AMRPA November Magazine

November 2018 • Vol. 21, No.11

16th Annual Educational Conference and Expo Wrap up

November 2018 • Vol. 21, No. 11

The official publication of the American Medical Rehabilitation Providers Association (AMRPA) Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation

Table of Contents Letter from the Chair

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Legislative Update

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Startling New OIG Report Issued on Medical Necessity and Documentation Errors in IRH/Us

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Common Quality Indicator Errors

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John Ferraro, MS AMRPA Executive Manager

CMS Reveals New BPCI-Advanced Participants

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Carolyn Zollar, MA, JD AMRPA Executive Vice President for Government Relations and Policy Development

MedPAC to Focus on Uniform Post-Acute Care Outcomes Measures

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AMRPA Holds 16th Annual Educational Conference in Boston

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Inspector General Raises Concern About Medicare Advantage Appeals and Oversight

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GAO Says Functional Status Data Could Improve Medicare Advantage Payment Accuracy

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Stroke Patients Treated at Teaching Hospitals Less Likely to Be Readmitted

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Neuropsychological and Functional Impairments are Associated with Increased Medicare Spending

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AHRQ Study Assesses Whether Instruments Used In Adult Lower Limb Amputees Were Valid

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Researchers Examine Whether Young Children with Mild Traumatic Brain Injuries Receive Needed Rehabilitation and Education Services

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CMS Revises Chapter 13 of the Medicare Program Integrity Manual

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Study Examines the Association Between Care Fragmentation in the Ambulatory Setting, ED Visits and Hospital Admissions

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Latest Research Findings

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Mimi Zhang AMRPA Senior Policy and Research Analyst Patricia Sullivan AMRPA Senior Editor Lovelyn Robinson AMRPA Researcher and Editor Brian McGowan AMRPA Design and Layout

AMRPA Magazine, Volume 21, Number 11 AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities.

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Advertising Contact: Samantha Schwarz, AMRPA, 529 14th St., NW, Washington, DC 20045 USA, Phone: +1-202-207-1132, Email: sschwarz@amrpa.org 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 Š2018

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 Kellen Company.

POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th St., NW, Suite 750, Washington, DC 20045

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AMRPA Magazine / November 2018

Letter from the Chair

16th Annual Educational Conference and Expo Wrap up From time to time I feel like my attention span is less than that of an ill-focused goldfish, but recently I was transfixed by the lectures at our 16th Annual Educational Conference and Expo in Boston. The plenary sessions were diverse and packed with relevant information on operational and clinical issues and current and future challenges and opportunities for our field. Kent Riddle, chair of AMRPA’s Education Committee, members of the committee, and our association staff created a rich environment for networking and learning. Congratulations and thank you to the great work of the committee which resulted in a most successful event.

Richard Kathrins, PhD, President & CEO, Bacharach Institute for Rehabilitation RKathrins@bacharach.org

The conference was among the most well-attended events that AMRPA has ever held!

Participants represented a varied group of rehabilitation clinicians and administrative staff. The program also offered a pre-workshop called the IRF Boot Camp. More than 90 attendees of the pre-workshop learned about key regulations governing our industry and gained knowledge about operational programming.

Roseann Sdoia, a Boston Marathon bombing survivor, gave an inspirational presentation.

Her story recounted her loss and recovery and kept the audience mesmerized. It was a poignant reminder of the value of the care we provide. Dr. John L. Melvin received the inaugural Edward A. Eckenhoff Memorial Award. His lecture provided us with great insights into lessons learned from the past. Those lessons included the increasing need for acute rehabilitation services, continued need for caring for those who require complex rehabilitation, and the value of AMRPA’s advocacy in Washington, DC. AMRPA also presented two Leadership Excellence Awards to individuals who have exemplified outstanding service and made significant contributions to the field of medical rehabilitation. This year’s recipients have certainly demonstrated leadership, integrity, vision and dedication to the field. The first award was given to Dr. William Restum, who has been CEO of the Rehabilitation Institute of Michigan since 2008. He has also served as the National Rehabilitation Leader for Tenet Health for the last few years. The second award was given to Lex Friedan, who is known nationally as a leader in disability rights. He currently serves as Director of the Independent Living Research Utilization Program at TIRR Memorial Hermann in Houston. From 1984 to 1988, Mr. Frieden served as Executive Director of the National Council on the Handicapped (now the National Council on Disability). In this capacity, he was instrumental in drafting the Americans with Disabilities Act. Congratulations to all our award recipients.

As always, the AMRPA Educational Conference and Expo provided our members with an excellent opportunity to learn and, share their knowledge and experience with others. We hope to see you at our next conference, the 2019 Spring Leadership Forum and Congressional Fly-In being held March 10-12, 2019, in Alexandria, Virginia. One of the strengths of our association is our willingness to come together to fight for patient access to our services. Your voice is needed and there is no one more suited to tell your story and those of your patients. I look forward to seeing you next spring when we come together in Washington to meet with congressional staff and learn the latest regulatory and legislative news.

AMRPA Magazine / November 2018

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Patient Throughput Management

Regulatory Compliance

8/21/18 11:10 AM

11:10 AM

Legislative Update

Martha M. Kendrick, Esq., Partner, Akin Gump Strauss Hauer & Feld LLP

Highlights: »»

An HHS OIG report released that addresses coverage and documentation requirements of IRF stays estimates that $5.7 billion of Medicare payments to IRH/ Us in 2013 were not medically necessary or reasonable.

»»

As MedPAC continues to develop recommendations on a post-acute care payment system, RTI, contracted by the Centers for Medicare and Medicaid Services (CMS), held its first Technical Expert Panel with stakeholders, including AMRPA, to gather information on developing a PAC unified payment system prototype.

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Before lawmakers returned to their states and districts to campaign for midterm elections, they successfully passed a Labor-HHS and Defense funding package that included a continuing resolution to keep the government running until December 7.

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Depending on the outcome of the midterm elections, a lame duck congressional session will look to finalize FY 2019 spending.

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Congress also managed to pass bipartisan opioid legislation which the president plans to sign into law.

OIG Report Worrisome to Future of IRFs On September 27, 2018, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements.

OIG explains that it conducted the review due to prior evaluations that found that some hospitals did not comply with Medicare coverage and documentation requirements for inpatient rehabilitation facilities (IRFs). Additionally, the Centers for Medicare and Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) program found that the error rate for IRFs increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. OIG then set out to determine whether IRFs complied with Medicare coverage and documentation requirements for fee-for-service (FFS) claims for services provided in 2013, auditing $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays.

OIG’s audit concluded that Medicare paid IRFs nationwide an estimated $5.7 billion for care to beneficiaries that was not reasonable and necessary. OIG made several recommendations to CMS that include improved education of IRF clinical and billing personnel on Medicare’s coverage and documentation requirements; post-payment medical review as a way to increase oversight; fair representation for IRFs at ALJ hearings, and a demonstration project that tests preauthorization for Medicare Part A FFS IRF modeled on Medicare Advantage practices. CMS concurs with OIG’s recommendations. AMRPA was aware of the development of this report and is requesting that AMRPA members decipher whether one of their hospitals was audited as part of this report. AMRPA has serious concerns about OIG’s assumptions, process and outcomes of this report. In response to a request from Bloomberg News to comment on the report, AMRPA Board Chair Richard Kathrins said that AMRPA has “grave reservations about the assumptions, process and supposed outcomes of this report. We all want to give Medicare beneficiaries—our patients—only appropriate care to achieve the best outcomes.”

RTI/CMS Hosts First Technical Expert Panel on PAC PPS On Monday, September 24, 2018, RTI International, along with the Centers for Medicare and Medicaid Services (CMS), held a technical expert panel (TEP) on developing a unified post-acute care payment system, as required by the IMPACT Act. RTI explained that CMS (and RTI) are interested in hearing from stakeholders on their “foundational questions” to help determine the path forward on developing a “technical prototype” for a post-acute care prospective payment system (PAC PPS), including exploratory options for a unified PAC PPS, defining costs, using claims and assessment data to predict cost, and ensuring quality of care and beneficiary choice. After several sessions focused on a variety of PAC PPS factors, consensus emerged from the stakeholder group that it supports moving to a more long-term perspective sooner in RTI’s analysis.

There is a possibility of multi-setting PAC providers, and with an understanding of

AMRPA Magazine / November 2018

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differences fixed costs/setting-specific costs could decrease at least for institutional settings driven by beneficiary characteristics.

Stakeholders mostly agreed it would be challenging to accommodate simply using beneficiary characteristics alone.

Participants also noted that it is important for RTI to understand post-acute vs. community-based care, and RTI needs to think about how to bring those services into its modeling. RTI should also consider exploring which data are viable, including cognitive items (frailty and relationship with function), and prior acute settings (which may be difficult to obtain). Additionally, RTI needs to navigate the challenges of data quality and should consider how to test things in smaller markets or by condition. RTI confirmed this process will take 12 to 18 months and that this TEP was the first of several gatherings.

the midterm elections on November 6, and then has only four weeks to pass additional spending bills to avoid a December government shutdown.

MedPAC Members Discuss Episode-Based PAC PPS On October 5, the Medicare Payment Advisory Commission (MedPAC) held a public meeting session titled, “Episode-based payments and outcome measures under a unified payment system for post-acute care.” Staff presented on the commission’s planned work on an episode-based post-acute care prospective payment system (PAC PPS) design and developing work on unified outcome measures. Staff discussed several advantages of an episode-based design, stating that it would encourage an efficient mix of PAC and reduce the number of care transitions.

The commissioners were broadly supportive of this approach.

Several members voiced concern about a proposed “discharge to community” measure, noting that home may not be the safest place for a beneficiary who lacks certain supports. MedPAC staff plan to report the results of their study of an episode-based PAC PPS in March.

Bipartisan Opioid Legislation to Become Law Following months of negotiations, House and Senate lawmakers on September 25 released the text of a compromise opioid package (H.R. 6). The House approved the conference agreement on September 28, and the Senate passed the bill on October 3.

As we go to print, President Trump has indicated he will sign the measure into law.

Government Shutdown Avoided…until December Lawmakers avoided a government shutdown at the end of September after President Trump signed into law a Fiscal Year (FY) 2019 spending package that includes a Continuing Resolution (CR) to keep many federal agencies funded through December 7. H.R. 6157 also includes full-year funding for the Department of Health and Human Services (HHS) and the Department of Defense. This is a major victory for Congress, marking the first time the Labor-HHS-Education Appropriations bill has been enacted on time since 1996.

The $178 billion Labor-HHS bill includes a $2 billion funding increase for the National Institutes of Health (NIH) and provides $3.8 billion to combat the opioid crisis – an increase of $206 million over last year. This includes $1.5 billion for the State Opioid Response Grants, along with a 15-percent set aside for the states most affected by the opioid epidemic. Notably, the final package does not include a House provision calling for the disclosure of drug price information in direct-to-consumer advertising. Negotiators also stripped out controversial House provisions to defund Planned Parenthood.

This year’s unusually bipartisan Appropriations process also saw the president sign into law H.R. 5895, which provides full FY 2019 funding for the Department of Energy, the Department of Veterans Affairs (VA), and the Legislative Branch. All told, Congress approved three-fourths of annual discretionary funding on time. Congress will return to several funding fights after 6

AMRPA Magazine / November 2018

If the House flips to Democratic control, heightened partisan tensions could complicate already fractious negotiations over issues such as border wall funding and environmental policy. With Defense and VA spending already off the table, it may be difficult for Republican leaders to shore up conservatives’ support for a government funding deal. Finally, it remains to be seen whether President Trump will be willing to shut down the government if Congress does not deliver additional funds for a U.S.-Mexico border wall. The president said last week that he will decide after the elections “as to whether or not we go for it."

The package authorizes new funding and resources for health care providers and includes policies to improve substance use disorder prevention, treatment and recovery. One major proposal would partially repeal the decades-old Institutions for Mental Disease (IMD) exclusion, which prohibits the use of federal Medicaid dollars for residential care at facilities with more than 16 beds. The limited repeal included in the bill would apply only to substance use disorder treatment and would expire after five years. The bill also includes provisions to crack down on the shipment of illicit drugs through the international mail and promote the development of non-opioid pain therapies.

Notably, the final bill does not include changes to 42 CFR Part 2 regulations regarding the confidentiality of substance use disorder patient records. Provisions to ease sharing of such records by aligning Part 2 rules with HIPAA were included in the House’s legislative effort on opioids, but did not make it into the Senate’s legislation. The final bill does include Jessie’s Law, which would require HHS to develop best practices to help providers access substance use disorder treatment information through electronic health records for consenting patients.

Brand name drug manufacturers were unable to secure inclusion of language to reduce their share of financial liability for beneficiaries in the Medicare Part D coverage gap, also known as the “donut hole.” A provision that increased manufacturers’ share from 50 percent to 70 percent was included in the Bipartisan Budget Act of 2018.

Drug Pricing Legislation Signed into Law The House on September 25 passed two bills to restrict the use of pharmacy “gag clauses.” S.2553, the Know the Lowest Price Act, would prohibit Medicare Part D or Medicare Advantage plans from restricting the ability of a pharmacy to inform patients when they could save money by paying without using insurance.

S. 2554, the Patient Right to Know Drug Prices Act, would bar such clauses for private plans. Both bills were previously

approved by the Senate, and President Trump signed the measures into law on October 10. A proposal to restrict gag clauses was included in the president’s drug pricing blueprint.

CMS Proposed Regulations to Promote Program Efficiency CMS on September 17 released a proposed rule to reduce the regulatory burden on health care providers by removing “unnecessary, obsolete or excessively burdensome” Medicare regulations. CMS proposes changes to requirements for a range of providers, including hospitals, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Critical Access Hospitals (CAHs), Rural Health Centers (RHCs), Federally Qualified Health Centers (FQHCs), ambulatory surgical centers (ASCs), hospices, and home health agencies (HHAs). Under the proposed rule, CMS would amend the utilization review plan requirements for CORFs by reducing the frequency of utilization reviews from four times a year to once a year. This would allow an entire year to collect and analyze data to inform changes to the facility and the services provided. Changing the requirement from a quarterly to an annual review would not preclude the CORF from implementing their utilization review plan more frequently, if required by facility policy. CMS also requests public comments on additional proposals or modifications to the proposals set forth in this rule that would further reduce burden on CORFs and create cost savings, while also preserving quality of care and patient health and safety. Further, multi-hospital systems would be allowed to have a unified and integrated Quality Assessment and Performance Improvement (QAPI) program, and a unified and integrated infection control program. The rule also proposes flexibilities around emergency preparedness requirements for health care facilities. Comments are due to CMS by November 19, 2018.

CMS Makes Next Move to Restart Home Health Pre-Claim Review Demonstration On September 27, CMS issued a second Paperwork Reduction Act (PRA) notice for a 30-day public comment period for the Home Health Pre-Claim Review Demonstration, now known as the Review Choice Demonstration (RCD). This notice proposes initially implementing the demonstration in Illinois on December 10, 2018. Back in May 2018, CMS released a request for public comments on a new pre-claim review demonstration for home health services to support the goal of reducing improper payments and lowering Medicare appeal rates.

HHAs could participate in either 100 percent pre-claim review or 100 percent post-payment review. CMS proposes to impose a 25 percent payment reduction on home health agencies that choose not to participate in the “voluntary” claims review demonstration.

Participating providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate. Once a HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, the provider may choose to be relieved from claim reviews, except for possible check-ins to ensure continued compliance. CMS still intends to launch the demonstration in IL, OH, NC, FL and TX with the option to expand to other States in the Palmetto/JM jurisdiction. A similar program was implemented in Illinois in 2016 but proved to do little to improve the identification of fraudulent claims and ultimately was halted by CMS due to administrative complexities.

The midterm elections are finally here and the results will help us strategize for the new Congressional session that will commence in 2019. If Democrats successfully take control of the House (Senate is less likely to flip), expect Republicans to pursue a conservative package of bills before they concede the Speaker’s gavel, which could include: repeal of the ACA’s employer mandate or further delay of other ACA taxes (e.g., medical device and/or Cadillac taxes); tax reform “2.0”; tax extenders; drug pricing and transparency legislation; supplemental disaster funding; and other lower-tier Medicare and health bills. If Republicans maintain their majority in the House and Senate, expect them to continue working on their “to do” list.

Regardless, AMRPA members should be ready to take action in these final weeks of 2018. Lame Duck sessions in Congress can be wild and unexpected legislation considered. With recent release of an unflattering OIG report, AMRPA rehab hospitals must take this time to educate Congressional Representatives about how critically important and medically necessary rehabilitative care is for its patients. Please cultivate additional Congressional champions for the field!

AMRPA Magazine / November 2018

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Startling New OIG Report Issued on Medical Necessity and Documentation Errors in IRH/Us

Peter W. Thomas, Principal, and Ronald S. Connelly, Principal, The Powers Law Firm

On September 27, 2018, the Office of Inspector General for the Department of Health and Human Services (OIG) issued a new report on inpatient rehabilitation hospital and unit (IRH/U) services. The report’s title, “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements,” only scratches the surface for the findings in the report. Under the report’s audit of 2013 IRH/U claims, the OIG calculates an error rate of 84 percent. This translates to an estimated $5.7 billion in claims inappropriately paid under the Medicare program out of $6.8 billion paid to IRH/U providers in calendar year 2013. This article will summarize the central findings and recommendations of the report. The full report can be read at https://oig.hhs.gov/ oas/reports/region1/11500500.pdf.

To be sure, AMRPA has developed a robust, multi-prong response to this critical report that will be implemented over the coming weeks and months.

Background Due to steadily increasing rates of payment error as identified by the Comprehensive Error Rate Testing (CERT) contractor, the OIG undertook an audit of 2013 IRH/U claims.1 In 2013, the Medicare program made payment on claims from 1,139 IRH/Us, totaling $6.75 billion. Under the audit, 164 IRH/Us were selected, and 220 claims were sampled.

The OIG hired an independent medical review contractor to handle the audit, but the name and credentials of the contractor were not included in the report. Of those 220 claims, 175 claims were determined by the contractor to be paid in error, representing 135 out of the 164 audited hospitals. Applying this error rate (84 percent) to the overall IRH/U payments in 2013, the OIG arrived at the $5.7 billion overpayment figure.

The audit was constructed as a stratified random sample. The strata were based on the dollar value of the claims. The sample included a much higher proportion of high-value claims than lower value claims. However, the lower value claim strata actually had higher error rates that the higher value strata.

Detailed Findings Of the 175 claims determined to be inappropriately paid, the contractor found 146 admissions failed on both coverage (i.e., medical necessity) and documentation grounds; an additional 29 stays were determined to be inappropriate solely on the grounds of missing documentation. For the stays denied on the grounds of medical necessity, the OIG summarized the reasons for denial as follows:

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AMRPA Magazine / November 2018

Patients did not have medical needs and functional goals that required the complexity and intensity of inpatient rehabilitation; Appropriate care would have required only individual therapy interventions rather than an intense interdisciplinary program with rehabilitation physician supervision; The high level of physician supervision that accompanies acute intensive rehabilitation therapy services would not have been required; The patients did not require interdisciplinary rehabilitation or the intensity of an acute-level rehabilitation program; and The patients were unable to participate in an intensive therapy program regardless of medical and rehabilitation needs.

As can be seen from the reasons set forth above, there are some contradictions in the reasons given for denial (i.e., patient did not require physician supervision but was nevertheless too impaired to participate in intensive therapy). The OIG failed to explain the contradictory rationale for denials. It is likely that the report was not written precisely and that the different rationales applied to different patients, but that is not clear from the language of the report.

For the claims determined to be inappropriate on the grounds of documentation (including those otherwise denied on medical necessity grounds), 28 had a single documentation deficiency and 147 had more than one documentation deficiency.

Specifically: 101 claims lacked a complete preadmission screening; 62 claims lacked a valid post-admission physician evaluation; 166 claims lacked a complete individualized plan of care; and 106 stays had deficient documentation of the required weekly team meetings.

In determining whether documentation requirements were met, the contractor used not only the regulations but also the guidance from the Medicare Benefit Policy Manual (MBPM), applying the standards from the manual as binding requirements.

This practice is under serious scrutiny because the MBPM was not subjected to public notice and comment rulemaking and, therefore, may not have the full force and effect of regulations.

For instance, in 33 stays, the contractor determined that the preadmission screening was invalid because it did not detail the conditions causing the need for intensive rehabilitation, the patient’s prior or current level of function, and the risk of clinical complications—all elements that are set forth in the manual but not the regulations. Interestingly, for the 29 claims determined to be inappropriate solely on the basis of documentation errors, 20 of the claims had identified deficiencies in the individualized plan of care, which is arguably the most fluid of the required documents under the regulations, relying almost entirely on manual guidance for details on its completion.

// Of the 175 claims determined to be inappropriately paid, the contractor found 146 admissions failed on both coverage (i.e., medical necessity) and documentation grounds; an additional 29 stays were determined to be inappropriate solely on the grounds of missing documentation.

Another notable facet of the audit involves the types of patients reviewed. In describing the types of patients reviewed and determined to be inappropriate for IRH/U admission, the report indicates that 56 stays involved patients with a diagnosis of debility (i.e., generalized weakness, overall fatigue and impaired mobility). Furthermore, the report indicates that the appropriate therapy would consist only of “regular activities.” Many of the other patients reviewed were orthopedic in nature (48 stays), and 73 claims were described as having no “new” impairing events.

These statements in the report suggest a lack of understanding of IRH/U patient care and the needs of this patient population.

The OIG’s Conclusions and Recommendations According to the OIG, the reasons for the high rate of payment error were as follows: 1. Many IRH/Us did not have adequate internal controls to prevent inappropriate admissions; 2. The Medicare Part A fee-for-service program lacked a prepayment review authority for IRH/U admissions; 3. The Medicare program’s extensive educational efforts and post-payment reviews were unable to control an increasing improper payment rate reported by the CERT since the 2013 audit period; 4. Administrative law judge (ALJ) hearings for IRH/U appeals did not always involve contractor participation to ensure that Medicare coverage and documentation requirements were accurately interpreted; and, 5. The IRH/U payment system did not align cost with payments, which may have provided IRH/Us with a financial incentive to admit patients inappropriately.

The first, second and third reasons posited by the OIG were based on the results of the audit and other elements of the Medicare program (e.g., prior authorization). The fourth echoes

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back to a prior OIG report issued in 2012, in which the OIG concluded that the high reversal rate at the ALJ appeal level was due to failures by ALJs to understand the coverage standards rather than the possibility that contractors were inappropriately denying claims and more objective ALJs were siding with providers on the merits. The OIG concluded at the time that IRH/ Us may be inappropriately incentivized to appeal denied claims as a result.

The final rationale listed by the OIG also suggests that financial incentives are driving IRH/U utilization. In positing that IRH/ Us may be admitting patients inappropriately due to financial incentives, the OIG implies that IRH/Us know that certain patients are not appropriate for admission but admit them anyway. This implication actually raises concerns about fraud and abuse, not simple payment error, and is one of the many reasons a strong response from AMRPA is necessary.

As a result, the OIG makes a number of suggestions, including: 1. Educate IRF clinical and billing personnel on Medicare coverage and documentation requirements and work with providers to develop best practices to improve internal controls; 2. Increase oversight activities for IRFs, such as post-payment medical review; 3. Work with the Office of Medicare Hearings and Appeals to ensure that Medicare coverage and documentation requirements for IRF care are fairly represented at ALJ hearings; and, 4. Re-evaluate the IRF payment system, which could include a demonstration project requiring preauthorization for Medicare Part A FFS IRF stays modeled on Medicare Advantage practices, a study of the relationship between IRF PPS payments and costs and take any necessary steps to more closely align them, and a consideration of the high error rate found in this report and CERT reviews in future acute inpatient rehabilitation service payment reform.

In its written comments to the OIG draft, CMS concurred with all of these recommendations and stated its commitment to implementing them, particularly with respect to provider education and audits. The recommendation to conduct a demonstration project on preauthorization akin to the Medicare Advantage program sends directly conflicting signals to CMS. OIG just recently issued a report highly critical of Medicare Advantage plans that significantly restrict benefits to beneficiaries through the use of preauthorization.

This OIG report is obviously a highly concerning development, but it is unsurprising that the OIG chose to focus on inpatient rehabilitation services. Not only have these services been under scrutiny for years, but they constitute relatively high dollar claims as well. AMRPA is committed to issuing an aggressive response to the audit report and is implementing a full action plan to pro-actively address any potential repercussions from the report. These repercussions may come in the form of a new surge in IRH/U audits, particularly in light of recent CMS approval for the Recovery Audit Contractors (RACs) to once again audit IRH/U claims nationwide. There may also be implications on the IMPACT Act timeline to implement a post-acute care uniform payment system.

END NOTE 1. For 2012, the CERT reported an error rate of nine percent for IRH/U payments.

The CERT-reported error rate for IRH/Us increased to 17.2 percent in 2013, 20.7 percent in 2014, 45.5 percent in 2015; and 62.4 percent in 2016.

Peter W. Thomas is counsel to AMRPA and a Principal with the Powers law firm. Christina A. Hughes, J.D., MPH, is counsel to the Powers law firm in Washington, D.C.

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AMRPA Magazine / November 2018 11 10/3/18 2:47 PM

Common Quality Indicator Errors

Significant changes to IRF-PAI discharges will begin on October 1, 2020. Functional items from the IRF QRP will replace the FIM™ as the basis for case mix groups (CMGs).

To accommodate this new approach, we will soon start preparing for changes to the electronic medical record. Next, we will think about how to train staff on the many nuances of scoring. It is the perfect time to review some of the common errors that I notice in my chart audits for clients.

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.

One area that people seem to have trouble with is how to code cases for patients who arrived and left on the same day without being fully assessed. The items on the Cognition tab in eRehabData® must be completed upon admission, but it is not possible to select code “88” to reflect an inability to test items due to medical illness.

It is important that staff know to complete the Brief Interview of Mental Status (BIMS) as close to the time of admission as possible. If the patient is unable to complete the assessment because they are found to be unable to complete the BIMS, consider defaulting to the Staff Assessment for Mental Status instead. This information may be obtained from other sections of the record, which, hopefully, staff have had the opportunity to document. Note that in eRehabData®, when answering “No” to question C0100 about whether the BIMS should be conducted, you must then skip directly to the C0900 questions. You do not answer C0600, which asks whether or not the Staff Assessment for Mental Status should be conducted. If you indicate that a patient is able to complete the BIMS, then answers to the BIMS questions are required in order to complete the IRF-PAI. If you have no answers, the result will be an incomplete IRF-PAI that will be counted toward the 5 percent threshold for the 2 percent payment reduction.

For the Function items, I have seen misuse of the code “9-Not applicable” in many records. Remember that the use of “9” indicates that the patient did not complete the activity prior to admission and is not expected to complete the activity following discharge. In the case of a patient who is unable to complete the stairs assessments now, but climbed stairs at home prior to this hospitalization, “9” is not the appropriate code to use to indicate that stairs were not tested. One exception to this rule is car transfers. However, in the event that you are unable to assess a car transfer because you do not have a car simulator and are unable to use another car, CMS has provided guidance to use a “9”.

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It appears that there is confusion about when the wheelchair items should be assessed. If your patient is assigned a wheelchair because you do not believe it is safe for them to ambulate within the rehabilitation hospital or unit, code the wheelchair items. Often the question of whether or not the patient uses a wheelchair is coded “no” so the remaining items are not reported. However, if your patient is in a wheelchair because it is unsafe for them to ambulate around the hospital as they wish, code the wheelchair items. CMS addressed a question about coding the wheelchair items and indicated that if the wheelchair is only used for transportation, the items can be skipped. Based on my observation, more often than not, the reason for the wheelchair includes transportation and more. If you ask the PT if they would take the wheelchair from the patient and only bring it back when the patient required transport and they answered no, then the wheelchair items should be assessed. Consider these items as data collection questions rather than having anything to do with your treatment plan and goals.

Therapists have been responsible for assessing section GG items since their introduction. This was intended to ensure completion and reduce burden. However, it has resulted in an IRF-PAI that may reflect different levels of assistance between the FIM and quality indicator items. While minor discrepancies should be expected because of the way scores are derived, I have concerns over vast differences. If we are trying to obtain and report the patient’s level before therapeutic intervention, then the nurses inputting data in areas such as transfers and toileting would do a better job communicating baseline performance than even the therapists might. Review your outcomes reports in eRehabData® to see if this is the case in your hospital or unit. As we begin to think toward the future, in order to capture the correct burden of care and CMG you will need to add the self care and mobility items to the nurse’s admission assessment. It is in your best interest to send data to CMS that truly reflects the burden of care at baseline as this is one of the best indicators of what makes the inpatient rehabilitation level of care unique.

Also remember to complete the ambulation and stairs assessments consecutively. First test one step, then four steps, and finally 12 steps. Because each assessment includes going up and down, they should be tested individually.

It is never too soon to begin educating staff on the quality indicators to ensure that they know the difference between FIM™ scoring and quality indicator scoring. You should also plan for any necessary changes to the EMR that need to be made in order to include nurses in the section GG scoring initiative. We have included many qualitative comments to our FIM documentation to ensure that staff considers all of the scoring nuances. Spend time reviewing your documentation for enhancements that will help staff select the correct section GG answers as well.

When assigning a code for the footwear item, do not forget to factor in the amount of assistance required with compression stockings. This differs from FIMTM assessments so it should be reviewed with therapy staff. The same is true for upper body orthotics like a thoracolumbosacral orthosis (TLSO) brace.

Consider the amount of help required to apply the brace in the upper body dressing item.

CMS has noted that they consider a patient discharging emergently as an incomplete stay. You may code the mobility items with code “88” if they were not assessed during the discharge window.

You have a year to prepare for the change. CMS has indicated that it will continue with ongoing education for providers. Make sure you take advantage of as much education as possible. Get ready, but do not take your eye off of the FIM™ ball just yet.

AMRPA Magazine / November 2018 13

CMS Reveals New BPCI-Advanced Participants

Carolyn C. Zollar, MA, JD, Executive Vice President for Government Relations and Policy Development

Highlights: »»

New BPCI Advanced includes 832 hospitals; some are AMRPA members.

»»

The majority of episodes focus on major joint replacement of the lower extremity, congestive heart failure, and sepsis.

On October 9, 2018, the Centers for Medicare and Medicaid Services (CMS) announced the participants in its new bundling program initiative, the Bundled Payment for Care Improvement-Advanced (BPCI-Advanced) program. The BPCI-Advanced Model was announced in January 2018, and it builds on the initial Bundled Payments for Care Improvement (BPCI) Initiative, which ended on September 30, 2018. The first round of the BPCI-Advanced Model will run from October 1, 2018, through December 31, 2021. The participants will receive bundled payments for specific episodes of care as an alternative to fee-forservice payments as CMS seeks to continue moving away from volume-driven payment.

// According to CMS, BPCI-Advanced participants include 832 acute care hospitals and 715 physician group practices for a total of 1,547 Medicare providers and suppliers, located in 49 states plus Washington, DC, and Puerto Rico.

According to CMS, BPCI-Advanced participants include 832 acute care hospitals and 715 physician group practices for a total of 1,547 Medicare providers and suppliers, located in 49 states plus Washington, DC, and Puerto Rico. By CMS’ design, BPCI-Advanced qualifies as an Advanced Alternative Payment Model (Advanced APM) under the Medicare Access and CHIP Reauthorization Act (MACRA), so participating providers can be exempted from the reporting requirements associated with the Merit-Based Incentive Payment System (MIPS).

CMS received numerous applications including potential partnering of acute and postacute care (PAC) hospitals. Applicants received a tremendous amount of data from CMS about health care expenditures in its area, which in and of itself was extremely informative. AMRPA spoke with several members who, after examining the program parameters and their data, decided not to participate.

Under the BPCI-Advanced episode payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are less than a spending target, which factors in measures of quality. However, if the expenditures exceed the

14 AMRPA Magazine / November 2018

target price, the participant must repay money to Medicare.

Hence it is a type of double sided risk model which CMS recently proposed be expanded in the Medicare Shared Savings ACO program.

A BPCI-Advanced participant is defined as an entity that enters into a Participation Agreement with CMS to participate in the model. Participants include conveners and non-conveners. Acute care hospitals (ACHs) and Physician Group Practices (PGPs) could participate as non-conveners. A Convener Participant brings together multiple downstream entities, referred to as Episode Initiators (EIs), facilitates coordination among its EIs, and bears and apportions financial risk under the Model. A Non-Convener Participant is a participant that is in itself an EI and does not bear risk on behalf of multiple downstream Episode Initiators.

Some differences between the BPCI initiative and the new BPCIAdvanced model are: The Advanced model is initiated by an acute care or outpatient procedure only. In contrast, the original BPCI included Model 3, which was initiated at admission to a postacute care provider.

BPCI-Advanced offers bundled payments for additional clinical episodes beyond those that were included in BPCI, including for the first-time outpatient episodes.

BPCI-Advanced provides participants with preliminary target prices before the start of each model year to allow for more effective planning. The target prices are the amount CMS will pay for episodes of care under the model.

Clinical episodes in BPCI-Advanced are all set at 90 days. The original BPCI allowed providers to choose between 30-, 60or 90-day episodes.

BPCI-Advanced qualifies as an Advanced APM. Participating clinicians assume risk for patients’ health care costs and also meet other requirements including meeting quality thresholds, potentially qualifying them for incentive payments and exempting them from the MIPS program.

BPCI-Advanced will initially include 32 bundled clinical episodes: 29 inpatient and three outpatient. Currently, the top three clinical episodes selected by the participants are major joint replacement of the lower extremity, congestive heart failure and sepsis.

When CMS originally announced the BPCI-Advanced program it stated that it would be defined by the following characteristics: Voluntary model A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode duration 29 inpatient clinical episodes 3 outpatient clinical episodes Qualifies as an Advanced APM Payment is tied to performance on quality measures Preliminary Target Prices provided in advance of the first performance period of each model year

Interested participants could select from 29 clinical episodes: Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis (New episode added to BPCI Advanced) Acute myocardial infarction Back and neck except spinal fusion Cardiac arrhythmia Cardiac defibrillator Cardiac valve Cellulitis Cervical spinal fusion COPD, bronchitis, asthma Combined anterior posterior spinal fusion Congestive heart failure Coronary artery bypass graft Double joint replacement of the lower extremity Fractures of the femur and hip or pelvis Gastrointestinal hemorrhage Gastrointestinal obstruction Hip and femur procedures except major joint Lower extremity/humerus procedure except hip, foot, femur Major bowel procedure Major joint replacement of the lower extremity Major joint replacement of the upper extremity Pacemaker Percutaneous coronary intervention Renal failure Sepsis Simple pneumonia and respiratory infections Spinal fusion (non-cervical) Stroke Urinary tract infection The three outpatient clinical episodes in the model are: Percutaneous coronary intervention (PCI) Cardiac defibrillator Back and neck except spinal fusion CMS also selected seven quality measures for the BPCI-Advanced Model. Two of them, All-cause Hospital Readmission Measure and Advance Care Plan, will be required for all clinical episodes.

The other five quality measures will only apply to select clinical episodes: All-cause Hospital Readmission Measure (NQF #1789) Advanced Care Plan (NQF #0326) Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/ or Total Knee Arthroplasty (TKA) (NQF #1550) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558) Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881) AHRQ Patient Safety Indicators (PSI 90) AMRPA filed an extensive comment letter on the initial proposal.

AMRPA Magazine / November 2018 15

Among other concerns, AMRPA and others in the rehabilitation community expressed serious concern that BPCI-Advanced does not include a post-acute care-only model and that the list of quality measures does not include any functional status measures.

Resources For more information about the BPCI-Advanced Model, visit: https://innovation.cms.gov/initiatives/bpci-advanced

for Models 2-4 of the original BPCI Initiative. To view the report, use this link: https://innovation.cms.gov/Files/reports/bpci-models2-4yr5evalrpt.pdf To view the accompanying “Findings At-A-Glance” document for the BPCI Initiative Models 2-4 fifth evaluation report, use this link: https://innovation.cms.gov/Files/reports/bpci2-4-fg-yr5evalrpt.pdf

An Excel spreadsheet listing the participants can be found at this webpage: https://innovation.cms.gov/initiatives/bpci-advanced On October 9, 2018, CMS also released the fifth evaluation report

Let’s Stay in Touch

AMRPA has new phone and fax numbers.

Please see the changes below to update your records.

AMRPA Government Relations & Policy Team AMRPA Main Phone: 202-591-2469 Fax: 202-591-2445

Mimi Zhang, AMRPA Senior Policy and Research Analyst Direct Phone Line: 202-860-1003

Carolyn Zollar, JD, MA, AMRPA EVP for Government Relations and Policy Development Direct Phone Line: 202-860-1002

Lovelyn Robinson, AMRPA Editorial and Research Assistant Direct Phone Line: 202-860-1005

Jonathan Gold, JD, AMRPA Regulatory and Government Relations Counsel Direct Phone Line: 202-860-1004

16 AMRPA Magazine / November 2018

Catherine Beal, AMRPA Staff Associate Direct Phone Line: 202-860-1006

MedPAC to Focus on Uniform Post-Acute Care Outcomes Measures

Mimi Zhang, Senior Policy and Research Analyst

Highlights: »»

MedPAC will create uniform post-acute care quality measures for readmissions, discharge to community, and Medicare Spending per Beneficiary.

»»

MedPAC continues to build upon its unified post-acute care payment system model.

On October 5, the Medicare Payment Advisory Commission (MedPAC) held a public meeting session titled, Episode-based Payments and Outcomes Measures Under a Unified Payment System for Post-acute Care. MedPAC staff outlined the direction of their work on the post-acute care prospective payment system (PAC PPS) for the upcoming year. They plan to develop an episode-based (or multi-site) PAC PPS model as well as uniform outcomes-based quality measures such as readmissions, discharge to community, Medicare Spending per Beneficiary (MSPB), and assessment-based function measures. MedPAC says that such measures could be used in a value-based purchasing program for post-acute care (PAC VBP).

Episode-based PAC PPS Model In 2016, MedPAC recommended a PAC PPS prototype that used stays – either an institutional PAC stay or a home health episode – as the unit of service. However, MedPAC believes the stay-based model could still be improved upon to further discourage volume-based utilization. Hence, an episode-based PPS model could encourage institutional PAC providers to offer a continuum of care (with the requisite regulatory changes) and reduce the number of care transitions a beneficiary experiences. This approach has been previously discussed by the commission as a “PAC-only bundle.”

Stay-based PPS

Episode-based PPS

Stay #1

Stay #2

A single payment for episode

Over the course of this year, MedPAC will evaluate an episode-based PAC PPS wherein providers would be paid for a sequence of PAC stays. The analysis will focus on those stays that are solo (e.g., an IRF stay alone) or in pairs (e.g., IRF + home health); combined, these stays account for 85 percent of all PAC sequences.

The episode-based PPS will be modeled using 2017 data and episodes will be built from individual PAC stays that are within seven days of each other. MedPAC will also compare the total costs associated with the stay-based PAC PPS versus the episodebased PAC PPS.

AMRPA Magazine / November 2018 17

Developing Uniform PAC Quality Measures Because the distinctions between PAC settings are less important in a unified PPS, quality measures that are uniform across settings are necessary to assess provider performance.

Although CMS has developed and adopted many of the measures required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, MedPAC believes the measures are too tailored for different settings and therefore not truly uniform. As such, it will develop alternate uniform measures that would allow for “direct comparisons” across settings. MedPAC has previously recommended the implementation of a unified PAC VBP concurrent with the PAC PPS. The measures being developed this year could be used to model a potential PAC VBP in future analytic cycles.

With regard to the specific measures, MedPAC will focus on: MSPB-PAC: The measures includes total spending for Part A and Part B services during the PAC provider’s own stay and 30 days after discharge. MedPAC has found that MSPB-PAC rates varied considerably across providers. Staff intend to pool together multiple years in their forthcoming analysis.

Readmissions: Staff will develop uniform, risk adjusted all-cause and potentially preventable readmission rates for both withinPAC stay and 30 days after discharge. The definition of a hospitalization will include community-admitted beneficiaries (which constitute two-thirds of home health stays) and observation stays. Staff referred to this as a “readmissions and admissions” measure.

18 AMRPA Magazine / November 2018

Discharge to community: Staff will build upon CMS’ measure to develop a uniform, risk-adjusted model to gauge how successfully providers discharge beneficiaries home with no planned readmissions or mortality within 31 days post-discharge.

During the meeting’s discussion period, several commissioners recommended that the measures be adjusted for socioeconomic status (SES) factors and that it would be particularly important for the discharge to community measure. The commissioners noted there are situations where a home/community discharge is not the safest option for the patient, and that this measure should not unintentionally encourage unsafe discharge when the optimal placement may be a facility setting such as a nursing home or assisted living facility.

Next Steps MedPAC plans to discuss uniform functional outcome measures at the next public meeting on November 4-5. In the spring, MedPAC staff plans to report results from the episode-based PAC PPS design and performance data from the uniform quality measures.

AMRPA Holds 16th Annual Educational Conference in Boston The American Medical Rehabilitation Providers Association (AMRPA) held its 16th Annual Educational Conference and Expo in Boston on September 24-26, 2018.

Over the two and a half days, conference attendees participated in five concurrent educational tracks and engaged in numerous networking events including educational roundtables, more than 30 interactive poster presentations, networking receptions and a vendor exhibit hall.

This year, attendees had the opportunity to attend the AMRPA IRF Boot Camp, a preconference event designed to provide rehabilitation managers and medical directors of acute rehabilitation programs with the fundamental knowledge needed before entering the conference. The Boot Camp covered key rules and regulations that govern an inpatient rehabilitation program and provide operational insight and solutions to common managerial issues facing rehabilitation programs today.

Many conference attendees took advantage of an exclusive tour of Spaulding Rehabilitation Hospital, a state-of-the-art hospital in Watertown, Mass. Following the morning tour, keynote speaker Roseann Sdoia, a Boston Marathon bombing survivor who received care at Spaulding, shared her inspirational story of strength and resilience to conference attendees.

This year, 50 captivating breakout sessions covered the following educational tracks: Business Operations and Leadership Development Clinical Care Delivery: A Team Approach Regulatory, Legislative and Accreditation Matters Marketing and Relationship Management Outside the Box The sessions focused, for example, on the industry experiences with the new service and delivery models such as integrated post-acute care networks, accountable care organization, bundled payments and how these models are affecting their operations.

Other sessions covered the many problems rehabilitation providers are facing with audits and denials from the Medicare contractors and best practices for challenging inappropriate denials from various payers, including Medicare Advantage plans. Several session discussed the future the post-acute care landscape and what a unified postacute care payment system may bring for inpatient rehabilitation hospitals and units.

AMRPA Magazine / November 2018 19

Lex Friedan is known nationally as a leader in disability rights activism in the world of independent living, rehabilitation, and access for all Americans with varied abilities. Mr. Friedan currently serves as Director of the Independent Living Research Utilization (ILRU) Program at TIRR Memorial Hermann in Houston in addition to serving as professor at The University of Texas Health Science Center in Houston.

From 1984 to 1988, Mr. Frieden served as Executive Director of the National Council on the Handicapped (now the National Council on Disability). In this capacity, he was instrumental in conceiving and drafting the Americans with Disabilities Act (ADA).

AMRPA Board Chair Richard Kathrins, PhD, and the AMRPA Awards Committee honored three leaders in the medical rehabilitation field with the AMRPA Leadership Execellence Award and the inaugural Edward Eckenholl Memorial Award and Lecture. Mr. Eckenhoff served on the AMRPA Board of Directors from its founding through 2010, including serving as board chair in 2000 and 2001. He also created and chaired AMRPA’s first Consumer Advocacy Committee, focusing on the needs of patients served by rehabilitation hospitals.

This year’s Leadership Award honorees exemplify leadership, integrity, vision, dedication and excellence in Transformative Leadership, Professional Experience, Life-long Service in the Field, Advocacy at the State and National Level, Mentorship of Future Leaders, Improved Patient Outcomes / Quality of Patient Care, Research and Critical Analysis and Education and Advancement of the Field.

Bill Restum, Ph.D., was named CEO of the Rehabilitation Institute of Michigan in 2008 and has also served as the National Rehabilitation Leader for Tenet Health in recent years. He has been involved with AMRPA for many years, showing national leadership and dedication to the rehabilitation field, having been an administrator of many rehabilitation programs in Southeastern Michigan in his 50 years of service.

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John L. Melvin, MD, MMSc, was honored as the first recipient of the Edward Eckenhoff Memorial Award and Lecture. Dr. Melvin as an academic physician has contributed to the development of programs for individuals with physical disabilities for more than 40 years. He has done this through active involvement in regional, national and international organizational leadership, advocacy, teaching, research and clinical initiatives. In the 1970s, Dr. Melvin provided leadership in developing guidelines that define when Medicare patients are clinically eligible to receive rehabilitation hospital services. These guidelines continue to be influential after more than 35 years, and have contributed to increased patient access of rehabilitation services. A decade later, he along with several of his colleagues demonstrated that patient function is a better predictor of rehabilitation outcomes and costs than medical diagnosis. This research provided the basis for the development of the prospective payment system for rehabilitation hospitals and units that was implemented by the federal government in 2002. In his lecture, Dr. Melvin shared his insights and storied experience on the history of the medical rehabilitation field and the unique value it brings to the evolving health care landscape.

Join Us in 2019!

Next year’s AMRPA Fall Educational Conference and Expo will take place at the Loews Coronado Bay Resort in San Diego October 14-16, 2019. The call for abstracts for this conference will be distributed over the next few months. Next year’s conference will feature a full day Inpatient Rehabilitation Hospital Boot Camp to provide Rehab managers and medical directors of inpatient rehabilitation programs with the fundamental knowledge needed before entering AMRPA’s concurrent educational tracks.

Inspector General Raises Concern About Medicare Advantage Appeals and Oversight

On September 16, the Office of Inspector General (OIG) with the U.S. Department of Health and Human Services (HHS) issued a report on Medicare Advantage (MA) plans (often referred to as “Medicare managed care”) and their handling of denials and appeals of services for Medicare beneficiaries.

Jonathan M. Gold, JD, AMRPA Regulatory and Government Relations Counsel

Highlights: »»

70 percent of appeals were fully successful at first level of appeal.

»»

Only 1 percent of claims were appealed.

»»

More than half of MA plans cited for incorrect denials.

Unsuccessful appeals Partially successful appeals

25%

Fully Successful appeals

70%

5% Source: OIG analysis of 2014-16 MAO annual performance data, 2018.

The OIG stated it conducted this review with two objectives: 1) to determine the extent of appeals and overturns of Medicare Advantage service and payment denials at each level of the appeals process during 2014-2016, and 2) to assess the Center for Medicare and Medicaid Services’ (CMS’) audit findings and resulting enforcement actions relating to Medicare Advantage denials and appeals. The OIG ultimately raised serious concerns about MA beneficiaries’ access to needed services due to the results of this study, including concerns consistent with experiences of AMRPA member hospitals.

Overturn of Denials and Appeal Rates To evaluate the rates of appeals and overturns of denials in the first level of appeal, the OIG used performance data that MA plans submitted to CMS for 2014, 2015 and 2016. This data included all claims processed by these plans, a total of 1.3 billion claims.

However, not all MA plans were included in this study because the performance data for some plans did not meeting the OIG’s validation standards. The OIG estimates the MA plans included in this study covered between 84 and 89 percent of all beneficiaries enrolled in MA plans. Ninety-four percent of the claims examined were requests for payment after the service had been delivered, and six percent were preauthorization requests.

Using this data, the OIG found that beneficiaries and providers were usually successful at the first level of appeal when appealing denials. Specifically, the OIG found that at the first level of appeal, which for most types of claims is handled by the MA plan itself (but in some instances is handled by a Quality Improvement Organization [QIO]), 70 percent of appellants received a fully favorable decision. Further, another five percent of audited of audited received a partially favorable decision, according to the OIG. In total, 649,000 of the contracts sent contracts insufficient madeplans were overturned in favor of the provider 863,000 appeals to MA or beneficiary. denial letters inappropriate

45%

56% denials

The OIG noted that most of the overturned denials (82 percent) were for services already provided, while 18 percent of the overturned denials were preauthorization claims. In addition, the report found that there was wide variation in the overturn rates between plans. While there was a median overturn rate of 77 percent, 76 of the approximately 420 MA plans examined in this study had 90 percent of their denials

AMRPA Magazine / November 2018 21

ally essful als

overturned, and 65 plans had less than 50 percent of their denials overturned. The OIG says in the report that not all overturns of initial denials were due to the MA plan initially reaching an incorrect decision because based upon receiving additional information from a provider, the MA plan may change its decision.

For those select cases handled by QIO’s for the first level of appeal (which includes discharge and discontinuation notices from inpatient acute care, comprehensive outpatient rehabilitation, home health or skilled nursing facilities), the OIG found that the QIO reversed the denials at a rate of 26 percent.

When examining the second, third and fourth levels of appeals, the OIG found that there was a much lower overturn rate.

Specifically, the report states that at the second level of appeal, which for most cases is conducted by an Independent Review Entity, the overturn rate was 10 percent. At the third level of appeal, which is handled by Administrative Law Judges, there was a 27 percent overturn rate. Finally, at the fourth and final level of administrative appeal, which is handled by the Medicare Appeals Council, there was a 23 percent overturn rate.

Unsuccessful appeals Partially successful appeals

25%

Oversight of Denials and Appeals Procedures In addition to examining data related to denials and appeals of MA plan claims, the OIG also examined CMS’ oversight of MA plans and their adherence to the requirements relating to denials and appeals. Specifically, the OIG evaluated the audits that CMS performed on 140 MA plans in 2015. Based on its review of these audits, the OIG concluded that there are persistent problems with MA plans’ adherence to Medicare regulations relating to denials and appeals.

First, when examining the audits conducted by CMS in 2015, OIG found that CMS cited 79 (56 percent) of the 140 audited MA plans for inappropriately denying claims. There were two types of errors relating to erroneous denial of claims that CMS identified. The first type of citation was for making the incorrect clinical decision based on all of the relevant clinical information.

The second type of citation was for not conducting appropriate outreach before making clinical decisions, including not taking appropriate steps to gather all the relevant information from the provider or beneficiary. Of the 79 cited plans, 12 were cited only for making the incorrect clinical decision based on all the relevant information, 21 were cited only for not conducting appropriate outreach, and 46 were cited for both violations.

56%

Fully Successful appeals

of audited contracts made inappropriate denials

70%

5% Source: OIG analysis of 2014-16 MAO annual performance data, 2018.

Despite high overturn rates, the OIG found providers and beneficiaries appealed denials at a very low rate. Overall, only approximately one percent of all denials were ever appealed to the first level of appeal. There was also notable variation of appeal rates across plans, ranging from 0 percent to 40.5 percent, with a median of 0.9 percent.

Unsuccessful appeals

25%

Fully Successful appeals

70%

%

rce: OIG analysis of 2014-16 MAO annual performance data, 2018.

22 AMRPA Magazine / November 2018

56%

of audited contracts made inappropriate denials

In addition to inappropriately denying claims, the OIG also found that CMS cited 45 percent of MA plans for sending deficient denial letters. Among the errors identified in these denial letters, CMS found that some denial letters did not clearly explain why a request was denied, some failed to used approved language, others were written in a manner not easily understandable to beneficiaries, and some otherwise contained incomplete or incorrect information.

45%

of audited contracts sent insufficient denial letters

CMS Enforcement Actions The OIG also examined CMS’ use of its compliance and enforcement mechanisms for MA plans. The report states that in 2015 CMS issued $1.9 million in civil money penalties to MA plans.

CMS issued these penalties for violations of procedures that may have led to unnecessary delay or denial of services, financial harm to beneficiaries, or prevented providers or beneficiaries from exercising appeals rights. Five of these MA plans were fined for violations that CMS had previously warned them about, and thus received an increased “aggravating factor” penalty.

Additionally, the OIG found that in 2015 CMS imposed sanctions that prevented 22 MA plans from enrolling any new beneficiaries until deficiencies were corrected. CMS says it took this action for violations it deemed so systemic and harmful to beneficiaries that it was inappropriate to continue to allow enrollment with the plans. The 22 MA plans implicated had nearly half a million enrolled beneficiaries at the time.

patients, who can be harmed by delays in approval of service. The OIG also pondered whether providers may be less inclined to order medically necessary services if their experience has been an appeal would be needed to get the service approved.

To correct these deficiencies, the OIG made a series of recommendations to CMS. First, it recommends CMS engage in more technical assistance, training, education and increased monitoring to ensure MA plans make appropriate clinical decisions and issue sufficient denial letters. The OIG also recommends CMS conduct additional oversight of MA plans with extremely high overturn rates or extremely low appeal rates to ensure they are not issuing inappropriate denials or insufficient denial letters. The OIG also suggest CMS could create new aggravating factors for civil money penalties, and require MA plans with repeated violations to hire their own independent auditors.

Conclusions and Recommendations The OIG said its findings raised serious concerns about beneficiary access to services through MA plans. Most concerning was the high overturn rate of denials, coupled with the very low appeal rate of only one percent of denials. This combination of factors led the OIG to conclude that there are likely many beneficiaries being inappropriately denied access to services, but for various reasons, never appeal the decision.

The OIG also expressed concern that there is no clear and easy way for beneficiaries to learn about serious MA plan violations.

Specifically, the OIG noted that violations will no longer effect MA plan Star Ratings, and CMS should reconsider that change, along with finding other ways to make serious violations more easily accessible to the public. CMS largely concurred with a need to further enhance oversight of MA plan performance, and said it is already performing some of the recommendations for the OIG. However, in its response, CMS did not provide much in the way of specifics in how it planned to further enhance oversight.

The report states that one such reason there may be such a low appeal rate is the high number of MA plans that were cited for insufficient denial letters. The OIG expressed concern that incomplete or incorrect information may be preventing the provider or beneficiary from filing appeals. Further, the OIG stated these shortcomings might be most detrimental to the sickest

For the full report, see “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials,” September 2018, OEI-09-16-00410. U.S. Department of Health and Human Services, Office of Inspector General.

AMRPA Magazine / November 2018 23

GAO Says Functional Status Data Could Improve Medicare Advantage Payment Accuracy Highlights: »»

GAO found that for the sample of beneficiaries analyzed, the MA risk adjustment model underestimated spending for those with functional limitations and overestimated spending for those without such limitations.

Accurate risk adjustment avoids the creation of a financial advantage or disadvantage for plans solely on the basis of the health status of enrolled beneficiaries. The 21st Century Cures Act contains a provision for the Government Accountability Office (GAO) to report on issues related to incorporating functional status into Medicare Advantage (MA) risk adjustment.

Specifically, the Act requires the GAO to examine: 1. The extent to which the Centers for Medicare and Medicaid Services (CMS) collects information on the functional status of Medicare beneficiaries; 2. The accuracy of the current CMS risk adjustment model for beneficiaries with functional limitations and any benefits associated with potentially improving accuracy by accounting for functional status in MA risk adjustment; and 3. The potential challenges of accounting for functional status in MA risk adjustment.

CMS's Risk Adjustment Model CMS pays MA plans a monthly capitated amount to provide coverage for enrolled beneficiaries. This amount is adjusted to reflect beneficiary health status, a process known as risk adjustment. Beneficiaries in poorer health are generally expected to use more health care services than beneficiaries in better health; thus, risk adjustment pays more to MA plans for beneficiaries in poorer health to compensate.

CMS's risk adjustment model estimates health care spending based on beneficiary demographic characteristics and clinical diagnoses. However, this model does not account for functional status—the ability to perform routine daily activities such as bathing or dressing. GAO estimated that about four in 10 beneficiaries had functional limitations in 2016.

GAO’s Analysis GAO analyzed 2014 data on diagnoses and survey data on functional status for a sample of community-residing FFS beneficiaries to estimate 2015 spending based on CMS's current risk adjustment model. GAO compared those estimates to actual 2015 total health care spending—the most recent year for which summarized data on beneficiary spending were available at the time of GAO's analysis. While the survey was designed to be representative of all FFS beneficiaries, the GAO notes that the sample it analyzed may not be representative of FFS beneficiaries who reside in the community because the sample was restricted to those who provided complete functional status survey information. GAO also reviewed CMS guidance documents and interviewed stakeholders, industry experts, and CMS officials.

Although CMS does not use functional status in its current risk adjustment model, GAO found that CMS did collect functional status information for up to 13.4 million (about 24 percent) Medicare beneficiaries from the following sources in 2015:

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Post-acute care (PAC) settings. CMS collected information from about 7 million (13 percent) beneficiaries through assessments in PAC settings, which include skilled nursing facilities, inpatient rehabilitation hospitals and units, long-term care hospitals and home health agencies. The information collected from PAC assessments is mainly used for care planning, quality measurement and payment adjustments.

Outpatient therapy settings. As required by CMS, providers who furnished physical, occupational or speech therapy in the FFS outpatient setting assessed and reported functional status information for about 5.9 million (11 percent) beneficiaries in order to track patient progress and outcomes.

Surveys. CMS also collected functional status information through surveys administered to samples of Medicare beneficiaries, which totaled about 0.5 million Medicare beneficiaries (less than 1 percent). The surveys are used to gather data on outcomes and experiences with care, and the data are used for research purposes and measuring quality.

Type of Functional Status Information Collected PAC assessments cover more domains of functional status than surveys do, including hearing, speech, vision, cognitive patterns and bladder and bowel function. In addition, PAC assessments collect more detailed information about activities of daily living limitations; for example, a PAC assessment question goes beyond asking if a beneficiary has difficulty dressing themselves, and asks detailed information about dressing the upper body, lower body and putting on footwear.

PAC assessments also account for whether and how much assistance a beneficiary needs from a caretaker or device, such as a wheelchair. Conversely, the outpatient therapy assessments and surveys collect less functional status information, both in terms of detail and quantity, and generally do not address the need for assistance.

GAO’s Findings GAO found that for the sample of beneficiaries analyzed, the MA risk adjustment model underestimated spending for those with functional limitations and overestimated spending for those without such limitations. These findings suggest that risk adjustment accuracy could be improved by accounting for functional status, which could in turn reduce any financial disadvantages plans may experience by enrolling beneficiaries with functional limitations.

GAO also found that CMS and other stakeholders could face substantial challenges if the risk adjustment model were revised to account for beneficiary functional status, in part because this information is not readily available.

For example, about three-fourths of beneficiaries do not receive health care in settings where functional status information is routinely collected. Stakeholders told GAO that expanding the collection of such information could be resource intensive for CMS, plans and health care providers, and an imposition for some beneficiaries. In addition, the potential for higher payments may give MA plans a financial incentive to identify beneficiaries with functional limitations.

If this incentive causes MA plans to identify functional limitations more completely than providers in fee-for-service (FFS) Medicare, the risk adjustment process would need to account for this to avoid inappropriately high payments to plans because the risk adjustment model is estimated based on FFS data.

For the complete report, see “Medicare Advantage: Benefits and Challenges of Payment Adjustments Based on Beneficiaries' Ability to Perform Daily Tasks” GAO-18-588: Published: Sep 10, 2018. Publicly Released: Sep 10, 2018

The methods CMS uses to collect functional status information differ by mode of administration, type of information collected, and frequency of information collection. (See table 1.)

AMRPA Magazine / November 2018 25

Stroke Patients Treated at Teaching Hospitals Less Likely to Be Readmitted

Highlights: »»

More than 90 percent of all 30-day stroke-related readmissions were unplanned and, depending on the stroke type, up to 13.6 percent were deemed potentially preventable.

»»

Patients discharged from nonteaching hospitals with a high volume of stroke patients were at a significantly higher risk of 30day readmission than those from teaching hospitals.

According to new research from the University of Texas Health Science Center at Houston (UTHealth), stroke patients discharged from teaching hospitals are less likely to land back in a hospital during the early stages of recovery.

The study, published in JAMA Network Open, provides the first comprehensive analysis of 30-day readmission rates for both Medicare and privately insured patients with different types of stroke.

Although readmissions fell by 3 percent a year on average between 2010 and 2014, the study found that patients discharged from nonteaching hospitals faced a significantly higher risk of readmission mainly due to having another stroke, related complications or septicemia.

The overall decline in readmissions was not attributed to reduced stroke recurrence, which in fact increased in some cases, but more a result of a drop in readmission rates for other high volume conditions likely to affect stroke patients, who tend to be older and have additional health issues.

// The overall decline in readmissions was not attributed to reduced stroke recurrence, which in fact increased in some cases, but more a result of a drop in readmission rates for other high volume conditions likely to affect stroke patients, who tend to be older and have additional health issues.

Results revealed more than 90 percent of all 30-day stroke-related readmissions were unplanned and, depending on the stroke type, up to 13.6 percent were deemed potentially preventable. The greatest danger of readmission applied to patients with hemorrhagic stroke, which carried a 13.7 percent likelihood. By contrast, patients with ischemic stroke faced a 12.4 percent risk.

26 AMRPA Magazine / November 2018

Nonteaching hospital stroke patients accounted for around half (46.4 percent) of all patients. The study authors found that the disparity between readmission rates compared to teaching hospitals widened as the number of stroke patients treated at the nonteaching hospitals grew.

Greater adherence to quality-of-care metrics, use of telestroke technology and organization of care delivery, as well as having adjoining outpatient clinics, were among the features common at teaching hospitals. The study highlights various considerations that individual hospitals can use to identify issues and take measures to prevent secondary complications of stroke.

“The research is important because readmissions have become a focus for improving quality of care while in a hospital, as well as

reducing costs, and very little has been published about stroke patients at this scale,” said the study’s lead author Farhaan Vahidy, MBBS, PhD, MPH, assistant professor of neurology at McGovern Medical School at UTHealth. “Our findings help set national performance benchmarks for readmission levels among patients of all ages, types of stroke and insurance classes. This provides potential to identify specific groups for readmission reduction through targeted interventions that improve continued support for discharged patients, which should start before they leave the hospital doors.”

For the announcement, see Stroke Patients Treated at a Teaching Hospital Are Less Likely to Be Readmitted, 17-Aug-2018, University of Texas Health Science Center at Houston.

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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

AMRPA: Working Together to Preserve Preserve Access to Medical Rehabilitation AMRPA: Working Together To Access To Medical Rehabilitation Maggie Ramirez · VP ofMember Membership Services · 347-573-3732 · mramirez@amrpa.org Julia Scott, AMRPA Services Coordinator, 202-207-1110, jscott@amrpa.org

AMRPA Magazine / November 2018 27

Neuropsychological and Functional Impairments are Associated with Increased Medicare Spending

Highlight: »»

Failure to account for patient neuropsychological and functional status may inappropriately penalize outpatient clinicians.

The Merit-Based Incentive Payment System (MIPS) program is a track in Medicare’s Quality Payment Program (QPP) that adjusts clinician’s Part B payments based on their performance on cost and measures. Specifically, MIPS judges outpatient clinicians’ performance on a measure of annual Medicare spending. As Medicare moves toward value-based payment however, this cost measure may disadvantage outpatient clinicians who care for vulnerable populations because the process omits meaningful determinants of cost, according to a recent study published in the JAMA Internal Medicine.

The study sought to determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, local area health resources and economic conditions are associated with Medicare total annual cost of care (TACC), and whether accounting for these factors improves the TACC performance of outpatient safety-net clinicians.

// The study sought to determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, local area health resources and economic conditions are associated with Medicare total annual cost of care (TACC)

The researchers used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Patient-level multivariable regression models estimated the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors. TACC is defined as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories.

28 AMRPA Magazine / November 2018

The study included Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non–safety-net clinics, contributing 76,927 person-years of data to the MCBS from 2006 through 2013. There were 111,414 unique identifiable physicians, and the final weighted sample included 213,904,324 patient-years (unweighted, 76,927 patient-years) from 30,058 unique patients, of whom 17,478 (58.1 percent) were women. The mean (SD) patient age was 71.84 (12.48) years. The mean TACC was $9,117.

Those with higher than mean TACC included beneficiaries with depression ($14,436), dementia ($18,311), and difficulty with 3 or more activities of daily living (ADLs, $19,113) or instrumental ADLs ($17,443). After adjusting for comorbidities, depression and dementia were still associated with $2,740 (95 percent CI, $2200$2739) and $2,922 (95 percent CI, $2399-$3445) higher TACC, respectively. Difficulty with 3 or more ADLs ($3,121 higher; 95 percent CI, $2,633-$3,609) or instrumental ADLs ($895 higher; 95 percent CI, $452-$1337) was also associated with higher TACC. Adding these neuropsychological and functional factors, as well as local residence area factors, to risk adjustment calculations reduced outpatient safety-net clinicians’ underperformance on Medicare TACC relative to non-safety–net clinicians by 52 percent (from 0.098 to 0.047 difference in the observed to expected ratio).

Results The study found that patient depression, dementia, limitations in ADL and residence in areas of mental health care shortage or high unemployment were associated with substantially higher TACC, after applying standard Medicare risk adjustment methods.

In a model adding these factors to risk adjustment, the TACC performance of safety-net clinicians was improved.

The study concluded that neuropsychological and functional impairment are common in Medicare beneficiaries and are associated with increased annual Medicare spending. Failure to account for these factors may inappropriately penalize clinicians who care for these vulnerable groups, such as safety-net clinicians, for factors that are arguably beyond their control.

For the full report, see “Association Between Patient Cognitive and Functional Status and Medicare Total Annual Cost of Care Implications for Value-Based Payment,”JAMA Internal Medicine, September 17, 2018.

A M E R I C A N M E D I C A L R E H A B I L I T AT I O N P R O V I D E R S A S S O C I AT I O N

Improving Access to Inpatient Rehabilitation Hospitals and Units www.AMRPAPAC.org

AMRPA Magazine / November 2018 29

AHRQ Study Assesses Whether Instruments Used In Adult Lower Limb Amputees Were Valid

Highlights: »»

AHRQ’s review did not find adequate evidence that instruments used by adult lower limb amputees can predict what specific LLP components are associated with optimal patient outcomes.

Candidates for lower limb prosthesis (LLP) are a diverse group and many LLP options exist, yet how to best match an amputee with an LLP remains unclear. To help address these issues, the Agency for Healthcare Research and Quality (AHRQ) conducted a review to assess the validity of instruments used in adult lower limb amputees, and whether patient characteristics can predict relative effectiveness of different LLP components and long-term LLP use. Optimal selection of devices should be guided by evidence on which amputees would do best with which LLP component or configuration, and which evaluation instruments are valid and reliable.

The researchers addressed questions pertaining to: Assessing validity, reliability and related psychometric properties for assessment techniques, predictor tools and outcome measures in lower limb amputees; Determining which patient and other characteristics may predict which LLP configuration or component would result in better clinical and patient-centered outcomes for different lower limb amputees (i.e., heterogeneity of treatment effect); Determining whether patient expectations align with outcomes; Evaluating whether patients are satisfied with the process of obtaining their LLPs; Describing long-term use of LLPs. The review did not evaluate overall comparative effectiveness among LLP components, nor does it include assessment of biomechanical outcomes.

Results The study found that while 30 of 50 evaluated instruments (ambulatory/functional outcomes and other measures) have evidence of validity and reliability, only 17 of these were deemed to be generalizable to the Medicare population. Based on a small number of studies, patient characteristics do not predict who would most benefit from a given LLP component. Furthermore, half of studies used non-validated instruments and analyses were inadequate.

Only a few studies assessed long-term LLP use; 11 percent to 22 percent of patients abandon their LLP after one year; persons with above-the-knee amputations are more likely to abandon their prostheses than persons with below-the-knee amputations; 24 percent to 29 percent of persons with LLPs use them only indoors one year after they first receive the prostheses. The studies, though, had important methodological

30 AMRPA Magazine / November 2018

issues. Two studies provide low strength of evidence that people are satisfied with their encounters with their prosthetists. No eligible study addressed how study participants’ pre-prescription expectations of ambulation align with outcomes. Overall, the studies did not identify participant characteristics that predict which lower limb amputees would benefit most from a given component.

pre-prescription instruments are predictive of which specific LLP component individuals should receive to maximize ambulation, function, and quality of life, or to minimize abandonment or limited use. Further high-quality research in representative samples of people with LLPs is needed to inform optimal matching of prosthetic components to patients and to assess patient expectations and satisfaction with care.

Conclusions The researchers concluded that numerous instruments assessing ambulation, function, quality of life and other patient-centered outcomes have evidence of validity and reliability for people with lower limb amputations. However, the literature does not provide adequate evidence regarding whether specific characteristics or

For the study, see Balk EM, Gazula A, Markozannes G, Kimmel HJ, Saldanha IJ, Resnik LJ, Trikalinos TA. Lower Limb Prostheses: Measurement Instruments, Comparison of Component Effects

by Subgroups, and Long-Term Outcomes. Comparative Effectiveness Review No. 213. AHRQ Publication No.18-EHC017EF, September 2018.

AMRPA Magazine / November 2018 31

Researchers Examine Whether Young Children with Mild Traumatic Brain Injuries Receive Needed Rehabilitation and Education Services

Highlight: 

Young children with traumatic brain injury may benefit from rehabilitation or special education services, even if their injuries are mild.

According to the Centers for Disease Control and Prevention (CDC) children age five years and younger have the highest number of emergency department visits for traumatic brain injury (TBI) and most are discharged to home at the time of injury. For young children, even mild TBI can have lasting effects on learning and behavior that may persist into the elementaryschool years and beyond. Research has shown that rehabilitation and educational supports may help these children successfully transition to school. However, many young children may not receive rehabilitation or educational supports after a TBI, especially if they are not hospitalized at the time of the injury.

// According to the Centers for Disease Control and Prevention (CDC) children age five years and younger have the highest number of emergency department visits for traumatic brain injury (TBI) and most are discharged to home at the time of injury.

In a recent study funded by the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), researchers asked parents of young children with TBI about their service history between the injury and first study visit. The researchers wanted to find out how many of the children received rehabilitation or preschool-based services related to their TBI. They also wanted to determine whether children with more severe injuries or longer hospital stays were more likely to receive services.

Researchers at the project on Language and Literacy Outcomes of Preschool Children with Traumatic Brain Injury interviewed the parents of 39 children with TBI at the time of the initial study visit. The children were between six to 10 years old, and all had experienced their TBI at least a year before the interview. On average, the children

32 AMRPA Magazine / November 2018

were 2.3 years old when they experienced their TBI and all had experienced their injury before beginning kindergarten. During the interviews, the parents were asked how long their child stayed in the hospital after injury, and whether or not their child received various services, including occupational, physical or speech therapy; neuropsychological testing; services from an early intervention program for toddlers; or special education preschool services. The researchers also reviewed medical records to obtain information on injury severity.

The researchers found that, although most of the children had mild injuries, more than half had injuries significant enough that skull or brain tissue damage appeared on imaging tests. Only about one-fourth of the children received any rehabilitation services such as physical or speech therapy after their TBI. In addition, only about one-fourth of the children received any neuropsychological assessment after their injury. None of the children received early intervention or special education preschool services after their TBI. When the researchers looked at who was most likely to receive services, they found that the children who had stayed in the hospital for five days or longer were almost six times more

likely than the children with shorter hospital stays to receive any rehabilitation services. However, children whose imaging tests showed evidence of skull or brain tissue damage were no more likely to receive these services than those whose imaging findings did not show such evidence.

Given that even mild TBI can have lasting effects on learning and behavior that may persist into the elementary-school years and beyond, the study authors noted that young children with TBI may benefit from rehabilitation or special education services, even if their injuries are mild. Medical professionals may wish to educate parents about the long-term impacts of TBI during follow-up appointments and make referrals to appropriate services available to young children at least for evaluation and monitoring. Early childhood educators may also wish to learn about the long-term impacts of childhood TBI in order to monitor children and make appropriate service recommendations.

For the complete study, see Haarbauer-Krupa, J., Lundine, J.P., DePompei, R., & King, T.Z. (2018) Rehabilitation and school services following traumatic brain injury in young children.

NeuroRehabilitation, 42, 259-267.

AMRPA Magazine / November 2018 33

CMS Revises Chapter 13 of the Medicare Program Integrity Manual

Highlights: »»

The updated manual responds to Congress’ requirement in the 21st Century Cures Act for more transparency in Medicare’s LCD process and aims to ensure an open LCD process that meets patients’ needs.

The Centers for Medicare and Medicaid Services (CMS) has revised Chapter 13 of the Medicare Program Integrity Manual (PIM), which describes the local coverage determinations (LCD) process. The revision was in response to a provision of the 21st Century Cures Act intended to improve transparency in the LCD process. The manual includes instructions, policies and procedures for Medicare Administrative Contractors (MACs) that administer the Medicare program in different regions of the country, as well as guidance for stakeholder engagement in the process.

// The revision was in response to a provision of the 21st Century Cures Act intended to improve transparency in the LCD process.

MACs determine which health care items and services meet requirements for Medicare coverage — taking into account local variations in the practice of medicine — through LCDs. LCDs are issued when national determinations do not exist or when MACs need to further define a national determination.

CMS states that the revised manual includes: Clear process roadmap. A step-by-step description of the LCD process in language that is accessible to all stakeholders.

Consistent presentation of evidence. Standardized summary of clinical evidence supporting LCD decisions and a MAC coverage determination rationale.

Informal meetings with MACs. Option to request an informal meeting with the MAC to discuss potential LCD requests.

New LCD request process. A novel process by which interested parties in a MAC jurisdiction can request a new LCD. Restructured Contractor Advisory Committee (CAC) meetings. Meetings open to the public. CAC members serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of an LCD. MACs can host CAC meetings in various ways (e.g., in-person, telephone, video, webinar). MACs determine how frequently these meetings occur based on the appropriateness and volume of LCDs requiring CAC input.

34 AMRPA Magazine / November 2018

More diverse representation on the CAC. In addition to physicians, other health care professionals (e.g., nurses, social workers, epidemiologists) can participate in the CAC. The CAC also must include beneficiary representation.

Consistent reconsideration process. LCD reconsideration process are consistent with the National Coverage Determination reconsideration process. MACs must follow the full LCD process for valid requests.

Repurposed public meetings. Open meetings in the MAC jurisdiction will present proposed coverage, including evidence and rationale of decisions. MACs clearly identify the location, dates and conference information (e.g., telephone, webinar) and distinguish these meetings from CAC meetings.

As part of CMS’s Patients Over Paperwork initiative, the agency has sought stakeholder input through Requests for Information (RFIs) to solicit ideas of ways to reduce administrative burden. Feedback from these RFIs informed the LCD process improvements reflected in the changes to the Program Integrity Manual.

No “old” proposed policies. Proposed policies will be retired if not finalized within one year of the original posting date.

CMS invites stakeholders to submit feedback on their experiences with the revised LCD process and the agency will consider additional revisions in the future. Feedback can be submitted to LCDmanual@cms.hhs.gov.

Relocation of codes. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10CM) and Current Procedure Terminology (CPT) codes are removed from LCDs in the future.

Better communication. MAC responses to public comments are linked to the final LCD and remain in the Medicare Coverage Database indefinitely (archives). MACs notify the public when they publish a final decision and provide a web link to it.

AMRPA Magazine / November 2018 35

Study Examines the Association Between Care Fragmentation in the Ambulatory Setting, ED Visits and Hospital Admissions Highlights: »»

The relationship between fragmented ambulatory care and subsequent health care utilization varies with the number of chronic conditions.

»»

Targeting interventions to patients whose care is fragmented among multiple providers could improve health outcomes and lower costs.

Many people, particularly those with chronic conditions, receive health services from a variety of providers with no single provider responsible for coordinating all that care. This fragmentation of care can lead to communication gaps and poorer outcomes for the patient according to a study published in the American Journal of Managed Care and funded by the Commonwealth Fund.

// Fragmented care is also associated with higher rates of emergency department (ED) visits and hospital admissions, as well as greater costs.

Fragmented care is also associated with higher rates of emergency department (ED) visits and hospital admissions, as well as greater costs. Patients routinely receive care from multiple ambulatory providers, especially if they have chronic conditions. Receiving care from multiple providers may be appropriate, but it often leads to gaps in communication across providers, which can result in suboptimal care.

Previous studies have found that more fragmented care (that is, care spread across many providers with no dominant provider) is associated with more testing, more overuse of proceduresmand lower patient satisfaction compared with less fragmented care. Prior studies have also identified associations between more fragmented care and higher rates of ED visits, higher rates of hospital admissions, and overall higher costs compared with less fragmented care.

To identify which patients are most affected by care fragmentation, researchers examined the relationship between ambulatory-care fragmentation and outcomes such as subsequent ED visits and hospital readmissions rates for patients with certain chronic conditions. The study included Medicare beneficiaries who received care from physicians in the Hudson Valley region of New York from 2010 to 2012.

36 AMRPA Magazine / November 2018

Study Findings Patients with one to two chronic conditions and high levels of ambulatory care fragmentation are 13 percent more likely to visit the emergency department.

Patients with one to four chronic conditions who had high rates of fragmented ambulatory care were more likely to visit the ED and be admitted to the hospital.

Among patients with high levels of fragmentation: Patients with no chronic conditions did not have an increased likelihood of ED visits or hospital admissions.

Patients with one to two chronic conditions were 13 percent more likely to visit the ED, and 14 percent more likely to have a hospital admission.

Patients with three to four chronic conditions were 14 percent more likely to visit the ED, and 6 percent more likely to have a hospital admission.

Patients with five or more chronic conditions were 10 percent more likely to visit the ED but were 5 percent less like to have a hospital admission.

Study Results Patients with a moderate number of chronic conditions and a high degree of fragmented ambulatory care are significantly more likely to visit the ED and be admitted to the hospital than those with lower rates of care fragmentation. Patients with a moderate number of chronic conditions who receive health care services from several different providers are more likely to visit emergency departments and require hospital admission.

Many previous interventions to improve health care have focused on the sickest patients. The study results indicate that a focus on patients who may be less sick but have highly fragmented care could have a large impact on overall health care costs and inefficiency.

For the complete report, see Lisa M. Kern et al., Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries, American Journal of Managed Care 24, no. 9 (Sept. 1, 2018): 294–300.

AMRPA Magazine / November 2018 37

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38 AMRPA Magazine / November 2018

Latest Research Findings

Study Examines the Characteristics of Health Care Utilization Following Spinal Cord Injury A recent study in the Journal of Spinal Cord Medicine examined the prevalence and characteristics of health care utilization among individuals with spinal cord injury (SCI).

initial hospitalization and 18 patients with unspecified SCI (defined

by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591.

The analysis used local acute trauma registry data for initial hospitalizations and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year.

The data included demographic and clinical characteristics, charges and health care utilization. Mean age was 46.1 years (Âą18.9 years), the majority of patients were male (74 percent), and Caucasian (58 percent). Of the 591 patients, 345 (58 percent) had additional inpatient or emergency health care utilization accounting for 769 additional visits (median of three visits per person). Of the 769 encounters, 534 (69 percent) were inpatient and 235 (31 percent) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension and tobacco use.

The study participants included 664 patients who were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty-five patients who expired during

The study found that individuals with SCI experience high levels of health care utilization that are costly and may be preventable.

Increasing the understanding of its prevalence and causes for health care utilization after acute SCI is important to target preventive strategies.

For more information, see “Health care utilization following spinal cord injury: Objective findings from a regional hospital registry,� J Spinal Cord Med. 2018 Oct 2.

AMRPA Magazine / November 2018 39

Study Analyzes the Cost and Resource Utilization of Hip and Femur Fracture Procedure Bundle The Centers for Medicare and Medicaid Services (CMS) has initiated several programs to transition from a volume-based fee-for-service (FFS) model to a value-based care model such as the voluntary Bundled Payments for Care Improvement Advanced (BPCI Advanced) program, which includes all hip and femur fractures that undergo operative fixation.

A recent study published in the Geriatric Orthopedic Surgery Rehabilitation analyzed the current cost and resource utilization of operatively fixed (nonarthroplasty) hip and femur fracture procedure bundle patients at a single level 1 trauma center within the framework of a risk stratification tool (Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA]) to identify areas of high utilization. The investigators were motivated to examine their hospitals historic spending for hip and femur fractures before they began participating in the BPCI Advanced program.

A cohort of Medicare-eligible patients discharged with the Diagnosis-Related Group (DRG) codes 480 to 482 (hip and femur fractures requiring surgical fixation) from a Level 1 trauma center between October 2014 and September 2016 was evaluated and assigned a STTGMA score.

Patients were stratified into groups based on these scores to create a minimal-, low-, moderate- and high-risk cohort. Length of stay (LOS), discharge location, need for Intensive Care Unit (ICU)/Step Down Unit (SDU) care, inpatient complications, readmission within 90 days, and inpatient admission costs were recorded.

One hundred seventy-three patients with a mean age of 81.5 (10.1) years met inclusion criteria. The mean LOS was 8.0 (4.2) days, with high-risk patients having four days greater LOS than lower-risk patients. The

40 AMRPA Magazine / November 2018

mean number of total complications was 0.9 with a significant difference between risk groups (P = .029). The mean total cost of admission for the entire cohort of patients was $25,446. The analysis found that high-risk patients cost $9,000 more than lowcost patients on average. Specifically, high-risk patients were more likely to have longer and more costly admissions with average index admission costs nearly $9,000 more than the lower-risk patient cohorts. These high-risk patients were also more likely to develop inpatient complications and require higher levels of care. High-cost services and areas of care included room/board, procedure and radiology.

Based on this cohort study, the authors concluded that the STTGMA risk stratification tool could be used to identify high-risk patients who are not suitable for inclusion in a BPCI-Advanced bundle for hip and femur procedures.

For the study, see “The Coming Hip and Femur Fracture Bundle: A New Inpatient Risk Stratification Tool for Care Providers,� Geriatr Orthop Surg Rehabil. September 25, 2018.

M

Save The Date

2019 Spring Conference & Congressional Fly-In March 10-12, 2019 • Ritz Carlton Pentagon City Hotel • Arlington, VA

AMRPA Magazine / November 2018 41

A M E R I C A N M E D I C A L R E H A B I L I T AT I O N P R O V I D E R S A S S O C I AT I O N

Announcing The AMRPA QRP Certification Program A New Era for Rehabilitation has Begun!

Starting October 1, 2019, CMS is eliminating FIM from the IRF-PAI and introducing CMGs based on the GG-H QRP questions. AMRPA is working on key aspects of this change, from policy review and critique to helping hospitals adjust their day-to-day operations.

As part of this work, AMRPA is happy to announce the AMRPA QRP Certification Program.

Available in early 2019, this system will allow AMRPA member hospitals, as well as eRehabData® subscribers, to electronically test staff on their expertise of the QRP data elements in the IRF-PAI. The tests will be administered through AMRPA’s own eRehabData® system.

Best of all, AMRPA member hospitals and eRehabData® subscribers will have unlimited use of this powerful resource, free of charge.

Together, we can make the transition from FIM to GG-H smooth and seamless.

To learn more, please visit eRehabData.com

42 AMRPA Magazine / November 2018

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AMRPA Magazine / November 2018 43

AMRPA & eRehabDataÂŽ Have Your Back

We adapt to regulatory updates to provide real time outcomes reports to inpatient rehabilitation hospitals and units.

Visit eRehabData.com to learn more, or contact Sam Fleming at sam@erehabdata.com to receive a free demo. Without losing any historical data, our staff help you migrate to the only patient assessment system that is trusted, owned, used, and supported by the medical rehabilitation industry.

44 AMRPA Magazine / November 2018