January 2017 • Vol. 20, No. 1
VALUES AND BELIEFS
WILL OVERCOME ANY OPPOSITION TO HELPING THOSE WHOM WE SERVE.
Volume 20, Number 1
Contributors Bruce Gans, MD Chair, AMRPA Board of Directors, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation, and National Medical Director for Rehabilitation, Select Medical Martha Kendrick, JD Partner, Akin Gump Strauss Hauer & Feld LLP
Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 HHS Reveals Details Behind ALJ Backlog......................................................... 6 HHS OIG Issues Annual Work Plan Which Continues a Focus on IRF Projects and New Projects for SNFs.................................................................. 9
Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Task Force, Principal, The Powers Law Firm
MEDPAC to Recommend Post-Acute Care Payment Cuts and Freezes
Leela K. Baggett, JD Associate, The Powers Law Firm
New Therapy Evaluation Codes for 2017........................................................ 15
Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Mimi Zhang Government Relations and Policy Associate, AMRPA
for FY 2018......................................................................................................... 11
21st Century Cures: A Legislative Feat of the 114th Congress...................... 17 Federal Court Orders HHS to Clear ALJ Backlog by 2020............................ 19 Justin Hunter Awarded AMRPA’s Leadership Excellence Award................... 21 Zero Preventable Deaths After Injury............................................................... 22
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-Advanced Outcomes Design
NIH Issues Third Round of Awards To Support BRAIN Initiative................... 23
Kendall Hussey Policy Advisor, Akin Gump Strauss Hauer & Feld LLP
Preferences......................................................................................................... 24
Ronald Connelly, JD Partner, The Powers Law Firm
AMRPA Comments on the Transfer of Health Information and Patient Care
Retention Time Period Changes to 60 Days for IRF-PAI Provider Reports................................................................................................ 26
Sean Feely Public Policy Specialist, Akin Gump Strauss Hauer & Feld LLP
AMRPA Comments on RAND PROMIS Fatigue Data.................................... 27
Lovelyn Robinson Editorial and Research Assistant, AMRPA
Transition to Value-Based Payment Models.................................................... 30
GAO Outlines Challenges Facing Small and Rural Practices in the
New Models Aim to Increase Patient Engagement in Care Decision AMRPA Magazine, Volume 20, Number 1. Published monthly by the American Medical Rehabilitation Providers Association.
Making................................................................................................................ 32
Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content Š2017 by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission. Design and layout services provided by Futures In Rehabilitation Management, Inc.
Study Finds Hospital Nutrition Program Shortens Patient Stays
Office of the Actuary Issues Report on 2015 National Health Spending...... 34
and Reduces Readmissions.............................................................................. 36 CMS Transmittals of Interest for Medical Rehabilitation Providers............... 37
POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th Street, NW, Suite 750, Washington, DC 20045 Cover photo by Sanit Fuangnakhon/Shutterstock
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AMRPA Magazine January 2017
LETTER FROM THE CHAIR
Letter from the Chair Bruce M. Gans, MD, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation and National Medical Director for Rehabilitation, Select Medical bgans@kessler-rehab.com
“Rehabilitation hospitals and units exist to provide care and services for people with health and functional limitations that have placed them in this minority status.”
T
he news is full of reports of increased hate crime activity, and much of that is believed to be linked to the recent presidential campaign rhetoric. Many of you will recall how one candidate ridiculed a reporter who had a visible physical disability. These events are a stark reminder that minority status is determined by a variety of factors, not just race, ethnicity, sexual identification, age, religion, or cultural heritage and includes health status and physical capabilities. Rehabilitation hospitals and units exist to provide care and services to people with health and functional limitations that have placed them in this minority status. As a consequence, we have a responsibility to counter any actions that would stereotype, bully, or discriminate against the people we help. How can AMRPA help its member organizations combat and counter any threats of this nature? One obvious way is through our advocacy efforts in Washington to protect and preserve legislation and regulations that promote the rights and access of impaired and disabled people to our care.
More subtly perhaps, is how we can continue to speak out on our values and beliefs, and serve as role models in our own communities for how to act responsibly to support the needs of those whom we serve. Participation in health fairs, helping voluntary health organizations to operate and fundraise, supporting community support groups, and promulgating favorable press exposure for the successes our patients experience and their positive contributions to our homes and communities are a few examples of things for which we can each take responsibility and collectively will have a large impact. We also share a responsibility to nip in the bud any growth of hateful and discriminatory language or actions that might be happening right now, and not let this “bad seed” of human misconduct take root and develop any further. AMRPA will do its part, and each of you should do yours. I welcome your thoughts and suggestions on this topic.
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AMRPA LEGISLATIVE UPDATE
By Martha M. Kendrick, JD, Partner, Akin Gump Strauss Hauer & Feld LLP
O
verview As Congress left town in December, Republicans are still expressing interest in aggressive use of Budget Reconciliation to proceed with repealing the Affordable Care Act (ACA) at the start of 2017 and the new 115th Congress. There continues to be discussion of passing two budgets in early 2017, one for FY 2017 and one for FY 2018, which would allow two separate reconciliation bills. Reconciliation bills are a product of the Congres-
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President-Elect Trump’s choice for HHS Secretary, Rep. Tom Price (R-GA), an or-
and Medicaid Services (CMS) played a major role in assisting then-Indiana Governor Mike Pence, now Vice-President Elect, in reforming his state’s Medicaid expansion program, Healthy Indiana. Additional potential vehicles for health care legislation in 2017 include the Children’s Health Insurance Program (CHIP) Reauthorization. Congress will need to act to maintain this program before September 30, 2017. Modifications to Medicare and Medicaid could also occur next year.
President-Elect Trump nominated Rep. Tom Price (R-GA), M.D., to be the Health and Human Services (HHS) Secretary. He also chose Seema Verma, an Indiana health care consultant, to be nominated as the Centers for Medicare and Medicaid Services (CMS) Administrator. On December 13, President Obama signed the 21st Century Cures Act (H.R. 34) into law. After a brief derailment from a few Senators over funding for coal miner retirees health plans, Congress passed a Continuing Resolution (CR) bill to fund the government through April 28, 2016. On December 8, the Medicare Payment and Advisory Commission (MedPAC) discussed a draft recommendation to reduce the Medicare payment rate for inpatient rehabilitation facilities by 5 percent.
sional Budget Act of 1974 that allows the Senate to pass legislation avoiding the 60 vote filibuster threshold, and are limited to specific “instructions” passed by the Budget Committees. Two sets of reconciliation instructions would allow Republicans to use reconciliation for ACA repeal and then tax reform legislation. Republicans are expected to use the ACA repeal Reconciliation legislation that passed in the 114th Congress as the blueprint for moving forward in 2017. The legislation is expected to be one of the first measures passed by the new Congress, reportedly even before the President-Elect, Donald Trump, has been sworn in. How Republicans choose to “replace” the ACA is still up for debate, and 4
reports have surfaced that the conservative Freedom Caucus does not support a transition period that would give Congress two to three years to develop a bipartisan replacement solution and provide insurance companies and the markets time to prepare and adjust. The Freedom Caucus will likely push for a repeal and replace plan that is completed in the 115th Congress (a two-year period).
thopedic surgeon who is Chairman of the Budget Committee and sits on the House Ways and Means Committee, has his own “repeal and replace” measure, The Empowering Patients First Act (H.R. 2300). The bill would provide a refundable age adjusted tax credit for individuals to purchase health insurance, expand the use of health savings accounts, and limits what businesses can deduct for their employees health insurance expenses. States would receive funding to create high-risk pools for individuals with pre-existing medical conditions who cannot afford coverage on the private market. Seema Verma, the Trump Administration’s announced nominee for the Administrator of Centers for Medicare
Speaker Paul Ryan (R-WI) has widely advocated for privatizing Medicare and blockgranting Medicaid. Congressional Committee Leadership Elections Held On November 29, Rep. Sander Levin (DMI) announced he would step down as Ranking Member of the House Ways and Means Committee. This set up a race between two senior Democrats on the powerful Committee – Rep. Xavier Becerra (DCA) and Rep. Richard Neal (D-MA). In an unexpected turn of events, shortly thereafter, Rep. Becerra was tapped to be California’s Attorney General. On December 2, Rep. Neal was officially chosen by the AMRPA Magazine January 2017
House Democratic Steering Committee to be the new Ranking Member of the Ways and Means Committee. Rep. Kevin Brady (R-TX) will remain as the Chairman. On December 1, Rep. Greg Walden (ROR) was selected by the House Republican Steering Committee, defeating Rep. John Shimkus (R-IL), to chair the Energy and Commerce Committee. Retiring Energy and Commerce Health Subcommittee Chairman Joe Pitts (R-PA) will be succeeded by a yet to be determined Republican and a Democrat will also be named in the near future to replace retiring Ranking Member of the Ways and Means Health Subcommittee Jim McDermott (D-WA). Subcommittee Chairmen and Ranking Members will likely be chosen in the early days of the 115th Congress. Congress Passes CR to Fund Government through April 2017 On December 9, not long before the current stop gap funding bill expired at midnight, the Senate succeeded in passing the House-approved Congressional Resolution (CR) that will keep the federal government funded through April 28, 2017 at a cap of $1.07 trillion. The CR includes 11 of the regular appropriations bills. Sen. Joe Manchin (D-WV) and other coal state Senators had briefly halted consideration of the CR because it contained only four months of health benefits for retired coal miners, rather than a longer arrangement. President Obama quickly signed the bill into law narrowly averting a government shutdown. 21st Century Cures Act Becomes Law After overwhelmingly bipartisan votes in the House (392-26) and Senate (94-5), President Obama signed the 21st Century Cures Act (H.R. 34) into law on December 13 (please see separate article on page 17). The medical innovation legislation aims to hasten how drugs and medical devices are reviewed and authorized by the Food and Drug Administration (FDA), and provides funding for the Precision Medicine Initiative, the “Cancer Moonshot,” and mental health initiatives. The bill also included hospital payment reform provisions supported by the House Ways and Means Committee. Specifically of interest to AMRPA members, the bill includes a temporary exception from site neutral payments for certain severe wound discharges from long-term care hospitals; reinstatement of the 50 per-
cent threshold for long-term care hospitals; site neutral relief for “mid-build” off-campus hospital outpatient departments and a requirement for CMS to implement a risk adjustment methodology that takes into account a hospital’s socioeconomic status under the hospital readmission reduction program. Senate Finance Committee Releases CHRONIC Care Act On December 6, the Senate Finance Committee released the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2016 (S. 3504), legislation which aims to improve care for Medicare beneficiaries with chronic conditions and expand telemedicine coverage. The measure, which is similar to the discussion draft that was released by the Committee in October, further extends the Independence at Home Model of Care by two years until September 20, 2019, permanently authorizes dual eligible special needs plans (SNPs), and allows Medicare Advantage (MA) plans to offer a wider variety of supplemental benefits to chronically ill beneficiaries, including telehealth. The bill would also eliminate the geographic restrictions and allow beneficiaries that present with stroke symptoms to receive a timely telehealth consultation. The legislation will likely be re-introduced at the beginning of the 115th Congress next year. MedPAC Convenes Sessions on PostAcute Care Provider Payment Updates On December 8, the Medicare Payment Advisory Commission (MedPAC) held several sessions to discuss draft recommendations regarding the payment update for inpatient rehabilitation hospital and units (IRH/Us), skilled nursing facilities (SNFs), and home health agencies (HHAs) for fiscal year (FY) 2018. For IRH/Us, MedPAC’s draft recommendation currently recommends that Congress reduce the Medicare payment rate for inpatient rehabilitation facilities by 5 percent. The Commission voted in favor of a five percent payment reduction for HHAs in FY 2018, but recommended keeping SNF rates flat in 2018 and 2019, while directing Medicare to work on reforming how it reimburses them. On December 9, the Commission also recommended eliminating the update to the payment rates for long-term care hospitals (LTCHs) in FY 2018. During the discussion, several Commissioners expressed frustration at CMS’ unwillingness to consider the
Commission’s PAC payment recommendations to date and urged the Commission that it may need to be more vocal next year. CMS Released Data on National Health Care Spending On December, 2, CMS released data on national health spending, showing that per-capita health care spending grew by 5.0 percent and overall health spending grew by 5.8 percent in 2015. The report by the CMS Office of the Actuary concludes that 2015 spending growth was due primarily to the increased use of services as health coverage expands, as well as spending growth for prescription drugs. Health spending grew 2.1 percentage points faster than GDP in 2015, the data show. HHS Inspector General Releases Final Rules on Fraud and Abuse On December 6, the HHS Office of Inspector General (OIG) issued two final rules to address Medicare fraud and abuse. The first rule includes new safe harbors to the Anti-Kickback Statute, finalizing protections for arrangements that provide free or discounted transportation to beneficiaries. The second final rule revises the OIG’s civil monetary penalty rules. *** We know many AMRPA members now have new Congressional Senate and House Representatives following the November election. While of course there is uncertainty of what a Trump Presidency brings, given new players and the musical chairs that occur every four years in D.C., nevertheless, it is more imperative than ever that AMRPA Members remain active and in contact with their Representatives and Senators about the important role and critical health care services rehab hospitals provide. We encourage you to invite them to visit your hospitals early in 2017. The value-based purchasing threat is not going away and the New Year will yield many legislative and regulatory twists and turns, and AMRPA must be ready to advocate for our hospitals and patients! We stand ready to support and assist you in your advocacy efforts so please do not hesitate to reach out to us. Regards, Martha M. Kendrick
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Report of the AMRPA Consumer and Clinical Affairs Task Force
HHS REVEALS DETAILS BEHIND ALJ BACKLOG
I
n connection with the lawsuit filed by the American Hospital Association against the Secretary of Health and Human Services to eliminate the backlog in Administration Law Judge (ALJ) appeals, the government filed a supplemental declaration on November 7, 2016, that detailed the current composition of the huge backlog of Medicare appeals. The supplemental declaration also provided insight into the types of appeals generated from the Recovery Audit Contractor (RAC) program, the results of certain initiatives to reduce the backlog, and the Secretary’s revised projections regarding the appeals pending at the Office of Medicare Hearings and Appeals (OMHA). OMHA’s Backlog Composition The supplemental declaration revealed the current composition of the OMHA appeals backlog. Currently, a wide range of beneficiaries, providers and suppliers, as well as State Medicaid Agencies, have pending appeals at OMHA. The OMHA backlog reflects appeals based on a variety of service categories. As of September 30, 2016, the composition of the pending appeals at OMHA was as follows:
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46%: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier appeals 23%: Acute care hospital appeals 14%: Home health and hospice claim appeals 6%: Outpatient therapy claim appeals 3%: Practitioner service appeals 2%: Ambulance service appeals
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6%: Categories that account for less than 2% of appeals pending
Where inpatient rehabilitation hospital (IRF) appeals appear in these data is not clear. Compared to other service categories, DMEPOS supplier appeals comprise a considerable number of appeals pending at OMHA. Remarkably, one durable medical equipment (DME) supplier is responsible for filing over 24% of all appeals pending at OMHA. This single largest appellant also has an error rate estimated at more than 24 percent, or a reversal rate of 76 percent, depending on how you look at it. In comparison, the acute care hospital with the highest number of pending appeals constitutes merely 0.4% of the total appeals pending at OMHA. Notably, the top ten appellants at the ALJ level of appeals constitute over 40% of all appeals pending at OMHA. The top 100 appellants constitute around 55% of all appeals pending at OMHA. According to the supplemental declaration, the breakdown of the top appellants by volume is demonstrated as follows:
ABOUT THE AUTHORS
Peter W. Thomas, JD Counsel, AMRPA Consumer and Clinical Affairs Committee and Denials Management Task Force
Leela K. Baggett, JD Associate, The Powers Law Firm AMRPA Magazine January 2017
The RAC Program The supplemental declaration also addressed RAC-related appeals data, including accuracy and overturn rates for certain years and data on the reduction of appeals generated from the RAC program.1 For instance, according to an independent validation contractor, the RAC accuracy rates are as follows: FY 2014
FY 2015
FY 2016
Accuracy rate of all RACs
At least 91%
At least 95%
At least 91%
Average accuracy rate of all RACs
Over 96%
Over 98%
Over 96%
These high accuracy rates for RACs conflict significantly with the experience of IRF providers over the years. Further, the supplemental declaration asserted that the first two levels of appeals—redetermination and reconsideration, respectively—“provide for meaningful review of RAC determinations,” a sentiment not shared by many providers who routinely experience a “rubber stamp” denial at both the redetermination and reconsideration levels of review. For instance, in fiscal year (FY) 2015, the supplemental declaration states that the RACs’ overturn rate was as follows:
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57% at the redetermination level—48,102 of the 84,533 redetermination decisions and dismissals concerning RAC determinations resulted in a favorable outcome for the provider.
Projections with no action taken Projections with impact of taking Administrative actions Projections with impacts of administrative and congressional actions
RAC-related appeals Percentage of total OMHA receipts
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FY 2013
FY 2014
FY 2015
FY 2016
193,105
273,407
31,624
15,761
50.3%
53.8%
14.1%
9.5%
17% at the reconsideration level—9,908 of the 56,793 reconsideration decisions and dismissals concerning RAC determinations resulted in a favorable outcome for the provider. 43% at the ALJ level—of the appeals that were not settled, 15,563 ALJ decisions and dismissals concerned RAC determinations and 6,704 of those decisions resulted in a favorable or partially favorable outcome for the provider.2
However, the supplemental declaration emphasized that RAC-related appeals (in terms of incoming appeals and currently pending appeals) have significantly decreased from FY 2013. According to the supplemental declaration, the number of RAC-related appeals received by OMHA has decreased as shown above. Moreover, at the end of FY 2016, there were 154,592 RAC-related appeals pending at OMHA—a reduction from the 437,524 RAC-related pending appeals at the end of FY 2015. Although the data cited are difficult to reconcile with the overall number of cases still pending in the backlog, HHS generally attributes the decrease in RAC-related appeals to several factors. HHS acknowledged that RAC activity temporarily declined during the time the Centers
for Medicare and Medicaid Services (CMS) negotiated a new Statement of Work with the RACs. However, HHS asserted that other changes are expected to continue reducing RAC-related appeals receipts, including a new process for reviewing patient status claims and revised Additional Documentation Request limits. Certain Initiatives to Reduce the Backlog The supplemental declaration addressed new initiatives to reduce the backlog and provided data regarding some previously existing initiatives. For instance, the original Hospital Appeals Settlement for inpatient status claims removed from the OMHA docket approximately 288,726 appeals. These cases were settled for 68 cents on the dollar and voluntarily withdrawn from the OMHA. Further, as of September 30, 2016, the OMHA Settlement Conference Facilitations resolved 9,088 appeals. HHS’ Current Projections Concerning Pending OMHA Cases The supplemental declaration updated previous projections regarding the impact of both administrative and legislative actions. The revised projections are contained in the following chart:
FY 2017
FY 2018
FY 2019
FY 2020
FY 2021
Cumulative pending-no action taken
850,627
29,273
1,113,344
1,306,109
1,507,529
Administrative actions impact total
(252,514)
(112,975)
(124,114)
(116,727)
(62,770)
Cumulative pending – with current actions taken
560,663
621,333
681,291
757,329
895,978
Legislative/ budget dependent actions impact total
(114,395)
(266,128)
(281,058)
(281,910)
(282,758)
Cumulative pending – legislative/ budget dependent actions taken
446,267
240,810
19,709
(186,163)
(330,272)
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In evaluating the current statistics and projections, the supplemental declaration indicated that the number of appeals pending at OMHA has declined. For instance, HHS estimates that 658,307 appeals were pending at OMHA at the end of FY 2016—approximately a 26% decrease from the 886,418 pending appeals from the beginning of FY 2016 and approximately a 13% reduction from HHS’ previous projection in May 2016 (757,090 appeals after taking into account the impact of administrative initiatives). The supplemental declaration also revealed that HHS expects the number of appeals pending over 90 days old at OMHA to be eliminated by the conclusion of FY 2019—two years earlier than HHS previously expected in May 2016. After taking into account the impact of administrative initiatives, HHS also projects that 560,663 appeals will be pending at OMHA at the end of FY 2017— approximately a 31% reduction from HHS’ previous projection in May 2016 (807,576 appeals) and approximately a 37% decrease from the 886,418 pending appeals from the beginning of FY 2016. HHS attributes the decline in pending appeals mainly to appeals resolved through the CMS Hospital Settlements, appeals resolved through OMHA Settlement Conference Facilitations, lower appeal receipts to OMHA, projected appeals potentially resolved through the reopening of the CMS Hospital Settlements, projected appeals potentially resolved through State Medicaid Agency settlements, and data reconciliation to catch cases that were duplicative in the data. Conclusion The supplemental declaration accompanying the Secretary’s motion for summary judgement in AHA v. Burwell indicates that HHS is making some progress to reduce the OMHA backlog. However, with the RACs coming back online and hundreds of thousands of appeals still pending, the existing efforts being taken by CMS and OMHA to reduce the appeals backlog are clearly inadequate. This is one reason the District Court decided in favor of the AHA, compelling the government to eliminate the ALJ appeals backlog entirely by the end of 2020.
Id. ¶ 9-10, 24-25. In FY 2015, “approximately 50% (204,273) of fully unfavorable reconsideration decisions [(concerning RAC-related and non-RAC-related appeals)] … were not appealed to OMHA.” Further, in FY 2015, “approximately 5% (nearly 10,000) of [all] appeals to OMHA were later voluntarily withdrawn by the appealing party with no attempt at escalation.” 1 2
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ADVERTISE IN OUR MAGAZINE
DISCOUNTS FOR MEMBERS AND EXHIBITORS/SPONSORS AT THE CONFERENCE AMRPA Magazine January 2017
HHS OIG ISSUES ANNUAL WORK PLAN WHICH CONTINUES A FOCUS ON IRF PROJECTS AND NEW PROJECTS FOR SNFS By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA
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s expected in November, the Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) issued its annual work plan for 2017. This year’s plan includes two projects that effect Inpatient Rehabilitation Facilities (IRFs). One of the projects is new and the other is a revision of prior work. There are also several projects looking into the quality and payment of Skilled Nursing Facilities (SNFs). In devising its work plan, the OIG takes a number of factors into account. It assesses the relative risks in the department’s programs and operations to identify those areas that are in most need of attention and sets its priorities accordingly. It also includes various factors in doing so, such as mandatory requirements for OIG reviews as set forth in various statutes, regulations or other directives; requests from the Congress, the Office of Management and Budget (OMB) and HHS management, as well as other factors.
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As readers will recall, last summer the OIG issued a report of adverse events in rehabilitation hospitals pertaining to the national incidence among Medicare beneficiaries. With respect to Medicare Parts A and B, it is focusing its Medicare oversight efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud and “foster economical payment policies.” The projects referenced in the work plan include:
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Case Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy In conducting a medical review for a separate evaluation to identify adverse events in IRFs, physician reviewers
Long-term-care hospitals (LTCHs) are inpatient hospitals that provide longterm care to clinically complex patients, such as those with multiple acute or chronic conditions. Medicare beneficiaries typically enter LTCHs following an acute-care hospital stay to receive intensive rehabilitation and medical care. LTCHs are the third most common type of post-acute care facility after SNFs and inpatient rehabilitation facilities. LTCHs account for nearly 11 percent of Medicare costs for postacute care ($5.4 billion in FY 2011). The OIG will estimate the national incidence of adverse and temporary harm events for Medicare beneficiaries receiving care in LTCHs. It will also identify factors contributing to these events and determine the extent to which the events were preventable.
found a small number of cases in which the patients appeared to be unsuited for intensive therapy. The purpose of this study is to assess a sample of rehabilitation hospital admissions to determine whether the patients participated in and benefited from intensive therapy. For patients who were not suitable candidates, the OIG will identify reasons they were not able to participate and benefit from therapy. The report is expected this fiscal year (FY 2017).
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Inpatient Rehabilitation Facility Payment System Requirements IRFs provide rehabilitation for patients recovering from illness and surgery who require an inpatient hospitalbased interdisciplinary rehabilitation program, supervised by a rehabilitation physician. Effective for discharges on or after January 1, 2010, specific medical record documentation, at the time of IRF admission, must support a reasonable expectation that the patient needs multiple intensive therapies, one of which must be physical or occupational therapy; is able to actively participate and demonstrate measurable improvement; and requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process. The OIG’s prior reviews of individual IRFs identified substantial Medicare overpayments. It will determine whether IRFs nationwide billed claims in compliance with Medicare documentation and coverage requirements. Long-Term-Care Hospitals – Adverse Events in Post-Acute Care for Medicare Beneficiaries
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Skilled Nursing Facilities – Unreported Incidents of Potential Abuse and Neglect SNFs provide skilled nursing care, including rehabilitation and various medical and nursing procedures. Ongoing OIG reviews at other settings indicate the potential for unreported instances of abuse and neglect. The OIG will assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs and determine whether these incidents were properly reported and investigated in accordance with applicable Federal and State requirements. It will also interview State officials to determine if each sampled incident was reported, if required, and whether each reportable incident was investigated and subsequently prosecuted by the State, if appropriate. 9
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Skilled Nursing Facility Reimbursement Some SNF patients require total assistance with their activities of daily living and have complex nursing and physical, speech, and occupational therapy needs. SNFs are required to periodically assess their patients using the Minimum Data Set (MDS) that helps classify each patient into a resource utilization group for payment. Medicare payment for SNF services varies based on the activities of daily living (ADL) score and the therapy minutes received by the beneficiary and reported on the MDS. The more care and therapy the patient requires, the higher the Medicare payment. Previous OIG work found that SNFs are billing for higher levels of therapy than were provided or were reasonable or necessary. The OIG will review the documentation at selected SNFs to determine if it meets the requirements for each particular resource utilization group. Skilled Nursing Facility Adverse Event Screening Tool The OIG developed the SNF adverse event trigger tool as part of its study, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries” (OEI-06-11-
00370), released in February 2014. The tool was developed with assistance from clinicians at the Institute for Healthcare Improvement (IHI), which also published the tool for industry use. This product will describe the purpose, use, and benefits of the SNF adverse event trigger tool and the guidance document released by IHI, including the methodology for developing the instrument and the instrument’s use in developing the February 2014 report findings. The product will also describe the contributions of OIG and IHI. The goal of this product is to disseminate practical information about the tool for use by those involved with the skilled nursing industry. •
Skilled Nursing Facility Prospective Payment System Requirements Medicare requires a beneficiary to be an inpatient of a hospital for at least three consecutive days before being discharged from the hospital to be eligible for SNF services. If the beneficiary is subsequently admitted to a SNF, the beneficiary is required to be admitted either within 30 days after discharge from the hospital or within such time as it would be medically appropriate to begin an active course of treatment. Prior OIG reviews found that Medicare
payments for SNF services were not compliant with the requirement of a 3-day inpatient hospital stay within 30 days of a SNF admission. It will review compliance with the SNF prospective payment system requirement related to a 3-day qualifying inpatient hospital stay. As readers are aware, the OIG is not the only set of eyes looking at IRFs, reviewing cases and in the case of the Medicare contractors (MACs), issuing denials. In addition, there is the Supplemental Medical Review Contractor (SMRC) which is a specialty review contractor for CMS which reviews selected Medicare claims to identify possible improperly paid claims. In selecting IRFs for review, it states that it does so based on an analysis of national claims data. It then issues an additional documentation request (ADR) which includes providing the medical records so identified. AMRPA has heard from several members that they have been contacted by the SMRC from large numbers of records all due usually within 45 days. If you are contacted by the SMRC or the OIG pursuant to the above projects, please let Carolyn Zollar (czollar@amrpa.org) at AMRPA know.
Leadership Forum and Congressional Fly-In Medical Directors Symposium Rehab Administrators Workshop: How to Manage a Successful Rehab Unit
MARCH 20-22, 2017 · WASHINGTON, DC 10
AMRPA Magazine January 2017
MEDPAC TO RECOMMEND POSTACUTE CARE PAYMENT CUTS AND FREEZES FOR FY 2018 By Mimi Zhang, Government Relations and Policy Associate, AMRPA
E
ach December, the Medicare Payment Advisory Commission (MedPAC) begins the process of developing recommendations for payment updates for the various Medicare payment systems. The Commission bases their recommendations for payment updates on four key criteria: beneficiary access to care, provider access to capital, quality of care for beneficiaries, and the provider’s cost of delivering services. The Commissioners also consider the Medicare margins for each payment system. Based on Commissioners’ feedback, MedPAC staff may modify these recommendations for the January meeting at which time the Commissioners will make a final determination on the recommendations. This year’s recommendations will be submitted to Congress in the Commission’s March 2017 Report to Congress: Medicare Payment Policy and are applicable to federal fiscal year (FY) 2018 payment updates. This article summarizes the payment updates for inpatient rehabilitation hospitals and units (IRH/Us), and other post-acute care (PAC) set-
tings such as long term care hospitals (LTCHs), skilled nursing facilities (SNFs), and home health agencies (HHAs). At the meeting, MedPAC Commissioners expressed frustration at CMS’ lack of movement with the Commission’s PAC payment recommendations in prior years and, hence, a perceived need to “step up the volume” this year. Several Commissioners noted that the various PAC payment systems are in need of reform to align Medicare payments with costs of care. Inpatient Rehabilitation Hospitals and Units In 2015, IRH/Us accounted for $7.4 billion of Medicare spending (a $0.4 billion increase compared to 2014) with 1,180 providers and 381,000 cases. The average payment per case was $19,100 and Medicare beneficiaries comprised 60 percent of all discharges. On a fee-for-service (FFS) basis, the volume of IRH/U cases has remained steady since 2008. Access to capital in the IRH/U sector also remains adequate. Between 2013 and 2015, the number of freestanding rehabilitation hospitals increased 3.8 percent, the number of for-profit
Highlights •
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MedPAC is recommending that Congress reduce Medicare payments by 5 percent for inpatient rehabilitation providers in 2018. MedPAC also recommends a 5 percent payment reduction for home health agencies, and payment updates of 0 for longterm care hospitals and skilled nursing facilities. The Commission will vote on its final recommendations in January 2017.
providers increased 4.6 percent and the number of nonprofits decreased 0.3 percent. With respect to freestanding rehabilitation hospitals, MedPAC staff reported that one major chain represents 46 percent of all providers and experienced good market standing, while little information is available for others. Since 2011, IRH/Us’ quality performances have remained stable or improved, according to six risk-adjusted measures developed for MedPAC by a contractor (see Table 1).
Table 1: IRH/U quality performance have improved since 2011 Risk-adjusted measures
2011
2015
Gain in motor function (points)
22.3
23.8
Gain in cognitive function (points)
3.6
3.9
74.0%
76.0%
Discharge to SNF
6.9%
6.8%
Potentially avoidable rehospitalizations during IRF stay
2.9%
2.4%
Potentially avoidable rehospitalizations within 30 days after IRF discharge
5.0%
2.4%
Discharge to community
11
Staff noted that IRH/Us’ rehospitalization rates are considerably lower than some other PAC settings’, but that is not unexpected given IRH/Us’ hospital capabilities and healthier patients who are admitted based on their ability to withstand intensive therapy. MedPAC reviewed their research from 2015 regarding IRH/U profitability, and differences in case mix and patient assessment practices across types. However, the staff did not present any new analysis at this time. Last year, the Commission discussed analysis demonstrating that high-margin IRH/Us have a different mix of patient cases and assessment practices, leading the Commission to express concerns regarding providers’ patient selection and coding behavior. MedPAC projects IRH/Us’ 2017 Medicare margin to be 14.3 percent, compared to the 13.5 projected for 2016. Actual 2015 margins averaged 13.9 percent. The non-profit IRH/U margin was 3.6 percent in 2015 and 25.0 percent for for-profit facilities. Freestanding hospitals had a 26.6 percent margin in 2015 and hospitalbased units had 2.0 percent margin. The average marginal profit, representing the profit to the provider of admitting one additional patient, was 20.5 percent for units and 41.5 percent for hospitals. All estimates account for the effects of sequestration. According to MedPAC, acute rehabilitation units have higher routine, ancillary, and indirect costs than freestanding IRH/Us and have a different case mix. The majority of units are also nonprofit and may be “less focused on cost control and tend to be smaller with lower occupancy,” with 65 percent of units having fewer than 25 beds. Staff noted that the costs per case have experienced low growth since 2009, and that payments now exceed the costs of care, based on their findings. The Commission expressed support for the draft recommendation to reduce the Medicare payment rate for inpatient rehabilitation facilities by 12
5 percent in 2018. The recommendation is expected to be finalized when the Commissioners review and vote on recommendations in January 2017. MedPAC staff acknowledged that the recommendation “may increase financial pressure on some providers, but the effect should be eased by an accompanying expansion in the outlier pool.” The Commission recommended expanding the IRF PPS high-cost outlier pool as a redistributive tool in its March 2016 Report to Congress, as one of two payment recommendations. It remains to be seen whether the outlier policy will again be included as a distinct and separate recommendation for 2018, in conjunction with a payment reduction. Long Term Care Hospitals In 2015, LTCH services accounted for $5.3 billion in Medicare spending. There were about 131,000 cases in 2015, for an average payment per case of roughly $41,000. Beginning in FY 2016, higher LTCH payments were allowed for qualifying cases with an immediately preceding acute care hospital (ACH) discharge and either 3+ ICU days in the referring ACH or a principal LTCH diagnosis that includes prolonged mechanical ventilation. All other LTCH cases are paid the lower of Inpatient Prospective Payment System (IPPS) based rates or costs. LTCH growth has declined since 2009, though there was a slight increase in beds and facilities between 2014 and 2015. The volume of LTCH services has also been declining since a peak in 2011. For 2015, unlike prior years, the decrease in volume was not observed in other inpatient settings. Data on LTCH performance on quality measures are limited, according to MedPAC. While the Centers for Medicare and Medicaid Services (CMS) has added new measures over the past few years, none of the data are available for analysis yet. Therefore, MedPAC staff rely on claims data to assess the quality of care,
which show that nearly a quarter of LTCH patients die in the facility or within 30 days of discharge. Staff stated that this illustrates just how critically ill some patients are at LTCH admission. MedPAC has focused on changes in capacity and use when considering how payments to LTCHs should be updated. There is wide geographic variation in LTCH use; the top ten percent of counties had 21 LTCH days per 100 fee-for-service (FFS) beneficiaries, while the bottom ten percent had less than two days. As done for other PAC providers, staff directed the Commissioners’ attention to the wide variation in LTCH margins. The bottom 25th percentile of providers have average margins of -14.6 percent, compared to 17.8 percent margins for the top 25th percentile. High-margin LTCHs have fewer high-cost outlier cases and fewer short-stay cases than lowmargin LTCHs. However, staff pointed to increasing provider cost in recent years with LTCHs’ per case cost growth outpacing payment growth since 2013. The 2015 Medicare margin for LTCHs was 4.6 percent, and 6.8 percent for qualifying cases. MedPAC projects a 2017 Medicare margin of 5.4 percent, with an alternative conservative estimate of 3.2 percent, noting that it remains to be seen how the mixed payment system will play out for provider profitability. The Commissioners voiced support for the Chairman’s draft recommendation to eliminate the LTCH payment rate update in FY 2018. Skilled Nursing Facilities In 2015, SNFs accounted for $29.8 billion of Medicare spending with 15,000 facilities and 1.7 million cases. Medicare accounted for 11 percent of SNF days and 21 percent of revenues. The supply of providers was unchanged from 2014 and access remained steady with approximately 88 percent of beneficiaries living in a county with three or more facilities. The occupancy rate declined very AMRPA Magazine January 2017
Table 2: SNF performance on MedPAC’s quality measures Risk-adjusted measures
2014
2015
Discharge to community
37.6%
38.8%
Potentially avoidable readmissions during the SNF stay
10.8%
10.4%
Potentially avoidable readmissions within 30 days after the SNF stay
5.6%
5.0%
Change in function: Improvement in 1+ mobility ADLs
43.4%
43.5%
Change in function: No decline in mobility
87.1%
87.1%
slightly from 2014 to 2015, dropping from 87 percent to 86 percent. One quarter of SNFs had occupancy rates less than 75 percent. In 2015, there was an increase in SNF admissions (up 3.2 percent), but the number of SNF days used continued to decline (down 0.9 percent). Compared to 2014, the average length in stay decreased 4.0 percent. With regard to quality, SNFs demonstrated mixed performance on five indicators, according to MedPAC’s analysis: Providers’ access to capital was adequate and is expected to remain but is getting tighter. According to MedPAC, lending wariness reflects trends in the shifting healthcare landscape in which the growth of bundled payments, accountable care organizations, and enrollment in Medicare Advantage (MA), which all have lower SNF utilization than traditional Medicare. In 2015, the average SNF Medicare margin was 12.6 percent (with sequestration), marking the sixteenth year of margins above 10 percent. MedPAC projects 2017 margins for freestanding SNFs to be 10.6 percent (no estimate was given for hospitalbased SNFs). The marginal profit of accepting one additional patient was 20 percent. Margins varied across the industry, with the 25th percentile achieving 2.4 percent margins and the 75th percentile achieving 21.0
percent margins on average. According to staff, high-margin SNFs generally have lower routine and ancillary costs per day, yet more intensive therapy days and fewer medically complex days. Staff noted that the SNF service mix continues to reflect biases of PPS design, in which payment is driven by the amount of therapy furnished rather than patient characteristics, and that therapy payments exceed therapy costs. They pointed to the wide variations in margins as reflective of differences in patient selection, service provision, and cost control. Furthermore, staff noted the SNF PPS’s shortcomings which, as an example, poorly targets payments for non-therapy ancillary services such as drugs. Commissioners were reminded that the recommendation to revise the SNF PPS and rebasing had been made several times before to Congress. They also voiced their impatience with the little movement seen from CMS or Congress, given the Commission’s repeated recommendations to rebase and revise the SNF payment system. In summary, Commissioners supported the Chairman’s draft recommendation to: 1. Eliminate the SNF PPS market basket update for 2018 and 2019, and
2. Direct the Secretary to revise the SNF PPS. 3. In 2020, the Secretary should report to Congress on the impacts of the reformed PPS and make any additional adjustments to payments needed to more closely align payments and costs. The recommendations are essentially identical to those made by the Commission last year. Home Health Agencies In 2015, HHAs accounted for $18.1 billion in Medicare expenditures with over 12,300 agencies and 6.6 million episodes for 3.5 million beneficiaries. Overall, the industry, measured by supply of agencies, has experienced 63 percent growth between 2004 and 2015. In 2015, HHA volume increased slightly, reversing the trend of modest declines observed in HHAs since 2011. Ninety-nine percent of Medicare beneficiaries live in an area served by home health. The number of users and the share of FFS beneficiaries increased slightly, with the number of episodes per user decreased. In a few areas, such as Texas, Florida and Michigan, the number of agencies has declined slightly as a result of recent federal initiatives to reduce fraud. These areas had experienced rapid higher utilization in growth and supply in previous years. Overall, providers’ access to capital
Table 3: Home health quality performance shows improvement Percent of non-hospitalized patients with improvement at home health discharge:
2004
2014
2015
-Transferring
51.0%
58.9%
63.3%
-Walking
37.2%
63.6%
66.9%
Hospitalization at the end of the episode
27.2%
27.8%
25.4% 13
is adequate, if less capital-intensive than other sectors. Staff reported that many PAC companies made home health acquisitions in the past year as they sought to expand into the sector. Quality measures, based on data from Home Health Compared, indicate improved quality performance in 2015 (see Table 3). The average HHA payment in 2015 was 1.8 percent higher than 2014, with growth in episodes with therapy contributing to this increase. According to MedPAC, relatively efficient HHAs outperform in cost quality, with higher episode volumes and lower rates of hospitalization than other HHAs. Efficient HHAs also had 11 percent lower median costs per visit and 10 percent higher Medicare margins than other agencies. Overall, the 2015 HHA Medicare margins
averaged 15.6 percent, ranging from a high of 24.5 percent for the top 25th percentile to -0.5 percent for the bottom 25th percentile. For-profit agencies had an average margins of 16.7 percent compared to 12.1 for non-profit HHAs. 2017 margins are projected to be 11.1 percent. According to MedPAC staff, although home health care is an effective service when appropriately targeted, Medicare home health care is a poorly-designed benefit with a history of program integrity issues. Specifically, the HH PPS is too heavily volume-based and payments are too high and not reflective of the cost of the typical episode.
1. Reduce payments by 5 percent in FY 2018; 2. Implement a two-year rebasing for the payment system beginning in 2019; and 3. Direct the Secretary to revise the PPS to eliminate the use of therapy visits as a factor in payment determination, concurrent with rebasing. Next steps The Commission will meet January 12-13, 2017 in Washington, D.C. to vote on final recommendations for its March 2017 Report to Congress.
The Commission expressed support for the Chairman’s draft recommendations to:
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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together To Preserve Access To Medical Rehabilitation Maggie Ramirez · Vice President of Membership Services · 347-573-3732 · mramirez@amrpa.org 14
AMRPA Magazine January 2017
NEW THERAPY EVALUATION CODES FOR 2017 By Lisa Werner, MBA, MS, SLP
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eginning on January 1, 2017, the evaluation codes for physical therapy and occupational therapy will change. To date we have had a single code for the initial evaluation and another for a re-evaluation. Going forward, instead of one code, the initial evaluation codes will be divided into three distinct codes based on complexity. The single re-evaluation code remains. Despite the fact that inpatient rehabilitation hospitals and units do not get paid based on the CPT codes charged, we do report these on the cost report, so modifying your use of the CPT codes is necessary for all therapists regardless of your setting.
The new PT initial evaluation codes which replace code 97001 are 97161 physical therapy evaluation: low complexity; 97162 physical therapy evaluation: moderate complexity; and 97163 physical therapy evaluation: high complexity. New PT re-evaluation code 97164 replaces code 97002. The new OT initial evaluation codes which replace code 97003 are 97165 occupational therapy evaluation: low complexity; 97166 occupational therapy evaluation: moderate complexity; and 97167 occupational therapy evaluation: high complexity. New OT re-evaluation code 97168 replaces code 97004.
To determine which code is most appropriate to use, you should determine how many components you evaluated and documented. The more complex the evaluation, the higher the code the therapist will use. Also, note that there is a typical time component associated with each code, so if a therapist is uncertain about the level of complexity to choose, he or she can consult the time spent as a helpful tool to ensure the correct code is selected. The components of the CPT codes are as follows (excerpted from CMS Transmittal 3654):
New CPT Codes and Long Descriptors for PT Evaluative Procedures 97161 Physical therapy evaluation, low complexity, requiring these components: • A history with no personal factors and/or comorbidities that impact the plan of care; • An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: • • •
body structure and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation, moderate complexity, requiring these components: • • • • •
A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 3 or more elements from any of the following: body structure and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation, high complexity, requiring these components: • • • • •
A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 4 or more elements from any of the following: body structure and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.
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97164 Reevaluation of physical therapy established plan of care, requiring these components: • • •
An examination including a review of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97165 Occupational therapy evaluation, low complexity, requiring these components: • • •
•
An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97166 Occupational therapy evaluation, moderate complexity, requiring these components: • • •
•
An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97167 Occupational therapy evaluation, high complexity, requiring these components: • • •
•
An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
97168 Reevaluation of occupational therapy established plan of care, requiring these components: • • • •
An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/ or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
When the code descriptions refer to complex history and reporting body function it takes on an unfamiliar air, but if you refer to your evaluation templates, you will likely find that you are documenting this information already. I commonly see therapy evaluations that go into detail about the patient’s functional ability prior to the current hospital stay because therapists need to know what devices they used, what troubles they encountered due to medical conditions, what activity limitations they had, etc. If you are reporting the information obtained during your interview with the patient and family, you likely already have the first component of the code covered. Reporting on body functions is different, but if you break that down and consider the International Classification of Functioning, Disability, and Health (ICF), you will see that it encompasses things like cognition, sensation, pain, respiratory and cardiac, urinary 16
and sexual functions, and neuromusculoskeletal and movement-related functions to name a few. Once again, you are using measures to capture deficits related to these systems. Consider doing an inventory of the standardized measures that you are currently using and remind therapists of how they relate to the body systems. Therapists should remember to document the standardized measure results with a description relating the test of the intended body system to clearly support the CPT code that they select when entering charges. The ICF also addresses activities and participation such as communication, mobility, self-care, domestic life, and community life to name a few. Ensure that your evaluation tool addresses activity and participation limitations, as these are a key component to the evaluation code selected. I believe that the documentation of your
evaluation should follow the format of the code components, which it naturally will based on what I have seen in my clinical audits. The evaluations should start with a history of present illness to include the patient’s status prior to admission, social history, and prior limitations. It should then move to the tests and measures used to evaluate the patient’s function and performance deficits. The reporting of these should be specific and include standardized measures for physical therapists. Next, the evaluation should be summarized with an assessment of the findings and the ongoing needs of the patient. Ensure that the summary is problem focused. With January 1 fast approaching, be sure that your code list is up to date since the old codes will be deleted. Claims listing those codes may be rejected, so make the switch effective for discharges on or after January 1. AMRPA Magazine January 2017
21ST CENTURY CURES: A LEGISLATIVE FEAT OF THE 114TH CONGRESS
A
fter almost two years of bicameral negotiations, Congressional hearings, and numerous renderings of legislation, the House and Senate passed The 21st Century Cures Act with broad bipartisan support. At the helm of the initiative were its Congressional architects, House Energy and Commerce Chairman Fred Upton (R-MI), and Rep. Diana DeGette (D-CO). Since its inception, the legislative initiative has had a mission to accelerate the time it takes to get innovative health research through the federal drug and device approval process and into the hands of patients desperately seeking cures and treatments. The bill was also built off the premise of personalized and precision medicine. Outgoing Chair Upton was fiercely determined to achieve passage of the legislation before he handed back the gavel during his last year as the top Republican on the Energy and Commerce Committee. The bill gained further support by the Obama Administration through its “Cancer Moonshot” initiative, spearheaded by Vice-President Joe Biden, after the tragic death of his son, Beau Biden, from cancer. On November 30, 2016, the House overwhelmingly passed the 21st Century Cures Act by a vote of 392-26, following by a vote in the Senate of 94-5 on December 7. President Obama held a formal signing ceremony and signed the bill into law (P.L.114 -255) on December 13, 2016. The bill went through several legislative hurdles before becoming law. As Chairman Upton’s leadership on the Committee came to a close due to term limits and legislative days were running out in the Lame Duck session, high level negotiations intensified. Several other legislative priorities made its way into the final bill, including mental health reform proposals and several Medicare priorities of the House Ways and Means Committee, in return for waving their jurisdiction. Of interest to some AMRPA members, the final package included proposals from
hospital payment reform legislation, the House-passed Helping Hospitals Improve Patient Care Act (H.R. 5273), as the price exacted by the Ways and Means Committee for waiving its jurisdiction over the revised Cures package and allowing the bill to move quickly to the House floor. Specifically, the 21st Century Cures Act includes several regulatory relief policies for long-term care hospitals (LTCHs) through October 2017. These include retroactively reinstating the 50 percent acute-care threshold, meaning that up to half of a LTCH’s Medicare patient population are permitted to come from a single acute care hospital before site-neutral Medicare payments would be employed. Further, the bill exempts from lower siteneutral payment rates specific inpatient services provided to Medicare beneficiaries treated during FY 2018 and FY 2019 for spinal and traumatic brain injuries at specific non-profit LTCHs that primarily provide treatment of these injuries. The law requires a study to be conducted by the General Accounting Office (GAO) on the impact of such hospitals that specialize in the treatment of spinal cord injuries. Additionally, the bill exempts grandfathered LTCHs treating specific severe wound cases (MS-LTC-DRGs 602, 603, 539, or 540) from lower site neutral reimbursements in FY 2018. The legislation also calls for a GAO report on treating severe wounds in rural and urban areas, and recommendations on how to pay for severe would care appropriately. Other regulatory relief provisions include allowing LTCHs that were mid-build when the current moratorium on LTCH expansion went into place (April 1, 2014) to be exempt from the bed expansion moratorium, which is paid for by a reduction to the high-cost outlier payment methodology; and new LTCHs established after December 2013 will now have their average length of stay calculated as existing LTCHs are currently calculated. The
ABOUT THE AUTHORS
Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP
Kendall Hussey, Policy Advisor, Akin Gump Strauss Hauer & Feld LLP
17
purpose of this policy is to determine whether an LTCH meets the 25 day average length of stay requirement. The Bipartisan Budget Act of 2015 (P.L. 114-74) includes a provision aimed to limit hospitals’ ability to purchase physician practices and use them to receive higher Medicare outpatient reimbursement rates. This surprise provision caused an uproar from hospitals, including cancer hospitals, many of whom had “mid-build” outpatient centers when the law was passed. The House-passed legislative fix to this problem has been stalled for this past year so many House members were pleased to see the provision cross the finish line. The 21st Century Cures Act included site neutral relief to hospital off-campus outpatient facilities that are defined as mid-build prior to November 2, 2015, and meet several other requirements such as mid-build certification from the providers’ CEO/COO
and a binding agreement for construction of the facility with an outside party. Off-campus cancer hospitals received similar relief and if they meet the certification requirements will no longer be subject to the to the payment changes for off-campus hospital outpatient departments. Additionally, of significant interest, the Centers for Medicare and Medicaid Services (CMS) is required to implement a temporary risk adjustment methodology that takes into account a hospital’s socioeconomic status under the hospital readmission reduction program until analysis, required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, is finalized and a more thoroughly developed methodology can be put in place. The current program does not account for a hospital’s socioeconomic factors, such as its dual eligible population, that can have a significant impact on readmis-
sion rates. The law also requires the Medicare Payment Advisory Commission (MedPAC) to study whether hospital readmissions are related to changes in the outpatient and emergency services provided. Finally, as part of the strategic plan for the future of the National Institutes of Health (NIH), the law also includes a provision to improve, support and coordinate medical rehabilitation research (Sec. 2040), specifically calling for the Director of the Center to update the Research Plan no less than every five years, confirming there is no duplication and interagency coordination with respect to medical rehabilitation research. The 21st Century Cures Act was a true testament to the rare case of bipartisanship on Capitol Hill, so it certainly heralds as one of the huge achievements of the 114th Congress.
CHICAGO
15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO
OCTOBER 23-25, 2017 • SWISSÔTEL
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AMRPA Magazine January 2017
FEDERAL COURT ORDERS HHS TO CLEAR ALJ BACKLOG BY 2020
O
n December 5, 2016, the United States District Court for the District of Columbia ordered the Department of Health and Human Services (HHS) to clear the backlog of Administrative Law Judge (ALJ) appeals by December 31, 2020. The case was brought by the American Hospital Association (AHA) and was assisted by AMRPA’s sister organization, the Fund for Access to Inpatient Rehabilitation (FAIR Fund), which filed several friend of the court briefs in support of AHA. The district court’s decision is an important milestone that may finally bring relief to inpatient rehabilitation hospitals and units (IRH/Us), which currently have hundreds of millions of dollars in Medicare claims pending before ALJs. HHS may still appeal the decision, however, which could delay the expedited decision schedule mandated by the district court.
Background AHA filed suit in 2014 against the Secretary of HHS, seeking a writ of mandamus, which is an order directing a government official to comply with a duty. Here, the duty is to decide ALJ appeals within 90 days as required by the Medicare statute.1 HHS has failed to meet this deadline for several years, and ALJ appeals filed today could take as long as ten years to resolve. In December 2014, the court dismissed AHA’s suit because the judge believed that the extensive delays in ALJ decisions should be addressed by HHS and Congress, not the courts.2 AHA appealed to the D.C. Circuit Court of Appeals, where the FAIR fund filed an amicus curiae (friend of the court) brief in support of AHA, arguing that the extensive delay had the effect of harming patients in addition to placing significant financial burdens on IRH/Us. The D.C. Circuit reversed the district court and held that hospitals have a clear right to ALJ decisions in 90 days; HHS has a clear duty to decide ALJ appeals in 90
days; and hospitals have no adequate alternative remedy other than mandamus.3 The D.C. Circuit noted that the ALJ backlog is having a real impact on human health and welfare because some providers are admitting fewer cases that are likely to be targeted by Recovery Audit Contractors (RACs). The D.C. Circuit remanded to the district court, however, to determine whether Congress and HHS are making “significant progress” toward solving the ALJ backlog. HHS’ first action on remand was to request that the district court stay proceedings until September 30, 2017. On September 19, 2016, the district court denied HHS’ motion to stay. Although the court did not, at that time, formally decide whether to order HHS to comply with the deadline, the judge did weigh factors for and against the issuance of a mandamus order when analyzing whether to grant the stay. The District Court determined that the factors in favor of a writ of mandamus outweighed the factors against. The court again mentioned the real impact on health and human welfare from the ALJ delay. The court discussed the statistics presented in a friend of the court brief by the FAIR Fund showing that IRH/Us have millions of dollars tied up in the backlog. Because IRH/Us win as many as 80% of their appeals—87% when the value of the claims are calculated—it follows that most of these funds rightfully belong to the IRH/Us that provided care to Medicare beneficiaries. The court agreed with AHA and the FAIR Fund that HHS’ current initiatives would not solve the ALJ backlog and would actually result in it growing over time. The court emphasized that “significant progress toward a solution cannot simply mean that things get worse more slowly than they would otherwise.” The court also faulted HHS for not exercising greater control over the RAC program. The court noted that Congress is unlikely to solve the backlog. The court again cited the FAIR Fund’s brief, which
ABOUT THE AUTHORS
Peter W. Thomas, JD Principal, The Powers Law Firm, and Counsel to the AMRPA Denials Task Force
Ronald S. Connelly, JD Principal, The Powers Law Firm 19
pointed out that the House and Senate Budget Committees have refused to hold hearings on the President’s 2017 budget, which would provide significant additional funding for ALJs. The court also agreed with the FAIR Fund that lack of action on legislation to alleviate the backlog shows that congressional relief is unlikely. The district court then ordered briefing on the types of remedies that it might impose on HHS to resolve the backlog. AHA proposed that HHS should expand the scope of the acute care “short stay” settlement to all Part A appeals, including IRH/U appeals; delay recoupment of denied claims and the assessment of interest until after the ALJ decision; and impose penalties on RACs for poor performance. In the alternative, AHA urged the court to impose hard deadlines for eliminating the backlog by the end of 2020 and to order default judgments in favor of appellants in all appeals pending for one year or more as of January 1, 2021. HHS opposed AHA’s remedies and asked the court to permit HHS to continue its existing initiatives. HHS also renewed its arguments that the court should not order HHS to comply with the ALJ deadline. District Court Orders HHS to Clear the Backlog On December 5, 2016, the D.C. District Court ruled in favor of AHA. The court declined to adopt the more prescriptive remedies that AHA proposed, such as expanded settlements and RAC penalties. The court instead adopted the timetable proposed by AHA for reducing the ALJ backlog. The order requires HHS to meet the following deadlines to eliminate the backlog:
• • • •
30% reduction in the backlog by December 31, 2017; 60% reduction in the backlog by December 31, 2018; 90% reduction in the backlog by December 31, 2019; and Elimination of the backlog by December 31, 2020.
The court also ordered HHS to file status reports every 90 days. The court did not impose AHA’s proposed remedy of default judgments for all appeals pending for more than one year as of January 1, 2021. The court stated, however, that AHA can file a motion for default judgments if HHS does not eliminate the backlog by the end of 2020. 20
Potential Next Steps The district court’s decision could end the litigation and force HHS to address the backlog in a meaningful way, but HHS can still appeal. An appeal would go to the D.C. Circuit Court of Appeals and perhaps to the Supreme Court. HHS has sixty days to appeal to the D.C. Circuit, and this deadline falls on February 3, 2017. If it appeals, HHS would likely ask the court to stay its order until the appeal concludes, which, if granted, would prolong the backlog even further. It is unlikely that the D.C. Circuit would reverse the district court. The D.C. Circuit has already held that HHS has a clear duty to decide ALJ appeals in 90 days, that HHS has a clear duty to meet that deadline, and that hospitals have no other adequate remedy than a mandamus order compelling HHS to comply. The D.C. Circuit also signaled in its prior opinion that the equities in favor of mandamus tilt in favor of hospitals. Moreover, the district court’s order is moderate—it does not intrude into HHS’ running of the agency by imposing specific remedies, and it gives HHS four years to come into compliance with the 90-day deadline. HHS may nonetheless appeal in order to seek later review by the Supreme Court, though the Court would not be required to take the case. HHS has long opposed the mandamus remedy in Medicare cases. The district court’s order is not the first time that a federal court has issued a writ of mandamus against HHS. Notably, courts have issued writs of mandamus ordering HHS to recalculate disproportionate share hospital payments.4 HHS may seek Supreme Court review to shield the agency both from the district court’s order and from similar mandamus orders in the future. If HHS does appeal, another case challenging the ALJ backlog could come to the fore. Casa Colina Hospital and Centers for Healthcare has filed a similar action in California. That case now awaits oral argument before the Ninth Circuit Court of Appeals. Thus, the D.C. Circuit may not be the last court of appeals to rule on the ALJ backlog. If HHS does not appeal, then it will have to take new and substantial steps to reduce the ALJ backlog if it is to meet the district court’s deadlines. It may wish to pursue ef-
forts to reduce the backlog whether or not it appeals, to show good faith to the court when the time arises. IRH/Us have thousands of appeals pending at the ALJ level, and so any measures to reduce the backlog will impact them. HHS might even be amenable to a global settlement of IRH/U appeals, perhaps structured similarly to the acute care shortstay cases, which were settled for 68% of the value of the claims. In its remedies brief before the district court, HHS suggested that it could offer a settlement to providers based on each particular provider’s historic win rate in the appeals process or, in the absence of a sufficient history of decided appeals, a sampling and extrapolation of the provider’s or supplier’s pending appeals. Evidence from IRH/U providers suggests data based on historic win rates would result in a reasonable settlement figure. This is an important court decision that may fuel HHS’ willingness to reengage with the IRH/U community to determine whether a settlement is possible. Last year, AMRPA, in conjunction with other stakeholders, presented data to HHS showing that IRH/ Us win approximately 85% of their appeals. HHS was not willing to settle with IRH/Us then, but the district court’s decision in the AHA case may prompt the agency to reconsider. If this were to occur, the data collected last year by the rehabilitation community on ALJ success rates could be used as a starting point for negotiations. Conclusion The decision by the D.C. District Court to order HHS to clear the backlog by 2020 is a significant victory for hospitals, including IRH/Us. IRH/Us have hundreds of millions of dollars tied up in the Medicare appeals process. Because IRH/Us tend to win the majority of appeals, HHS is holding vast sums that rightfully belong to IRH/Us that could put the money toward patient care. However, it is too soon to say whether HHS will choose to comply with the court’s order or whether it will instead continue the litigation.
42 U.S.C. § 1395ff(d)(1)(A). AHA v. Burwell, 76 F. Supp. 3d 43 (D.D.C. 2014). 3 AHA v. Burwell, 812 F.3d 183, 192 (D.C. Cir. 2016). 4 Monmouth Medical Center v. Thompson, 257 F.3d 807 (D.C. Cir. 2001); In re Medicare Reimbursement Litigation, 414 F.3d 7 (D.C. Cir. 2005) (“Baystate”). 1
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AMRPA Magazine January 2017
JUSTIN HUNTER AWARDED AMRPA’S LEADERSHIP EXCELLENCE AWARD
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n enjoyable event in connection with AMRPA’s 14th Annual Education Conference was the awarding of the Association’s highest Leadership Award. In recognition of his significant contributions to the field of medical rehabilitation, Justin Hunter, Senior Vice President of Public Policy, Legislation, and Regulations at HealthSouth, received the American Medical Rehabilitation Providers Association’s (AMRPA) Leadership Excellence Award in October. The award is given to individuals who demonstrate leadership excellence in the field of rehabilitation in two or more of the following areas:
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Transformative leadership initiatives Life-long service in the field of Physical Medicine and Rehabilitation Advocacy – local and national leadership Mentoring of future leaders Improved patient outcomes Research Education
“AMRPA is privileged to recognize Justin Hunter’s outstanding and continuing con-
tributions to defending our country’s rehabilitation hospitals and units,” said Bruce M. Gans, M.D., AMRPA Board Chair, and Executive Vice President and Chief Medical Officer of Kessler Institute for Rehabilitation, in presenting the award. “His tireless efforts to help lead us to effectively protect our patients and our program are deeply appreciated.” HealthSouth President Mark Tarr joined Dr. Gans at the podium as Mr. Hunter received the award.
ABOUT THE AUTHORS
Mr. Hunter was nominated for the award by Tracey Nixon, MS, CHC, who recently completed service on AMRPA’s Board of Directors. In nominating Justin, Tracey discussed his advocacy for the inpatient rehabilitation facility (IRF) sector, stating: “Justin’s strong relationships with both the legislative and executive branches of government have allowed for advocacy for IRF initiatives and have made him a subject matter expert that legislators turn to for clarification and/or advice regarding IRF policy.” Justin is the second HealthSouth employee to receive the award, following former HealthSouth Chief Medical Officer Dexanne Clohan in 2014.
Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Felp LLP
Sean Feely, Public Policy Specialist, Akin Gump Strauss Hauer & Felp LLP
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ZERO PREVENTABLE DEATHS AFTER INJURY (FIRST PERSON ACCOUNT OF A TRAUMA SURVIVOR AT A RECENT NATIONAL TRAUMA MEETING) By Peter W. Thomas, AMRPA counsel, Principal, The Powers Law Firm
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s a trauma survivor and bilateral amputee for the past 40 years, I was invited to participate in an invitation-only meeting at Walter Reed Army Medical Center in November hosted by the National Academies of Sciences, Engineering, and Medicine. I was asked to represent the patient perspective. The conference organizers thought my work with AMRPA, the disability community, and the American Trauma Society (on whose board I sit) would offer a diversity of perspective to the meeting. The conference focused on the announcement of a major report issued in June 2016 by the Health and Medicine Division (formally the Institute of Medicine (IOM)) entitled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” The full report can be accessed at www.nationalacademies.org/TraumaCare. In 1966, the National Academy of Sciences published “Accidental Death and Disability: The Neglected Disease of Modern Society.” This became a seminal work in the area of emergency medicine and trauma and is credited with containing many of the recommendations that led to the development of the modern Emergency Medical Services (EMS) and trauma center system throughout the country. Although the IOM and the National Academy have published a number of trauma and emergency medicinerelated studies throughout the years, this new report was routinely referred to as being in the same category as the 1966
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report. Many speakers at the conference openly professed their hopes that this report would become another seminal work similar to the 1966 report.
health system principals applied across the continuum of care, from point of injury to hospitalization, rehabilitation, and beyond.”
The Committee that developed the report was led by Donald Berwick from the Institute for Health Care Improvement. Dr. Berwick was formally the CMS Acting Administrator and has had a long and distinguished career in the area of health care quality improvement. The committee included a number of senior leaders in the world of trauma and emergency medicine, both from the civilian and military systems.
The report includes eleven major recommendations. Essentially, the report seeks White House involvement in setting a national aim by achieving zero preventable deaths after injury and minimizing trauma-related disability. The Secretaries of Defense and Health and Human Services would be tasked with responsibility for integration of the civilian and military trauma systems in order to create one integrated national trauma care system that would ensure the development of common best practices, data standards, research, and work flow across the continuum of trauma care.
One of the key findings of the report is that military medicine dramatically improves throughout the course of a given conflict but that expertise is often lost between conflicts. One of the professed goals of the report from the military side is to provide the same level of care on the battlefield to the first soldier in a new war as the last soldier received in the previous war. Another overarching goal of the report is to transition the expertise of military emergency medicine to the civilian sector. The report highlighted how the military trauma system relies on a “learning health system” which immediately reacts to and adopts practices that produce good outcomes. This contrasts with the civilian system that tends to rely more heavily on evidence based medicine, which by definition takes much longer to impact and consistently improve health care delivery. The report calls for the very ambitious goal of developing “a national trauma care system grounded in sound learning
The leadership of both the Department of Defense and Health and Human Services would be accountable to coordinate with other government entities at the federal, state and local levels, with academic institutions, and with private sector partners to address care from the point of injury to rehabilitation and post-acute care. These two federal departments would work to integrate a data network that measures rates of prevention, mortality, disability, mental health, patient experience, and other immediate and final clinical and cost outcomes which could be made to be readily accessible to relevant providers and agencies. Another major goal of the report is to strengthen the trauma research agenda. The report calls for multiple agencies to participate in this goal. All military and civilian trauma systems would be called AMRPA Magazine January 2017
upon to participate in a structured trauma quality improvement process. The report also recommends that Congress identify and implement mechanisms to ensure that EMS is included as a seamless component of health care delivery rather than merely a transport mechanism. The final recommendation involves the development of career pathways for trauma care, to foster new trauma leadership, and to remove career barriers between the military and civilian trauma care systems. As the only patient representative at the conference, I was asked to discuss the patient perspective and implications of these recommendations on persons with injuries, illnesses, and disabilities. Chapter 6 in the report focuses on patient centeredness and the importance of limiting disability to the maximum extent possible, not just achieving zero preventable deaths. I emphasized the importance of recovery and rehabilitation, and how rehabilitation should be viewed as starting in the operating room in many instances. I discussed my experience with peer mentoring during rehabilitation and post-trauma care and stressed the American Trauma Society’s Trauma Survivors Network as a model. I also discussed the importance of psychosocial factors that are highly relevant to the patient experience following a traumatic injury. A consortium of non-governmental stakeholder organizations will likely be developed to help implement the formidable recommendations in the Zero Preventable Deaths report. The initiative offers an ideal opportunity for the rehabilitation community to better integrate with the trauma community for the benefit of trauma survivors.
NIH ISSUES THIRD ROUND OF AWARDS TO SUPPORT BRAIN INITIATIVE
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he National Institutes of Health (NIH) has announced its third round of awards to support the goals of the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, bringing NIH’s total fiscal year 2016 investment over $150 million.
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The awards expand NIH’s efforts to develop new tools to understand neural circuit function and capture a dynamic view of the brain in action.
According to NIH, previous research has shown that deep brain stimulation (DBS) can promote the brain’s plasticity and ability to form new neural connections during recovery from stroke. Stroke is the leading cause of long-term disabilities in the United States. One-third of stroke patients maintain long-term motor deficits severe enough to be disabling, despite rehabilitative efforts. According to NIH, previous research has shown that deep brain stimulation (DBS) can promote the brain’s plasticity and ability to form new neural connections during recovery from stroke. Over one hundred new awards, totaling more than $70 million, will go to over 170 investigators working at 60 institutions. The awards expand NIH’s efforts to develop new tools and technologies to understand neural circuit function and capture a dynamic view of the brain in action. Projects include proposals to develop computer programs that may help researchers detect and diagnose autism and Alzheimer’s disease from brain scans, build a cap that uses ultrasound waves to precisely stimulate brain cells, create a “neural dust” system made of tiny electric sensors for wirelessly recording brain activity, improve current rehabilitation technologies for helping the lives of stroke patients, and study how the brain reads and speaks. In 2013, President Obama launched the BRAIN Initiative in an effort to equip researchers with insights necessary for treating a wide variety of brain disorders like Alzheimer’s, schizophrenia, autism, epilepsy, and traumatic brain injury (TBI). The World Health Organization (WHO) estimates that devastating brain disorders affect more than one billion people worldwide. The NIH component of the BRAIN Initiative is guided by the long-term scientific plan, “BRAIN 2025: A Scientific Vision,” which emphasized an early investment in basic neuroscience research. Over the past two years, NIH BRAIN Initiative funded researchers have produced several breakthroughs and published over 125 academic research articles. For a list of the new grants and more information about the BRAIN Initiative, please visit: http://www.braininitiative.nih.gov/nih-brain-awards.htm. For the announcement, please see: https://www.nih.gov/news-events/newsreleases/nih-nearly-doubles-investment-brain-initiative-research.
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AMRPA COMMENTS ON THE TRANSFER OF HEALTH INFORMATION AND PATIENT CARE PREFERENCES Editor’s Note: On December 11, 2016, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to its request for public comment on draft cross-setting quality measures for post-acute care providers regarding the transfer of health information and patient care preferences. The complete letter is below and can also be found at www.amrpa.org. December 11, 2016 RTI International 3040 E Cornwallis Rd Durham, NC 27709 Delivered electronically to TOHPublicComments@rti.org. To RTI International and the Centers for Medicare and Medicaid Services: This comment letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) in response to the Call for Public Comment on two quality measures under development for post-acute care (PAC) providers pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The measures are: 1. Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings; and 2. Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings. AMRPA is the national trade association whose members provide rehabilitation services across the spectrum of health care settings including inpatient rehabilitation facilities (IRFs), hospital outpatient departments (HOPDs), and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, long-term care hospitals (LTCHs), and skilled nursing facilities (SNFs). AMRPA members help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. AMRPA has reviewed the report prepared by RTI International, Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies, and we offer the following comments. I. Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings A. General Comments 24
As PAC providers, IRFs receive approximately 85 percent of patients as referrals from acute care hospitals. Hence, the acute care hospital is the primary provider from which IRFs receive discharge and other patient health information. Unfortunately, the quality of that information varies widely for multiple reasons. Acute care hospitals do not have to provide the type of proposed information requested on transferring a patient. We believe the only requirements they must follow to participate in Medicare are those set forth in the Hospital Conditions of Participation. If there is a way to develop this measure to incentivize acute care hospitals to provide complete information when transferring the patients, we urge that it be tackled. B. Use as a Quality Measure AMRPA does not support the use of this proposed measure as a quality measure. A quality metric generally presumes an outcome or result on which the measured provider’s behavior or actions could affect. That is not the case for this proposed measure which fundamentally assesses the behavior of an upstream entity – namely, did they transfer information to the receiving PAC provider. Hence, we recommend that the discussion about the measure be reframed so it is classified instead as a benchmarking and data collection effort, similar to the proposed assessment questions on the Route of Health Information Transfer. Essentially this measure asks the receiving PAC provider: a) Did you receive any information and, if so, then b) Did you receive it in the stated categories? In its proposed usage as a quality measure utilizing a numerator and denominator, this metric implies that a higher percentage equates to better performance. However, measuring receipt of information on admission as a percentage will measure only the referring entities’ behavior, not the IRFs’, and IRFs should not be penalized or otherwise held accountable for the behavior of the referring provider. Furthermore, at no time does the measure imply there is an affirmative duty placed on the receiving provider to contact the sending provider for the information. Hence, if IRFs are expected to do so, that would be an additional burden they must incur and there is a concern that it could cause tension with referring providers. Notably, most IRFs obtain practically all the information sought through this measure when the IRF’s clinicians conduct the required Patient Admission Screening (PAS) prior to admitting a new IRF patient. The PAS could be transferred to this proposed measure but would not reflect what information the referring entity provided. C. Specific Information Requested In reviewing the proposed eleven categories of health information, we recommend that psycho/social informaAMRPA Magazine January 2017
tion also be collected. In addition, we are concerned that obtaining accurate medication information is difficult. For purposes of this proposed measure, however, the question is whether or not it was provided, not if it seemed appropriate or accurate. With respect to the eleven categories, we offer the following comments: a. Several of the items are redundant and therefore increase the reporting burden. Items such as “Administrative information” should be reexamined and narrowed. b. Functional status should be retained and encompass mobility and self-care at a minimum. c. Cognitive function and mental status should be retained. d. Special services should be retained. e. Medical conditions and co-morbidities should be retained. f. Impairments should be retained. g. Medication instruction should be retained and explained. h. Patient care preferences should be retained and also expanded to include preference regarding language used and religion as examples. i. Goals of care needs to be clarified whether they cover the goals of care in acute care or the referring providers’ projected goals of care for the PAC provider. j. Diet/nutrition should be retained. According to the proposed specifications, if one of the eleven categories of information is transferred, the PAC provider would check that category in the assessment form and the measure numerator is considered fulfilled. However, this begs the question of whether PAC providers will just check one in order to save time, regardless of how many types of information is received. If so, then there would be no benefit to the provider in checking more than one category. Again, the intent of this measure is more appropriate for data collection and benchmarking purposes, and not for quality and performance measurement purposes. D. Denominator Specifications One of the objectives of the IMPACT Act is to collect comparable data across all four of the PAC providers encompassed within the Act. To do so implies that utilized measures are essentially identical if there is to be a true comparison. However, the populations to be used in the denominators for the various providers are different for this proposed measure. For example, for IRFs the population for the denominator is Medicare Part A (traditional fee for service Medicare) and Part C (Medicare Advantage) patients. For SNFs, it is only Part A residents. As a result, the final data collected would be comparable within provider types but not across provider type. AMRPA recommends this approach be reconsidered. It is critically important that CMS prioritize cross-setting standardiza-
tion as it develops and implements PAC quality measures. We are concerned that these measures could result in selective sampling of the patient population that would skew the collected data and distort or otherwise invalidate meaningful comparisons across measures and across PAC settings. AMRPA believes that the measures should be applied to a uniform Medicare patient population that is inclusive of Medicare Parts A and C beneficiaries. II. Transfer of Information at Post-Acute Care: Discharge or End of Care to Other Providers/Settings A. General Comments AMRPA supports collection of data of this nature. Furthermore, we support efforts to delineate the information to be included at the time of transfer from the PAC provider and to the families, patient, and caregivers as well. B. Use as a Quality Measure AMRPA believes this proposed measure lends itself more readily to being characterized as a quality measure as the information was in the control of the PAC provider. C. Specific Information Requested to be Transferred Again, similar to the Transfer of Information at Admission measure, various information categories proposed for the discharge measure are redundant and unnecessarily burdensome. In reality, IRFs generally provide this information at discharge. However, to pull it from the patient record and then cross-reference it by the measure’s categorical definitions may be an extra burdensome task. We are foremost concerned with the heavy obligation this measure would create for providers. Items such as “Administrative information” should be reexamined and narrowed, as they are redundant and therefore increase reporting costs and obligations unnecessarily. While we support the intent of Questions 3-5, since “Question 5: Types of Health Information Provided to the Patient/ Family/Caregiver at Discharge or Transfer” duplicates the eleven information categories from “Question 2: Types of Health Information Provided at Discharge or Transfer,” the two could be combined to serve a single function. Alternatively, if Question 5 is retained, it should be pared down in scope to focus on the categories of information most meaningful to the patient/family/caregiver at discharge and to minimize provider burden. Of the eleven categories, “Goals of care” needs to be clarified as to whether it refers to the goals of care at the discharge PAC setting or the projected goals of care for the receiving PAC setting. D. Denominator Specifications The Medicare populations proposed for this measure denominator are, again, different for the various PAC settings. AMRPA recommends that CMS and its contractors prioritize cross-setting standardization as it develops PAC quality measures. Doing so ensures that cross-setting quality measures implemented under the framework of the IMPACT Act are truly standardized and generate valid and 25
meaningful comparisons across settings. III. Summary AMRPA appreciates the opportunity to comment on the report Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies. In summary: A. We do not support the use of “Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings” as a quality measure. We recommend that the assessment questions pursuant to this measure be reframed as befitting data collection for benchmarking purposes. B. We recommend that CMS refrain from creating unnecessary burden for PAC providers by eliminating some categories of required information or collapsing some assessment questions as we suggest. C. We recommend that Medicare beneficiary population for the measures’ denominators be aligned and consistent across the PAC settings. D. We urge CMS to incorporate acute care hospitals in the assessment of transfer of patient information. CMS should focus on efforts that would incentivize hospitals to provide complete information when transferring/discharging patients to PAC settings.
contact Carolyn Zollar, JD, Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org), or Mimi Zhang, Policy and Research Associate (mzhang@amrpa.org) at 202-223-1920. Sincerely,
Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical
Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Vice President/Administrator, Carolinas Rehabilitation-Charlotte Carolinas HealthCare System
If you have any questions regarding our recommendations, please
RETENTION TIME PERIOD CHANGES TO 60 DAYS FOR IRF-PAI PROVIDER REPORTS
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n December 4, 2016, the Centers for Medicare and Medicaid Services (CMS) announced that the retention time period for the IRF-PAI and LTCH provider reports will change from 730 days to 60 days.
Effective December 1, 2016, the reports requested from the IRF-PAI and for LTCH provider report category in the CASPER Reporting application will only be stored 60 days. Any IRF-PAI and LTCH provider reports requested 60 days or more prior to December 1, 2016 will be permanently deleted from your CASPER folder. If a provider wishes to retain these reports, it may print or save a copy prior to the report retention time period change. Any reports not printed or saved prior to the retention period time change will be permanently deleted. If providers’ copies are lost, they may recreate these reports on demand from the IRF-PAI and LTCH provider report category in the CASPER Reporting application. For a list of affected reports in the IRF-PAI and LTCH provider report category or for detailed instructions on printing or saving CASPER reports, please refer to the CASPER Reporting User’s Guide. The CASPER Reporting User’s Guide is available on the QTSO LTCH User Guides and Training webpage.
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AMRPA Magazine January 2017
AMRPA COMMENTS ON RAND PROMIS FATIGUE DATA Editors Note: On December 14, 2016, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the RAND Corporation on its development of Patient-Reported Outcome Measurement Information System (PROMIS) items proposed for patient-reported fatigue pursuant to the requirements of the Improving Medicare PostAcute Care Transformation (IMPACT) Act. The complete letter is provided below and is available on the AMRPA website at www.amrpa.org. December 14, 2016 RAND Corporation Elizabeth L. Petrun Sayers, PhD Associate Behavioral and Social Scientist Behavioral and Policy Sciences Department 1200 South Hayes Street Arlington, VA 22202-5050 Delivered electronically to: impactfeedback@rand.org. Re: Request for Comments on PROMIS Fatigue items. Dear Dr. Sayers: These comments are submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) with respect to the above captioned Request for Stakeholder Input. We welcome the opportunity to comment on the development of standardized assessment items pursuant to the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. AMRPA supports the principles and objectives of the Act and remains committed to working with the Centers for Medicare and Medicaid Services (CMS) and its contractor, the RAND Corporation, to achieve them. AMRPA is the national trade association whose members provide rehabilitation services across the spectrum of health care settings including inpatient rehabilitation hospitals and units (IRFs), hospital outpatient departments (HOPDs), and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, long-term care hospitals (LTCHs), and skilled nursing facilities (SNFs). AMRPA members help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. AMRPA has reviewed the list of 95 Patient-Reported Outcome Measurement Information System (PROMIS) items the RAND Corporation proposes for patient-reported fatigue items with our Quality Committee and member clinicians. We offer the following comments.
I. PROMIS and Inpatient Rehabilitation Through an informal literature review, we did not find strong evidence that the PROMIS item bank has been satisfactorily or sufficiently validated in inpatient institutional/non-community settings, and even less so for institutional post-acute care (PAC) settings such as IRFs and LTCHs. Hence, we do not think that PROMIS and the fatigue sub-scoring items have been normed, or would be appropriate, for the inpatient PAC population at this time. There is no doubt that patient reported outcome measures (PROMs) provide a valuable and patient-centric information source in describing health changes during a hospitalization. Furthermore, outcomesbased quality metrics, such as change in functional status, are especially valuable in assessing IRF patients’ wellbeing. However, there are admittedly major challenges in using PROMs for accountability and performance improvement, including limited use in clinical practice and uncertainty about how to aggregate PROMs for performance improvement. PROMs in medical rehabilitation remain an ongoing area of research. The Rehabilitation Institute of Chicago (RIC) was awarded a grant in 2013 from the Patient Centered Outcomes Research Institute (PCORI) to study these issues further.1 PCORI also awarded a grant in 2014 to the University of Washington Center on Outcomes Research in Rehabilitation (UWCORR) to assess the application of PROMIS items on patients with chronic pain and disability.2 Both projects are in progress. AMRPA encourages CMS and its contractors to refer to these findings, when published, to identify vetted PROMs, PROMIS items, and application methods that are clinically suitable for PAC settings. In the interim, we do not support moving forward with applying any PROMIS items for data collection purposes pursuant to the IMPACT Act until they have been tested and validated for inpatient PAC providers such as IRFs, and we perceive there is a risk of negative unintended consequences for doing so. Furthermore, we have questions regarding when during the PAC stay patients would be asked the fatigue questions and how it would be conducted. IRF stays are often shorter than seven days, which is the proposed lookback period for the PROMIS fatigue items. As such, that timeline may not be appropriate for IRF if patients are asked these questions, especially at the end of their stay. Additionally, IRFs may be at a disadvantage in this scoring because IRF patients, due to their shorter lengths of stay and more intensive therapy regiments, could appear to be more tired than patients in other PAC settings with longer lengths of stay such as SNFs and LTCHs. II. Terminology The list of 95 PROMIS fatigue items frequently use the terms “fatigue” and “tired” interchangeably. According to our physician members, tiredness and fatigue have different clini27
patient felt fatigued with respect to being able to:
cal definitions and this difference is particularly germane to the rehabilitation patient population. In oncology rehabilitation, for example, cancer-related fatigue (CRF) is defined as an “overwhelming and sustained exhaustion and decreased capacity for physical and mental work…not relieved by rest.”3 Conversely, when a patient is tired, he or she can sleep and the tiredness goes away, and the patient is able to resume work or activities of daily living (ADLs). Fatigue, however, is not responsive to rest and patients may be unable to return to their ADLs despite resting. As such, rehabilitation patients with true fatigue are at greater risk of sustaining functional loss. In addition, fatigue has been shown to negatively impact one’s economic, social, and emotional status.4 While there may not yet be complete uniformity in medical terminology regarding the nuances of tiredness and fatigue, the latter has a distinct usage in the clinical setting and a defined impact on patient well-being in rehabilitation medicine. We suggest CMS and the RAND Corporation not use the two terms interchangeably in developing standardized PRO items for PAC given the evolving understanding in their clinical utilization. We recommend the items use “fatigue,” but it is important that patients receive a clear explanation of its clinical definition so they can report outcomes correctly. III. Impact on Care Delivery AMRPA remains concerned with the direction of PRO data collection as it is not clear how data on patients’ levels of fatigue will improve the efficiency and quality of the care they receive in PAC. There are currently multiple PROMIS-focused projects out of PCORI, given the institute’s focus on clinical effectiveness research (CER). As CMS and its contractors continue to develop standardized cross-setting assessment items for PAC pursuant to the IMPACT Act, we strongly urge CMS to prioritize and consider in concert both the administrative burden to providers of collecting PRO data and the data’s clinical effectiveness and utility.
• • • •
Eat; Think with mental clarity; Make decisions; and Engage in physical activities including mobility and self-care.
A second set of items we suggest would ask how often the patient felt: • • •
Forgetful; More drained of energy; or More fatigued than usual.
Conclusion AMRPA appreciates the opportunity to provide input on the development of cross-setting PAC standardized patient assessment data elements. We seek to ensure these elements achieve the data collection objectives of the IMPACT Act while being minimally burdensome for PAC providers. If you have any questions, please contact Carolyn Zollar, JD, Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org) and Mimi Zhang, Policy and Research Associate (mzhang@amrpa.org) at 202-223-1920. Sincerely,
Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical
IV. Specific Feedback on Fatigue Items We offer the following recommendations with respect to the list of 95 PROMIS fatigue items: 1. Several questions cannot be scaled on the frequency rating scale proposed, such as “How tired were you on average?” or simply “I have energy.” We recommend that items that do not fit the rating scale be eliminated. 2. Questions on social activities, such as socializing with friends and family, and engaging in “usual activities” are not suitable for inpatient settings such as IRFs. These are better suited for community-based settings but not institutional PAC providers. 3. The items should eliminate slang used such as “bushed,” “washed out,” or “sluggish.” 4. A number of the questions appear to be repetitive or close to it in their phrasing. Eliminating many of them would make it easier for the patient to respond. 5. If CMS/RAND move forward in selecting PROMIS items however, we suggest that they focus on the following areas and be framed so that they are scalable on the scale suggested. Hence, the questions would be how often the 28
Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Vice President/Administrator, Carolinas Rehabilitation-Charlotte Carolinas HealthCare System
See PCORI website for study: “Developing Quality Metrics from PatientReported Outcomes for Medical Rehabilitation.” http://www.pcori.org/researchresults/2013/developing-quality-metrics-patient-reported-outcomes-medicalrehabilitation 2 See PCORI website: “Extending PROMIS Pain Item Banks: Pain Self-Efficacy and Pain Catastrophizing.” http://www.pcori.org/research-results/2014/extendingpromis-pain-item-banks-pain-self-efficacy-and-pain-catastrophizing 3 Julie K. Silver, MD, Jennifer Baima, MD, R. Samuel Mayer, MD. “Impairmentdriven cancer rehabilitation: An essential component of quality care and survivorship.” CA: A Cancer Journal for Clinicians, Volume 63, Issue 5. September/October 2013 (emphasis added). 4 Id. 1
AMRPA Magazine January 2017
• Fighting Restrictive Medicare Policies • Challenging Aggressive Contractors • Ensuring Access and Quality of Life for Seniors
We Are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of America’s Top Inpatient Rehabilitation Hospitals and Units.
For more information, please contact Deb Curington at dcurington@firminc.com or at (217) 753-1190 29
GAO OUTLINES CHALLENGES FACING SMALL AND RURAL PRACTICES IN THE TRANSITION TO VALUEBASED PAYMENT MODELS
A
re small and rural physician practices prepared for the transition to value based payment models? The Government Accountability Office (GAO) examines this issue in a recent a report entitled: “Medicare ValueBased Payment Models Participation Challenges and Available Assistance for Small and Rural Practices” which found that some practices have small budgets, making it harder for them to invest in the training and technology they need in order to participate in the value based payment (VBP) models. Background The Centers for Medicare and Medicaid Services (CMS) has implemented valuebased payment models which focus on physicians (and other providers) sharing in the financial risk of caring for beneficiaries. Value-based payment models generally include “upside risk,” where physicians receive additional payments for providing high-value care that is based on certain quality and efficiency metrics and “downside risk,” where physicians may be financially penalized for increased expenditures and care that does not meet quality and efficiency standards. CMS has been trying to encourage physicians to participate in models with both upside and downside risk by including larger financial incentives for positive results in those models than it does in models with upside risk only. Providers may receive additional payments for providing high-value care based on quality and cost metrics designed for each model or be financially penalized for care that does not meet certain standards. In accordance with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), beginning in 2017 CMS will implement the Quality Payment Program, which will include the Merit-based Incentive Payment System (MIPS) for physicians and other providers, as well as incentives for participation in certain alternative payment models. MIPS will consolidate components of programs currently used to tie payments to quality and provide incentives for quality, resource use, clinical practice improvement activities, and advancing care information through the meaningful use of electronic health record (EHR) technology.
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Why GAO Did This Study MACRA includes a provision that GAO examine organizations that can assist small physician practices with participation in these models.
cal practices (or treatments) that have been shown to result in high-quality or efficient care. Examples of process measures are those that measure care coordination, such as the percentage of patients with major depressive disorder whose medical records show that their physician is communicating with the patients’ other physicians who are treating comorbid conditions. Outcome measures track results of health care, such as mortality, infections, and patients’ experiences of that care. Efficiency measures may vary across models. For example, models may require that a minimum savings rate be achieved, which is established using a benchmark based on fee-for-service claims as well as other information such as patient characteristics, or that cost targets are achieved for various episodes of care.
The report describes: 1. Stakeholders’ perspectives on the challenges faced by small and rural physician practices when trying to participate in Medicare value-based payment models; and 2. The types of organizations that help these practices participate, and the activities they conduct. GAO defined small and rural practices as those with 15 or fewer physicians and those located outside of an urban area, respectively. To address the objectives, GAO reviewed literature and CMS documents on valuebased payment models and interviewed 38 stakeholders, including CMS, providers, and organizations that assist with valuebased payment models. GAO identified stakeholders through research and referrals from the stakeholders interviewed. GAO’s findings are not generalizable beyond the stakeholders interviewed; however, the findings provide insights into the challenges faced by small and rural practices when deciding whether to participate or when participating in value-based payment models. GAO conducted the performance audit from November 2015 to December 2016. The Transition to Value-based Payment According to CMS documentation, the transition to value-based payment generally involves two major shifts from traditional fee-for-service payment. 1. Accountability for both quality and efficiency. Value-based payment models link payments to providers to the results of health care quality and efficiency measures. CMS uses a variety of measures to assess health care quality and efficiency and to hold physicians and other providers accountable for the health care they deliver. Quality measures include process and outcome measures. Process measures assess the extent to which providers effectively implement clini-
2. Focus on population health management. Value-based payment models encourage physicians to focus on the overall health and well-being of their patients. Population health management includes provider activities such as coordination of patient care with other providers; identification and provision of care management strategies for patients at greatest risk, such as those with chronic conditions; promotion of health and wellness; tracking patient experience; and using health information technology (IT) to support population health. CMS’ Innovation Center has developed and is testing a number of value-based payment models, often referred to as alternative payment models (APMs), in which physicians and other providers are paid and responsible for the care of a beneficiary for a long period and accountable for the quality and efficiency of the care provided. The following are examples of Medicare value-based payment models in which physician practices can participate. •
Accountable Care Organization (ACOs). ACOs are groups of physicians—including independent physician practices—hospitals, and other health care providers who voluntarily work together to give coordinated AMRPA Magazine January 2017
care to the Medicare patients they serve. When an ACO succeeds in delivering high-quality care and spending health care dollars more efficiently, part of the savings generated goes to the ACO and part is kept by Medicare. ACOs participate in models with upside risk only or models with both upside and downside risk. •
•
Bundled payment models. Bundled payment models provide a “bundled” payment intended to cover the multiple services beneficiaries receive during an episode of care for certain health conditions, such as cardiac arrhythmia, hip fracture, and stroke. If providers are able to treat patients with these conditions for less than the target bundled payment amount and can meet performance accountability standards, they can share in the resulting savings with Medicare. The Bundled Payments for Care Improvement (BPCI) Initiative tests four broadly defined models of care, under which organizations enter into payment arrangements that include financial and performance accountability for episodes of care. Comprehensive primary care models. Comprehensive primary care models are designed to strengthen primary care. CMS has collaborated with commercial and state health insurance plans to form the Comprehensive Primary Care (CPC) initiative which provides participating primary
care physician practices two forms of financial support:
vices. The challenges identified are in five (5) key topic areas.
1. A monthly non-visit-based care management payment; and 2. The opportunity to share in any net savings to the Medicare program. In January 2017, CMS will build upon the CPC initiative, which ends December 31, 2016, by beginning CPC Plus, a comprehensive primary care model that includes downside risk.
Conclusion GAO concluded that organizations offer a variety of services that can help small and rural physician practices with challenges to participating in Medicare’s value-based payment models, but not all small and rural practices can access these services. These organizations include group practices, private companies, nonprofit groups, and universities. GAO grouped the organizations that can assist into two categories: partner and non-partner organizations. Partner organizations share financial risk associated with model participation and provide comprehensive services that can mitigate challenges. These services may include sharing resources, such as data systems and care management staff, and conducting analysis to manage patient care. Non-partner organizations do not share financial risk but provide specific services that can help with certain challenges, such as health IT and data challenges. However, not all small and rural practices have access to organizations and the services they provide. For example, some partner organization stakeholders told GAO that they are selective about the practices they will form partnerships with. Further, some stakeholders said that small and rural practices may have limited financial resources that prevent them from hiring the organizations that could best assist them with participation.
In contrast, Medicare fee-for-service payments to providers are tied only to volume, rewarding providers, for example, on the basis of the number of tests run, patients seen, or procedures performed, regardless of whether these services helped (or harmed) the patient. GAO states that this shift in care delivery can require substantial investments by providers. For example, providers may need to invest in health IT to manage patients and record data necessary for quality and efficiency measurement and reporting. Providers may also need to hire additional staff to assist with population health management activities, such as care coordination. GAO’s Findings Based on its literature review and interviews with 38 stakeholders, GAO identified fourteen (14) challenges faced by small and rural physician practices when participating in Medicare’s new payment models. The value-based payment model is intended to reward health care providers for resource use and quality, rather than volume, of ser-
The complete report is available on GAO’s website at; http://www.gao.gov/assets/690/681541.pdf.
Examples of Challenges Faced by Small and Rural Physician Practices, by Key Topic Area Key topic area
Examples of challenges
1. Financial resources and risk management
1. Limited ability to take on financial risk because of having fewer financial resources/reserves compared with
2. Health IT and data
4. Difficulties with data system interoperability and limited ability to access data outside the practices’ own systems. 5. Difficulties with educating and training staff about EHR systems and the data entry, management, and analysis needed for participation.
larger providers.
2. High costs of initial and ongoing investments needed for participation. 3. Difficulties with recovering investments in a timely manner.
6. Patient preferences and geographic location affect practices’ ability to implement population health man3. Population health agement care delivery and account for total cost of care. management care delivery 7. Provider resistance to making adjustments needed for population health management care delivery. 4. Quality and efficiency performance measurement and reporting
8. Difficulties with receiving timely performance feedback. 9. Misalignment of quality measures between various value-based payment models and payers. 10. Performance measurement accuracy for practices with a small number of Medicare patients
5. Effects of model participation and managing compliance with requirements
11. Difficulties with maintaining practice independence. 12. Limited time of staff and physicians to complete administrative duties required for model participation. 13. Difficulties with understanding and managing compliance with the terms and conditions of waivers related to various fraud and abuse laws. 14. Difficulties with staying abreast of regulatory changes and managing compliance with multiple requirements of value-based payment models
Source: GAO analysis of literature and stakeholder interviews. | GAO-17-55 31
NEW MODELS AIM TO INCREASE PATIENT ENGAGEMENT IN CARE DECISION MAKING
T
he Centers for Medicare and Medicaid Innovation (CMMI) recently announced two new models that will test different approaches to shared decision making: The Shared Decision Making Model and the Direct Decision Support Model. The purpose of the two new models is to improve the quality of care for Medicare beneficiaries. This article discusses the goals of both models. Shared Decision Making Model Shared Decision Making is a process of communication, deliberation, and decision making that includes sharing information with the beneficiary that outlines treatment options, including harms, benefits, and alternatives; eliciting and supporting the beneficiary’s values and preferences; maintaining an interactive and meaningful dialogue based on the best medical evidence tailored to the beneficiary’s condition; and making an optimal decision that takes into account the evidence on options, practitioner/care team expertise, and the beneficiary’s values and preferences. The SDM Model will test the integration of a specific, structured Four Step process to shared decision making into routine clinical practice workflows of practitioners participating in Accountable Care Organizations (ACOs), resulting in informed and engaged beneficiaries who collaborate with their practitioners to make medical decisions that align with their values and preferences. The Model seeks to determine if this design results in improved beneficiary outcomes and lower Medicare spending while maintaining or improving quality, and whether it results in increased beneficiary satisfaction with care decisions. Beneficiaries who have one of the six preference-sensitive conditions will be offered an in-person collaborative process by their clinician that can help them understand and thoughtfully weigh their treatment options. These preference-sen32
sitive conditions include: stable ischemic heart disease, hip or knee osteoarthritis, herniated disk or spinal stenosis, clinically localized prostate cancer (cancer that is confined to the prostate gland), and benign prostate hyperplasia. For example, information provided will help the beneficiary decide whether surgery or other medical treatments are the right choice for them. The SDM Model stipulates the use of decision aids and a structured Four Step process to be applied at all participating ACO practices, and expects to engage over 150,000 Medicare beneficiaries annually. Direct Decision Support Model The DDS Model will test an approach to shared decision making provided outside of the doctor’s office, by Decision Support Organizations that provide health management and decision support services. For example, beneficiaries will be contacted by these organizations and provided access to a website or electronic application that provides them with unbiased and evidence-based information on their condition and/or treatment options. The beneficiary can then bring this information to their doctor’s office to enable them to consider their options with their clinician. This Model is designed to determine whether engaging beneficiaries outside the clinical care setting will enable them to become more informed, empowered and engaged health care consumers, and have a positive impact on their health care decision making. A major goal of the DDS Model is to encourage beneficiaries to have a greater role in their care by building and fostering the physician-patient relationship. It will use patient-friendly material to educate patients about their condition and encourage them to have a conversation with their practitioners about care options to determine what care is best for them. Providing information directly to patients about their health decisions acknowledges that patients make decisions about their medical conditions outside of,
Shared Decision Making Model The Shared Decision Making Model will test a specific approach to integrate a structured Four Step shared decision making process into the clinical practice of practitioners who are participating ACOs. The shared decision making process is a collaboration between the beneficiary and the practitioner. Direct Decision Support Model The Direct Decision Support Model will test an approach to shared decision making provided outside of the clinical delivery system by an organization that provides health management and decision support services. as well as inside, their doctor’s office. The model seeks to determine if this design results in reducing Medicare spending while maintaining or improving quality, and whether it results in increased beneficiary satisfaction with care decisions. The DDS Model uses organizations that are responsible for engaging an assigned population of Medicare fee-for-service beneficiaries in ongoing communications and medical decision support on behalf of CMS. These organizations may be commercial firms that already provide similar health information and decision support services to insured populations. Decision Support Organizations will not be health care providers or suppliers, will not engage in the practice of medicine, and will not interfere with the practitionerpatient relationship. They provide beneficiaries with reliable information that they can incorporate into discussions with their practitioners regarding health care decisions. The Model expects to reach 700,000 Medicare fee-for-service beneficiaries annually. An independent evaluation will be conducted separately for the SDM and DDS models with the goal of determining whether the model improves the quality of care without increasing spending; reduces spending without reducing quality AMRPA Magazine January 2017
of care; or improves quality of care and reduces spending. The evaluation will explore what aspects of the particular model contribute most to success and how contextual factors influence this success. To Participate Decision Support Organizations that are interested in participating in the DDS Model, and ACOs that are currently in the Medicare Shared Savings Program or Next Generation ACO Model and are interested in participating in the SDM Model must submit an electronic, non-binding Letter of Intent (LOI) for consideration for participation in the DDS and SDM Models, the first step of the application process. The LOI submission period began on December 8, 2016 and closes on March 5, 2017. More information is available on the BEI Models website at: https://innovation.cms. gov/initiatives/Beneficiary-Engagement/. For more information on the SDM model, see: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Factsheets-items/2016-12-08-2.html. For more information on the DDS model, see: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Factsheets-items/2016-12-08.html.
Leadership Forum and Congressional Fly-In
Medical Directors Symposium Rehab Administrators Workshop: How to Manage a Successful Rehab Unit
MARCH 20-22, 2017 WASHINGTON, DC www.amrpa.org
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OFFICE OF THE ACTUARY ISSUES REPORT ON 2015 NATIONAL HEALTH SPENDING
N
ational health care spending grew by 5.0 percent and overall health spending grew by 5.8 percent in 2015 primarily due to the result of increased use and intensity of services as millions gained health coverage under the Affordable Care Act (ACA). A second factor was significant growth in spending for retail prescription drugs according to results published in a recent report by the Office of the Actuary (OAC). In 2015, the federal government and households accounted for the largest shares of spending (29 percent and 28 percent respectively), followed by private businesses (20 percent), and state and local governments (17 percent). Health care spending grew 2.1 percentage points faster than the overall economy in 2015, resulting in a 0.4 percentage-point increase in the health spending share of gross domestic product (GDP) – from 17.4 percent in 2014 to 17.8 percent in 2015. Private Health Insurance Total per-enrollee private health insurance spending increased by 4.5 percent in 2015, compared to average growth in per-enrollee spending of 7.4 percent during 2000-2009. Overall, private health insurance expenditures (33 percent of total health care spending) reached $1.1 trillion in 2015, and increased 7.2 percent in 2015. The faster rate of growth reflected increased enrollment in private health insurance associated with coverage expansions under the ACA, and a notable increase in the enrollment in employersponsored plans. Those annual rates continue to be below the rates of most years prior to passage of the ACA. Over a twoyear period, 20.0 million individuals either gained private health insurance coverage or enrolled in the Medicaid program, primarily as the result of the ACA. The share of the population with health coverage increased from 86.0 percent in 2013 to 90.9 percent in 2015. 34
Medicare Spending Per-enrollee Medicare spending increased by 1.7 percent, about the same rate as in 2014. Medicare spending, which represented 20 percent of national total health care spending in 2015, grew 4.5 percent to $646.2 billion, slightly slower than the 4.8 percent growth in 2014. The 2015 rate of growth reflected mixed trends among services compared to 2014 as Medicare hospital spending growth slowed and nursing home and home health care spending grew faster. Medicaid Spending Overall Medicaid spending and enrollment grew at a slower rate in 2015 than in 2014 with per-enrollee Medicaid spending increasing 3.8 percent. Medicaid spending, which totaled $545.1 billion, accounted for 17 percent of total spending on health care. Also, growth in Medicaid enrollment slowed to 5.7 percent in 2015, significantly lower than the 2014 increase of 11.1 percent. Out of Pocket and Prescription Drug Spending The report found that out-of-pocket spending ($338.1 billion) grew 2.6 percent in 2015, compared to average annual growth in out-of-pocket spending during 2000 and 2009 of 4.6 percent. From 2008 through 2015, average annual growth of out-of-pocket spending was 1.9 percent, lower than the average annual growth in overall health spending of 4.3 percent during that same time period. As a result, the share of out-of-pocket spending of total health expenditures fell from 13 percent in 2007 to 11 percent in 2015.
Highlights •
•
•
Medicare spending grew 4.5 percent, slightly slower than the 4.8 percent growth in 2014. Medicaid spending accounted for 17 percent of total spending on health care. Prescription drug spending growth was faster than that of any other service in 2015.
in prescription drug spending was faster than that of any other service in 2015. Recent rapid growth was due to increased spending for new medicines, price growth in existing brand-name drugs, increased spending on generics, and a decrease in the number of expensive blockbuster drugs whose patents expired. Medicare prescription drug spending continued to grow by double digits with an 11.0 percent increase in 2015 following a 14.5 increase in 2014. The CMS Office of the Actuary’s report is available at: https://www.cms.gov/ Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
Spending on prescription drugs increased 9.0 percent in 2015, lower than the 12.4 percent growth in 2014, yet significantly higher when compared to 2.3 percent growth in 2013. Retail prescription drug spending continued to outpace overall health expenditure growth in 2015, increasing 9.0 percent to $324.6 billion after rising 12.4 percent in 2014. Growth AMRPA Magazine January 2017
EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE
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COMMITTEES Members are eligible to serve and participate on the Committees of the AMRPA Board of Directors and are invited to increase their involvement in shaping AMRPA’s Advocacy Agenda.
Members receive a subscription to the monthly AMRPA Magazine which reports on Medical Rehabilitation issues and trends including in-depth analysis of legislative, regulatory and operational issues affecting Medical Rehabilitation providers. ACTION ALERTS AMRPA issues Action Alerts to its Members which are specialized, timely electronic alerts and/or calls to action designed to mobilize national member responses to critical issues requiring Congressional action. ADVOCACY SUPPORT AMRPA promotes grassroots efforts among its Members on critical legislative issues. AMRPA counsel and staff are also available to provide support and assistance to members in grassroots efforts to educate members of Congress. MEMBERSHIP CALLS Members are invited to participate on AMRPA-sponsored “Membership Calls” which are held as needed and are designed to provide timely communications with members on emerging developments and issues affecting the field. SOCIAL MEDIA GROUP SITE on LINKEDIN AMRPA Members receive access to AMRPA’s social media group on LINKEDIN which is designed to provide information and opportunities for members to network with each other. ANNUAL FALL EDUCATIONAL CONFERENCE, LEADERSHIP FORUM, REGIONAL SEMINARS and WEB- BASED SEMINARS Educational sessions are held throughout the year and are designed to provide the latest intelligence, information and facts about “hot” issues impacting medical rehabilitation providers.
BOARD OF DIRECTORS Members are eligible to be nominated to serve on AMRPA’s Board of Directors. TOOLS AMRPA researches, develops and distributes specialized toolkits to support and assist members with key issues, such as the Medicare Appeals Process. STAFF AMRPA staff are available to facilitate access to information or expertise on a broad range of issues and business challenges. MEMBERSHIP SURVEYS Regular surveys of the membership are conducted on key issues of interest or concern as well as for assessing the overall level of satisfaction with AMRPA benefits and services. eRehabData® AMRPA sponsors the highly-acclaimed eRehabData® for use by the field, produces regular reports on data trends, distributes data analysis of national and regional trends in medical rehabilitation to all members and incorporates eRehabData trends and analysis in all AMRPA advocacy and educational initiatives. RESEARCH AMRPA promotes the funding of research to advance the field and to develop evidence-based practice and public policy through the ARA Research Institute.
AMRPA: Working Together To Preserve Access To Medical Rehabilitation · Maggie Ramirez · Vice President of Membership Services · 347-573-3732 · mramirez@amrpa.org
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STUDY FINDS HOSPITAL NUTRITION PROGRAM SHORTENS PATIENT STAYS AND REDUCES READMISSIONS
P
roper nutrition is critical for patients recovering in the hospital. A new study released by Advocate Health Care and Abbott has found that optimizing nutrition care in hospitals could help reduce 30-day readmission rates by 27 percent and the average hospital stay by almost two days for malnourished patients. The study entitled: “A Comprehensive Nutrition-focused Quality Improvement Program Reduces 30-day Readmissions and Length of Stay in Hospitalized Patients” was published online December 6 in the Journal of Parenteral and Enteral Nutrition, a multi-site, two-group, prepost study to evaluate two nutrition Quality Improvement Programs (QIP). To help improve care for malnourished patients, Advocate implemented two versions of a nutrition care program – basic and enhanced – at four of its Chicago hospitals. Two hospitals implemented a basic program (QIPb), which: •
•
Included screening patients for malnutrition using a validated tool and providing treatment (oral nutrition supplements) and nutrition support within 24-48 hours of admission; and Provided oral nutrition supplements and nutrition support within 24 hours through the hospitals’ electronic medical records, and added postdischarge support including instructions, coupons and follow-up phone calls to confirm patients continued taking their oral nutrition supplement.
Both programs required care teams to conduct patient malnutrition risk screenings using a validated tool on the hospitals’ electronic medical records system, and provide nutrition treatment and support for malnourished or at-risk patients. The enhanced program included more immediate treatment upon hospital admission and follow-up calls to confirm 36
their continued nutrition treatment after leaving the hospital. Study Methods Researchers at the four hospitals followed more than 1,200 adults at-risk of malnutrition during their stay to assess the impact of the nutrition programs on the patients’ chances of hospital readmissions, as well as their lengths of hospital stays. When compared to the hospitals’ previous readmission rates and lengths of stay for malnourished patients, researchers found that using either of the nutrition care programs had an impact, on average, of: •
•
Reducing the risk of patient readmissions from 22.1 percent to 16.1 percent (27 percent reduction); and Shortening the risk of a patient’s length of stay from 7.2 days to 5.4 days (25 percent reduction).
Study Findings Proper nutrition is critical for patients recovering in the hospital and the study confirms the need for hospitals: • • •
To use a validated nutrition screening tool at admission, Initiate early treatment for patients at-risk of malnutrition, and Provide nutrition education at discharge.
Finding •
The study builds on existing research that confirms that nutrition can be a simple, cost-effective tool and reduces readmissions.
unplanned readmissions, with a secondary outcome of hospital length of stay (LOS). A total of 1,269 participants aged 18+ at risk of malnutrition were enrolled between October 13, 2014 and April 2, 2015. The study was funded by Abbott, which had no role in data collection or analysis. For the announcement, please see: http://abbott.mediaroom.com/201612-06-Study-Hospital-Nutrition-ProgramShortens-Patient-Stays-and-ReducesReadmissions#assets_111. For the report, A Comprehensive Nutrition-Focused Quality Improvement Program Reduces 30-Day Readmissions and Length of Stay in Hospitalized Patients, please see: http://pen.sagepub.com/content/early/2016/12/05/0148607116681468.full. pdf+html.
The study found that as hospitals look for ways to improve patient care and reduce readmissions, it builds on existing research that confirms that nutrition can be a simple, cost-effective tool. While nutrition screenings are considered standard-of-care in the hospital, not all use a validated screening tool or implement treatment immediately if someone is considered at-risk. Moreover, when people leave the hospital, many times they do not receive education or follow-up to ensure they are following a nutrition plan to aid their recovery. The study’s primary outcome was 30-day AMRPA Magazine January 2017
CMS Transmittals of Interest for Medical Rehabilitation Providers
December 2016
Note: The Centers for Medicare and Medicaid Services (CMS) daily publishes official transmittals used for communicating reminder items, requests for action or information to fiscal intermediaries and carriers. In this section of the AMRPA Magazine, you will find specifically selected transmittals listed that would be of interest to medical rehabilitation providers. To view the entire list, please see: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2016-Transmittals.html. Subject
Implementation Date
Transmittal #
Issue Date
R3674CP
2016-12-09
January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0
2017-01-03
R230BP
2016-12-09
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Updates
2017-03-09
R3671CP
2016-12-05
CY 2017 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
2017-01-03
R3669CP
2016-12-02
HCPCS Code Update for Preventive Services
2017-01-03
R103GI
2016-12-02
Update to Medicare Deductible, Coinsurance and Premium Rates for 2017
2017-01-03
R3670CP
2016-12-01
Update to Editing of Therapy Services to Reflect Coding Changes
2017-04-03
R1704OTN
2016-11-25
Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015
2017-01-03
R3668CP
2016-11-25
Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2017
2017-01-03
R276FM
2016-11-25
New Physician Specialty Code for Hospitalist
2017-04-03
R3665CP
2016-11-23
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE
2017-04-03
R3663CP
2016-11-22
Common Edits and Enhancements Modules (CEM) Code Set Update
2017-04-03
R3661CP
2016-11-18
Claims Status Category and Claims Status Codes Update
2017-04-03
R3660CP
2016-11-18
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
2017-04-03
37
R1756OTN
2016-11-18
Analysis Only - Modification of Process for Handling the Provider Enrollment Chain Ownership System (PECOS) Extract File
2017-04-03
R1755OTN
2016-11-18
ICD-10 Coding Revisions to National Coverage Determination (NCDs)
2017-04-03
R1745OTN
2016-11-18
Common Working File and Fraud Prevention System 2.0 Predictive Modeling and Edits, Data Feed Migration
2017-01-03
R1757OTN
2016-11-18
Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare CostSharing
2017-03-08
R1753OTN
2016-11-17
Coding Revisions to National Coverage Determination (NCDs)
2017-01-03
124MCM
2016-11-10
Update of Chapter 1 of the Managed Care Manual
2016-11-10
R3654CP
2016-11-10
2017 Annual Update to the Therapy Code List
2017-01-03
R3655CP
2016-11-10
Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment System
2017-01-03
SE1629
2016-11-08
Guidance to Physician/Practitioner and Supplier Billing Offices that Submit Hard Copy Claims to Medicare to Help Reduce Incidence of Claims Not Crossing Over Due to Duplicate Diagnosis Codes and Diagnosis Code Pointers
R164SOMA
2016-11-04
Revisions to the State Operations Manual (SOM) Chapter 2
2016-11-04
R1746OTN
2016-11-04
Medicare Electronic Health Record (EHR) Incentive Program – Analysis of Meaningful Use Hospital Transition into Hospital Quality Reporting System
2017-04-03
R1747OTN
2016-11-04
Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare CostSharing
2017-03-08
R161DEMO
2016-11-04
Shared System Enhancement 2015: Archive/Remove Inactive Medicare Demonstration Projects
2017-04-03
R3644CP
2016-10-28
Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2017
2016-10-28
R1740OTN
2016-10-28
Shared System Enhancement 2015: National Coverage Determination (NCD) – Fiscal Intermediary Shared System (FISS) Implementation
2017-04-03
Updated as of December 15, 2016
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AMRPA Magazine January 2017
NEED HELP WITH MEDICARE AUDITS AND APPEALS? Powers Pyles Sutter & Verville has successfully assisted inpatient rehabilitation hospitals and units in thousands of coverage appeals resulting from payment denials by Recovery Audit Contractors, Medicare Administrative Contractors, Zone Program Integrity Contractors, and other Medicare auditors. The Powers team of experienced attorneys works with all provider types but specializes in IRF claims. We understand both the legal standards for IRF payment and the errors that auditors typically make when reviewing IRF claims. We can help you navigate through the fivelevel Medicare appeals process. Our services are tailored to the particular needs of each IRF and can include any of the following: • • • • • • • • • • •
Representing IRFs and other providers at all levels of administrative appeal Preparing witnesses for Administrative Law Judge hearings Developing audit and appeal strategies Creating customized appeal “templates” for IRF use Revising appeal documents prepared by the IRF Writing appeals and organizing exhibits Developing and implementing proactive compliance measures Advising on report and repay requirements Counseling on fraud, abuse, and overpayment allegations Appealing extrapolated denials Training medical staff on Medicare documentation requirements
Powers also represents IRFs in the federal courts on Medicare coverage matters. The firm has represented IRFs in the U.S. Courts of Appeals in challenges to RAC audit procedures and delays in Administrative Law Judge decisions.
FOR MORE INFORMATION, CONTACT: PETER THOMAS Peter.Thomas@PowersLaw.com 202-872-6730
Powers Pyles Sutter &Verville PC
RONALD CONNELLY Ron.Connelly@PowersLaw.com 202-872-6762
CHRISTINA HUGHES Christina.Hughes@PowersLaw.com 202-349-4248
@PowersPylesSutterAndVervillePC
@PowersLawFirm
Powers Pyles Sutter & Verville |1501 M Street NW | Seventh Floor | Washington, DC 20005 | (202) 466-6550 39
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AMRPA Magazine January 2017