One critical role all Medicare Administrative Contractors (MACs) perform is safeguarding the Medicare Trust Fund from fraud and abuse.

We are continually looking for new and innovative ways to further this mission. In August 2023, we implemented a new Review Choice Demonstration (RCD) program for Inpatient Rehabilitation Facility (IRF) services. The demonstration ensures the right payments are made at the right time for IRF services through either pre-claim or post-payment review. The overall goal of the demonstration is to reduce the number of Medicare appeals, improve provider compliance with Medicare program requirements, prevent unnecessary delay in care to Medicare beneficiaries and improve methods for the identification of potential Medicare fraud. 

A team of nurses complete the medical reviews with the help of a support team that also includes quality assurance, training coordinators, analysts and techs. Cassie Mills, the MR Manager, along with Amanda Moye, the Clinical Reporting Supervisor, are the primary program leads. Dr. Caitlin Hutchison is the Chief Medical Director for IRF RCD and oversees the quality program.

CMS is expanding the demonstration into Pennsylvania, Texas, and California. These additional states were chosen due to their high rates of improper payments for IRF services.

“Demonstration programs like IRF RCD are vital tools within the Medicare program; highlighting the innovative ideas and realizing the gained efficiencies through cost savings which brings further value to CMS and our beneficiaries.” 

- Jennifer Dowell, Assistant Vice President - Prior Authorization Programs