MISSION

The FAIR Fund, or the Fund for Access to Inpatient Rehabilitation, is a common legal defense fund comprised primarily of leaders of inpatient rehabilitation hospitals and units who have organized to bring legal challenges to overly restrictive interpretations of medical necessity, burdensome documentation, and violations of procedural requirements by Medicare contractors.

The FAIR Fund’s mission is to raise awareness of, and build support for, policies that will preserve and increase access to inpatient hospital rehabilitation. Members and supporters of the FAIR Fund believe that exercising the legal rights of providers is vital, and providers must challenge the restrictions in access to inpatient hospital rehabilitation that the Centers for Medicare and Medicaid Services (CMS) and its contractors have systematically pursued in the recent past.

The FAIR Fund seeks to establish precedent-setting decisions with widespread application at the federal court level that will clarify medical necessity and documentation requirements for inpatient hospital rehabilitation and ensure that Medicare contractors use proper procedures when auditing claims.  The FAIR Fund will also challenge extensive delays in Medicare appeals and seek a global resolution of pending and future overpayment determinations, for the benefit of the entire IRF field.

CURRENT FAIR FUND PRIORITIES

The FAIR Fund has three immediate areas of focus in the coming months and years:

• Preserving Access to Patient Care:
  • Challenging the Centers for Medicare & Medicaid Services (CMS) to ensure access to inpatient rehabilitation facility (IRF) care
  • Eliminating overly restrictive interpretations of medical necessity
  • Opposing overly aggressive actions by Medicare contractors
• Reducing Denials; Lessening Provider Burden:
  • Seeking more accurate reviews of IRF claims by better defining medical necessity of IRF admissions
  • Ensuring government contractors have sufficient training and expertise in medical rehabilitation
  • Eliminating denials based on guidance documents rather than regulatory requirements
  • Reducing the sheer number of audits from multiple Medicare contractors
  • Opposing the IRF Review Choice Demonstration as a dramatic overreach by the federal government
  • Limiting prior authorization and the use of proprietary coverage guidelines under Medicare Advantage
  • Increasing the weight given to rehabilitation physician judgment in IRF treatment decisions
  • Challenging IRF denials based on hyper-technical interpretations of Medicare standards
• Allowing IRFs to Focus on their Mission:
  • Providing FAIR Fund members with resources to submit strong, compelling appeals when denials occur
  • Facilitating communication among IRF providers on best practices in demonstrating medical necessity
  • Empowering IRFs to spend their time treating patients and improving health and functional outcomes

ACCOMPLISHMENTS

Negotiated a global settlement with CMS to settle IRF appeals which contains the most generous settlement terms of any global settlement in recent Medicare history.

Engaged federal agencies and Congress to improve access to IRF care, including promoting improvements in regulations, proposing regulatory relief, opposing the use of non-Medicare coverage guidelines by Medicare Advantage plans, and encouraging reforms to the Medicare audit and appeals process.

Participated in litigation to force the Department of Health and Human Services (HHS) to decide ALJ appeals within the 90-day deadline required by the Medicare statute, which dramatically reduced the massive ALJ backlog. The FAIR Fund convinced the Court of Appeals that the backlog harms patient health and welfare.

Opposed Recovery Audit Contractors (RACs) in litigation in the Ninth Circuit Court of Appeals.