _________________________________
Date of Birth: _________________________________
Admission Date: _________________________________
Discharge Date: _________________________________

CLAIM INFORMATION:
Primary Diagnosis: _________________________________
ICD-10 Code: _________________________________
Impairment Group Code (IGC): _________________________________
RIC Tier: _________________________________

CASE SUMMARY - WHY THIS CASE MEETS IRF MEDICAL NECESSITY:

1. APPROPRIATE DIAGNOSIS:
   [Describe the primary diagnosis and why it requires intensive rehabilitation]

2. MULTIPLE THERAPY DISCIPLINES:
   ☐ Physical Therapy (PT)
   ☐ Occupational Therapy (OT)
   ☐ Speech-Language Pathology (ST)
   [Explain why patient required multiple disciplines]

3. INTENSIVE THERAPY PROGRAM:
   • Patient received _____ hours of therapy in first 7 days
   • Patient tolerated therapy well and actively participated
   • Therapy schedule: _____ days per week

4. PHYSICIAN OVERSIGHT:
   • Rehabilitation physician face-to-face visits: Week 1: _____, Week 2: _____, Week 3: _____
   • Physician led IDT meetings documented: [Dates]

5. MEASURABLE IMPROVEMENT:
   • Admission functional status: [Brief description]
   • Discharge functional status: [Brief description]
   • Improvement of practical value: [Specific examples]

6. MEDICAL COMPLEXITY:
   • Comorbidities: _________________________________
   • Complications during stay: _________________________________
   • Nursing interventions required: _________________________________

DOCUMENTATION INDEX:
☐ Pre-Admission Screening (PAS) - Page _____
☐ Individualized Plan of Care (IPOC) - Page _____
☐ Physician Orders - Page _____
☐ Physician Progress Notes - Page _____
☐ IDT Meeting Notes - Page _____
☐ PT Evaluation & Daily Notes - Page _____
☐ OT Evaluation & Daily Notes - Page _____
☐ ST Evaluation & Daily Notes - Page _____
☐ Nursing Assessment & Daily Notes - Page _____
☐ Discharge Summary - Page _____
☐ IRF-PAI Admission Assessment - Page _____
☐ IRF-PAI Discharge Assessment - Page _____

Prepared by: _________________________________
Date: _________________________________

Best Practices for Audit Success

Tell a story - The cover sheet should explain WHY the patient needed IRF-level care, not just list facts
Highlight strengths - Point the reviewer to the strongest documentation supporting medical necessity
Be professional - Maintain a respectful, cooperative tone throughout all communications
Anticipate questions - If there are any potential weaknesses in the case, address them proactively
Keep copies - Maintain a complete copy of everything you submit for future reference

Step 1: Acknowledge Receipt & Organize (Day 1)

Step 2: Gather Complete Medical Records (Days 2-10)

Step 3: Review for Completeness & Quality (Days 11-20)

Step 4: Prepare Cover Letter & Claim Sheets (Days 21-25)

Step 5: Submit Response (Days 26-28)