AMRPA Magazine | December 2019

December 2019 • Vol. 22, No.12

The American Medical Rehabilitation Providers Association is pleased to introduce its new logo.

Advocating. Educating. Connecting.

The new AMRPA logo complements the association’s new Vision and Mission Statements, helping solidify its role as a leader in the medical rehabilitation field.

VISION STATEMENT Transforming lives through access to the highest quality of medical rehabilitation care.

MISSION STATEMENT Advancing the field of medical rehabilitation through advocacy, education, and the promotion of access to care.

December 2019 • Vol. 22, No. 12

The official publication of the American Medical Rehabilitation Providers Association (AMRPA)

Table of Contents Letter from the Chair

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Legislative Update

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“Three-Hour Rule” Legislation Ready for Introduction

10

A Month in Review

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CMS Seeks to Refine Medicare Program Integrity Oversight via New Data and Advanced Analytics

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Carolyn Zollar, MA, JD AMRPA Senior Policy Counsel

CJR Second Annual Evaluation Report Continues to Find Reduced IRF and SNF Use in CMS’ Mandatory Joint Replacement Bundles

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Mimi Zhang AMRPA Director of Payment Innovation, Quality and Research

HHS OIG and CMS Propose Changes to Modernize Anti-Kickback and Self-Referral Rules

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AMRPA Hosts Successful Annual Fall Educational Conference & Expo in San Diego

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A Profile in Courage: Retired Sergeant First Class Cory Remsburg Inspires at AMRPA Fall Conference

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AMRPA Honors Leaders in the Medical Rehabilitation Field

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Richard Kathrins, PhD Chair, AMRPA Board of Directors, President & CEO, Bacharach Institute for Rehabilitation John Ferraro, MS AMRPA Executive Director Kate Beller, JD AMRPA Executive Vice President for Government Relations and Policy Development

Remy Kerr, MPH AMRPA Health Policy and Research Manager Patricia Sullivan AMRPA Senior Editor Brian McGowan Design and Layout AMRPA Magazine, Volume 22, Number 12

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.

SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues.

Send subscription requests to AMRPA, 529 14th St., NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1,500; Half page = $1,000; Third page = $750. Ads may be B&W or full color.

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Advertising Contact: Julia Scott, AMRPA, 529 14th St., NW, Suite 1280,Washington, DC 20045 USA, Phone: +1-202-207-1110, Email: jscott@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 ©2019

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 1280, Washington, DC 20045

AMRPA Magazine / December 2019

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Letter from the Chair

Looking Back on 2019 As this year quickly comes to a close we can look back to what was accomplished and look forward to continuing with many of AMRPA’s initiatives. Members of the association and staff continue to work on these critical issues:

Preserving patient access to hospital-level medical rehabilitation Engaging with all medical rehabilitation post-acute care provider groups on various issues facing us and on innovative platforms for the delivery of care.

Maintaining and increasing the value of membership in AMRPA through engagement

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

with our members on important issues

Development of a Continuing Care Network (CCNet) project. The project is a patientcentered program bringing payers, acute care hospitals, post-acute care providers and patients together to offer the care needed at the right level and moving the patient efficiently within the continuum.

Ensuring that we have access to reliable data to support our legislative and regulatory efforts. eRehabData® continues to provide us with this data that is increasingly important to our industry because of all the challenges we face now and will face in the future.

Development of our AMRPA Education and Credentialing Program for rehabilitation administrators and managers, and continuing to enhance the medical rehabilitation field through various educational and networking opportunities If you received your AMRPA membership renewal, I am sure that you saw the list of accomplishments our association has achieved over the last year. Our legislative and regulatory team had many successes. The list of accomplishments is exhaustive. In particular, we can look at our work in the following areas: positive payment updates, responses to CMS’ request for information on regulatory relief issues, ongoing discussions with regulators on issues such as Medicare Advantage coverage reforms, IRF global settlement for denied claims, prior authorization challenges, and our work with other post-acute care provider groups on key priorities and considerations for future alternative payment models.

To ensure that we are moving all of these initiatives forward, we are fortunate to have a highly engaged board and staff. We also have a fully committed and dedicated group of officers and Executive Committee members.

I am very pleased to announce our new slate of officers for the AMRPA Board of Directors who will transition to their new voluntary positions on January 1.

Dr. Robert Krug, Chair, Mount Sinai Rehabilitation Hospital Anthony Cuzzola, Vice Chair, JFK Johnson Rehabilitation Institute David Storto, Treasurer, Partners Continuing Care and Spaulding Rehabilitation Network

Christopher Lee, Secretary, Madonna Rehabilitation Hospital Mark Tarr, Member-at-Large, Encompass Health Gregg Stanley, Member-at-Large, HCA Healthcare Richard Kathrins, Immediate Past Chair I am thankful for all the support I received from you, our members, over the last two years and look forward to continuing to work with you and the association to ensure that patients have access to quality medical rehabilitation.

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AMRPA Magazine / December 2019

Find new and exciting opportunities in AMRPA’s Career Center.

Our newly updated Career Center provides services and resources to help the medical rehabilitation field meet their professional goals.

All rehabilitation professionals may browse and apply for jobs at no cost, and AMRPA members will receive discounted rates for posting positions.

Visit our Career Center Here:

careercenter.amrpa.org

Begin by creating your free Career Cast account, which can be found on the top right hand corner of the website.

From there, you can upload and manage multiple resumes, browse through hundreds of job postings, and even research salaries of the positions in question! AMRPA members and affiliates may also purchase Posting Packages at a standard, premium, or platinum level.

AMRPA members will receive a 50% discount on all job postings.

For questions about our Career Center, please contact Elizabeth Katsion, AMRPA Member Services Coordinator, at ekatsion@amrpa.org or 202-207-1102.

AMRPA Magazine / December 2019

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Legislative Update

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

Highlights: »» »»

»»

»»

»»

n October 31, the House voted 232O 196 to officially establish procedures for public impeachment hearings.

Congress faces a November 21 deadline to finalize FY 2020 Appropriations, as well as other expiring health care extenders.

Another stopgap funding bill extending the deadline into December or even possibly into 2020 remains a possible approach.

Impeachment inquiry in the House may impact the future of drug pricing and other pending health care proposals, but Democrats still plan to vote on Speaker Pelosi’s proposal, H.R.3, in December.

A group of bipartisan, bicameral members reintroduced the Connect for Health Act to improve access to telehealth initiatives.

CMS releases final payment regulations for home health, physicians and outpatient services.

Impact of Impeachment Proceedings On October 31, the House voted 232-196 to officially establish procedures for public impeachment hearings. Impeachment proceedings threaten to derail plans for congressional action on drug pricing and surprise billing this year, as a lengthy impeachment trial would consume valuable year-end floor time in the Senate. In addition, some lawmakers are worried that the divisiveness of public impeachment proceedings would disrupt bipartisan negotiations on health care issues, making it much harder to find a solution amenable to Congressional leaders and the White House. Still, there is significant pressure for Congress to pass a number of health care extender provisions before year-end, and these could be wrapped up in a Continuing Resolution (CR) or other appropriations vehicle.

FY 2020 Appropriations Remain in Limbo While there is little appetite in Congress for a shutdown, especially coming up on a crucial election year, President Trump has refused to rule out the possibility of a funding lapse if Democrats do not stop their impeachment inquiry. Still, the House and Senate continue to move forward on Fiscal Year (FY) 2020 Appropriation bills.

On October 31, the Senate passed a four-bill minibus that combines the FY 2020 Agriculture-FDA, Commerce-Justice-Science, Interior-Environment, and Transportation-HUD appropriations bills. Another four-bill package (H.R. 2740) that includes the Defense, Labor-HHS-Education, State Foreign-Operations and EnergyWater bills failed a procedural vote, however, amid partisan disagreement over funding levels and controversy around border security and abortion.

On November 21, Congress passed another stopgap spending bill that funds the federal government through December 20, 2019. The Continuing Resolution (CR) included short-term extensions of key Medicare, Medicaid, and public health “extender” provisions. In addition, appropriators have reached agreement on topline Fiscal Year 2020 spending levels, and a year-end spending package may emerge this month that could carry a number of health care provisions. Still, at least a partial CR will likely be necessary given the controversy over the Labor-HHS and Homeland Security spending measures. The president’s demand for shifting funding to construction of a wall along the U.S. southern border continues to be a major obstacle in discussions.

Surprise Billing Negotiations Continue and CR May Be a Vehicle Work continues behind the scenes to find a bipartisan solution on surprise medical billing. Leaders of the House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee continue to discuss areas of agreement between their respective bills. They may seek to include a “compromise”

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AMRPA Magazine / December 2019

surprise billing proposal as part of the next CR as a way to pay for another extension of expiring health care “extender” provisions. It seems likely that a compromise proposal would including some element of arbitration.

Drug Pricing Vote May Slip to 2020 Democrats plan to take up H.R. 3, the Elijah Cummings Lower Drug Costs Now Act, in early December. The legislation will likely reflect changes made during markups held by the Energy and Commerce, Ways and Means, and Education and Labor Committees in recent weeks. The White House has come out against Speaker Pelosi’s bill, with Domestic Policy Council Chief Joe Grogan instead urging lawmakers to instead pass the Senate Finance Committee’s Prescription Drug Pricing Reduction Act (S. 2543). Grogan signaled that the administration would also be open to dropping the inflationary rebate provisions in the bill that have drawn the ire of many Republican senators. Majority Leader McConnell (R-KY) has not committed to bringing the Finance package to the floor, and it is growing more likely that action on drug pricing could be pushed to next year.

Lawmakers Introduce Updated Connected Health Legislation On October 30, Sens. Schatz (D-HI), Wicker (R-MS), Cardin (D-MD), Thune (R-SD), Warner (D-VA), and Hyde-Smith (R-MS) and Reps. Thompson (D-CA), Welch (D-VT), Schweikert (R-AZ), & Johnson (R-OH) introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019. The bipartisan legislation would expand telehealth services through Medicare, improve health care outcomes, facilitate patients’ ability to connect with their physicians, as well as help cut costs for patients and providers. The legislation has been endorsed by more than 120 organizations, including AMRPA. Specifically, the bill would amend the current statutory restrictions to telehealth, such as geographic and originating site requirements that only permit beneficiaries to receive telehealth services if they are in certain rural areas and at certain clinical sites for mental health and emergency medical care, and would allow rural health clinics and other community-based health care centers to provide telehealth services. The legislation would require the Medicare Payment Advisory Commission (MedPAC) to study more ways to expand telehealth services so that more people can access health care services in their own homes, and authorizes a model to test allowing additional health professionals to furnish telehealth services.

Final Medicare Payment Regulations Released On November 1, CMS released the Calendar Year (CY) 2020 Hospital Outpatient Prospective Payment System (OPPS) Final Rule, that increases Medicare hospital outpatient prospective payment system (OPPS) rates by a net 2.6% in calendar year 2020 compared to 2019. In addition, the rule continues to implement the site-neutral rate (40% of the OPPS rate) for clinic visits provided in grandfathered off-campus departments for CY 2020. CMS also moved forward with cuts to drugs purchased under the 340B drug savings program. Both of these policies have been threatened by court decisions and

CMS confirms the agency is reviewing its appeal rights, but maintains it has the authority to continue these policies.

Of note, the final rule does not include the proposed hospital price transparency requirements. Instead, these provisions were severed from the Outpatient Final Rule and a separate rule titled "CY 2020 Hospital Outpatient PPS Policy Changes: Price Transparency Requirements for Hospitals to Make Standard Charges Public" was finalized on November 15. CMS likely uncoupled the price transparency proposal from the OPPS final rule to avoid potential litigation from stakeholders.

On October 31, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2020 Home Health Prospective Payment System Final Rule. The regulation finalizes payments to home health agencies (HHAs) by 1.3% ($250 million) for 2020, which includes reductions to the rural add-on payments mandated by the Bipartisan Budget Act of 2018. The rate also includes adjustments for changes expected with implementation of the Patient-Driven Groupings Model (PDGM) and the 30-day unit of payment, as well as updates to the home health wage index data and outlier payments determined by the fixed-dollar loss ratio.

As expected, PDGM will begin on January 1, 2020, accompanied by a change in the unit of home health payment from 60-day episodes of care to 30-day periods of care, which will be adjusted for outliers and partial episodes, as applicable.

CMS will move forward with the same behavioral assumptions finalized in the 2019 pay rule, but the CY 2020 30-day payment amount (for those HHAs that report the required quality data) will be $1,864.03, which reflects an adjustment of -4.36% to maintain overall budget neutrality under the PDGM. This adjustment has been nearly halved from the proposed 8.01%.

CMS also released its CY 2020 Physician Fee Schedule Final Rule on November 1. The finalized CY 2020 PFS conversion factor is $36.09, a slight increase of $0.05 above CY 2019. As expected, CMS finalized several changes to the documentation of and payment of Evaluation and Management (E/M) visits, which will go into effect on January 1, 2021. Last year, CMS had proposed to simplify E/M codes by collapsing the levels into a single, blended payment rate. Stakeholders objected, and the American Medical Association’s (AMA) CPT Editorial Panel proposed a plan which CMS ultimately finalized. The five levels of E/M codes will remain for current patients but the number of coding levels will be reduced to four for new patients. Revisions were also made to the code definitions, and clinicians will now be able to choose the E/M visit level based on either time or medical decision-making. Value recommendations from the AMA’s Specialty Society Relative Value Scale Update Committee (the RUC) were also included in the Final Rule, and therefore overall office/outpatient EM/M visits should see an increase in reimbursement. The Final Rule provides more flexibility for physician assistants to practice more independently, and reduces medical record documentation burden by allowing other clinicians to review and verify medical records. CMS also created a new code for patients with only one serious

AMRPA Magazine / December 2019

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and high-risk chronic condition, and increased payment for transitional care management (TCM) services. Additionally, CMS established modifiers to identify services provided by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10% standard for when these modifiers will apply to specific services beginning on January 1, 2020.

CMS Announces 2020 Medicare Parts A & B Premiums and Deductibles On November 8, CMS released several notices regarding 2020 premiums, deductibles and coinsurance amounts for Medicare Part A and B. As required by the Social Security Act, Medicare premiums, deductibles, and copayment rates are adjusted annually. For 2020 the Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,408, an increase of $44 from $1,364 in 2019.

Beneficiaries will pay a coinsurance amount of $352 per day for the 61st through 90th day of a hospitalization ($341 in 2019) in a benefit period and $704 per day for lifetime reserve days ($682 in 2019) in 2020. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $176.00 in 2020 ($170.50 in 2019). For 2020, the Medicare Part B monthly premiums and the annual deductible are higher than the 2019 amounts, which CMS explained is due to the increased spending on physicianadministered drugs. The standard monthly premium for Medicare Part B enrollees will be $144.60 for 2020, an increase of $9.10 from $135.50 in 2019. The 2020 annual deductible for all Medicare Part B beneficiaries is $198, an increase of $13 from the annual deductible of $185 in 2019. *** It is hard to believe that the final month of 2019 is upon us, and we are gearing up to enter a new decade. You can expect the final days of the first session of the 116th Congress to

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AMRPA Magazine / December 2019

be tempestuous at best. Lawmakers and their staff will be feverishly working to pass their legislative priorities over the next few weeks, while also dealing with how to keep the federal government open and avoiding another yearend shutdown.

And, of course, on top of all this, House Democrats have begun impeachment hearings, which may curtail prospects of good faith negotiations with the Trump administration. Members are scheduled to wrap up their legislative work by the second week in December, but we do expect them to stay several days longer before officially concluding for the year.

Please utilize the upcoming winter recess to meet with your members of Congress to alert and educate them on the value of medical rehabilitation and AMRPA’s legislative priorities, including the negative impact of prior authorization for inpatient rehabilitation services and three-hour rule reform. Urge your Representatives to reform the prior authorization program in Medicare. Members of Congress need to be educated about the adverse impact of the use of prior authorization in the Medicare Advantage (MA) program, and the care delays and patient access issues that MA practices present certain types of providers, including inpatient rehabilitation hospitals and units. Specifically, encourage them to co-sponsor H.R. 3107, the Improving Seniors’ Timely Access to Care Act of 2019 which tackles some of the most challenging problems presented by prior authorization.

We are happy to provide you with any additional information and assistance you may need in reaching out to your Senators and individual members of Congress. Please be in touch if you need any assistance! In this still-new Congress, we greatly appreciate your time and willingness to help AMRPA build relationships and educate Members of Congress about key issues of concern to the field.

AMRPA Schedule of Events CONFERENCE DATES 2020 Spring Conference and Congressional Fly-In March 22-24, 2020 Washington, DC AMRPA WEBINARS Wednesday, December 11, from 1:00 p.m. - 2:00 p.m. ET CMS Discharge Planning Final Rule: What You Need to Know Presented by: Peter W. Thomas, JD, Powers Pyles Sutter & Verville, PC, and Tracey Nixon, MS, CHC, ROC Healthcare Advisors Wednesday, December 18, from Noon - 1:00 p.m. ET Lessons Learned During Implementation of an Interdisciplinary Medication Management Program Presented by: Carolyn Ferrer, MOT, OTR/L, CPAM and Kathleen Sell, MS, OTR/L, CKTP, Rehabilitation Institute of Michigan eRehabData® WEBINARS: AVAILABLE TO eRehabData® SUBSCRIBERS ONLY Visit eRehabData.com for more Information.

Please visit www.amrpa.org for registration information.

AMRPA Magazine / December 2019

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“Three-Hour Rule” Legislation Ready for Introduction

ARMPA's 2019 policy priorities include a focus on updating outdated regulatory requirements to put patients back at the center of their care. The Centers for Medicare and Medicaid Services (CMS) calls its initiative on regulatory relief, “Patients Over Paperwork.” One of these outdated requirements is the so-called “three-hour rule,” which governs Medicare’s interpretation of the intensity of therapy requirement that must be met for patients to be admitted to an inpatient rehabilitation hospital or unit (IRF).

Peter W. Thomas, JD, Principal, Powers Pyles Sutter & Verville, PC

Along with the American Academy of Physical Medicine and Rehabilitation and other stakeholder organizations, AMRPA has worked to develop soon-to-be-introduced legislation in the House to restore rehabilitation physician judgment when determining the mix of skilled services that can count toward the three-hour rule. We expect to see this important bipartisan bill officially introduced in the coming weeks by Rep. Glenn “G.T.” Thompson (R-PA) and will continue to work to support its enactment into law.

Background CMS uses an intensity of therapy requirement as one of the factors in determining which Medicare beneficiaries qualify for treatment in an IRF. This so-called “three-hour rule” requires a patient to be able to participate in, and benefit from, at least three hours of rehabilitation therapy per day, five days per week (or if documented appropriately, 15 hours of skilled therapy over a consecutive seven-day period).

Prior to 2010, CMS regulations for IRFs explicitly recognized physical therapy, occupational therapy, speech therapy, and/or orthotic and prosthetic services as countable toward the three hour rule. Additionally, the physician and the rehabilitation team were given the authority to prescribe an appropriate mix of “other therapeutic modalities” on a priority basis in addition to the skilled services listed in the regulation, based on the individual treatment needs of the patient.

These other skilled modalities could be counted toward satisfaction of the three-hour rule based on Medicare carrier discretion. This language allowed rehabilitation physicians (and the rehabilitation team) to prescribe the mix of skilled therapies and services most appropriate to meet each patient’s needs, as each patient progressed through their rehabilitation stay, and count these other skilled therapies toward the three hour rule.

In 2010, CMS revised the IRF regulations and limited the three-hour rule to only the four previously listed modalities, removing the physician’s discretion to count additional skilled therapeutic services toward satisfaction of the rule. Other skilled therapies including recreational therapy, psychological services, respiratory therapy and neuropsychological services can no longer be counted toward the rule. Although these services remain covered in IRFs and IRFs are permitted to provide these services (and many do), the fact

10 AMRPA Magazine / December 2019

that they cannot be counted toward the rule has limited their availability in many rehabilitation hospitals and units.

When CMS redefined the three-hour rule in 2010, the agency’s rationale for the change was that the four listed therapies (PT, OT, SLP and O&P) formed the “core” of skilled therapy services available in an IRF. IRF stakeholders at the time questioned whether speech therapy was “core” to rehabilitation of a patient without a speech impairment, or whether prosthetic services were “core” to a patient without limb loss. Nonetheless, CMS finalized its rule and clarified that the final regulation not preclude IRFs from offering additional services and noted that unlisted therapy services should not be used to demonstrate a patient’s need for intensive therapy.

Although CMS regulations state that “rules of thumb” cannot be used to deny admission of Medicare patients to IRFs and, therefore, the three-hour rule is not supposed to be used as the explicit basis for a coverage denial, the fact remains that the strict limitation on therapies able to be counted toward the three-hour rule has been viewed by the IRF field as a limitation in access to these other skilled services in IRFs. Previous Legislation In past years, AMRPA has supported legislation in Congress to revise the three-hour rule to allow recreational therapy to be counted toward the intensity of therapy requirement.

Recreational therapy, also known as therapeutic recreation, is a skilled rehabilitation service designed to restore, remediate and rehabilitate a patient’s level of functioning and independence in life activities, to promote health and wellness, as well as to reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition.

Recreational therapy in IRFs is provided by certified recreational therapy specialists (CTRS) when required by the patient’s condition and prescribed by a physician as part of a patient’s plan of care.

In the 115th Congress, Rep. Glenn “G.T.” Thompson (R-PA), a former therapist himself, and Rep. G.K. Butterfield (D-NC) introduced the Access to Inpatient Rehabilitation Therapy Act of 2017, H.R. 626. The bill would have revised the Social Security Act to explicitly include recreational therapy services among the therapeutic modalities that could be used to demonstrate an intensive rehabilitation program under the three-hour rule.

Unfortunately, the bill did not gain much traction in its previous iterations, likely due to a lack of familiarity and understanding of recreational therapy and the limited scope of the proposed changes.

Current Legislation In response to the barriers the legislation faced in past years, AMRPA’s Washington representatives worked with Thompson’s staff to improve the language of the bill. The current version, soon to be introduced in the 116th Congress, would largely return to the pre-2010 interpretation of the rule. It will restate the focus on the

four main skilled therapies already listed in the regulation but then provide a greater focus on physician judgment when determining which other skilled services can be counted toward satisfaction of the three-hour rule. This change in the legislative text would help facilitate access to the appropriate mix of skilled services in the IRF setting and would benefit people with brain injuries, spinal cord injuries, those who have sustained strokes and amputations, individuals living with neurological disorders, and IRF patients with a wide range of other conditions.

The new language maintains the explicit focus on physical therapy, occupational therapy, speech language pathology and orthotics and prosthetics services, while adding flexibility for the physician and the rehabilitation team to determine the appropriate mix of skilled services that will best suit an individual patient, providing a more patient-centered, intensive treatment plan. Specifically, the bill would revise the Social Security Act to state that CMS shall allow a rehabilitation physician to include “other skilled therapeutic modalities as part of the intensive rehabilitation program” to fulfill the three-hour rule. The bill further specifies that “other skilled therapeutic modalities” shall include “recreational therapy, psychological services, neuropsychological services, respiratory therapy, and other skilled services as determined by the Secretary.”

This revision of the past legislation would expand the scope of the previous version of the legislation and increase patient access to medically necessary therapies that currently cannot count toward the three-hour rule. Providing rehabilitation physicians and their care teams the authority to design a rehabilitation plan based on the individual patient’s specific needs of care should help achieve better health outcomes for patients, allow better coordination of therapy teams in the IRF, and, hopefully, reduce unnecessary readmissions to acute care settings.

Current Status and Support AMRPA has been working diligently with AAPM&R ahead of the bill’s introduction to shore up bipartisan support for this legislation, meeting with several congressional offices as potential leads on the legislation with Thompson. The bill has already received support from a diverse group of organizations, including the American Therapeutic Recreation Association, the Association of Rehabilitative Nurses, the Brain Injury Association of America, the Christopher and Dana Reeve Foundation, the National Association of State Head Injury Administrators, and the United Spinal Association.

Staff in Thompson’s office and the congressman himself are committed to advancing this bill across the finish line in this Congress. Enacting the Access to Inpatient Rehabilitation Therapy Act will expand patient access to needed therapies in order to best restore their health and function, and will allow physicians the leeway needed to prescribe the best care for their patients.

We look forward to the introduction of the legislation in the coming weeks and will keep our members up to date on new developments regarding this important bill.

AMRPA Magazine / December 2019 11

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Visit www.amrpa.org/PAC-Market-Analysis-Reports for more information, or contact Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org.

AMRPA Magazine / December 2019 13

A Month in Review

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

As of press time, the new section GG/H Case Mix Groups (CMGs) have formed the basis of inpatient rehabilitation facilities’ (IRFs) payments for more than one month. This is a good time to reflect on lessons learned and to highlight the questions that remain unanswered. There are plenty of examples of both. I will start by comparing data points.

According to eRehabData®, the industry case mix index (CMI) for 3rd Quarter 2019, which was the last quarter of FIM™-based CMGs for Medicare patients, was 1.3999. The CMI for October 2019, the first month of the new GG/H CMGs, was 1.4185. This represents an additional $306.70 per case based on the federal fiscal year (FY) 2020 base pay rate. For October discharges, the average admission subscale is 49.55. This breaks down to 21.20 for the self-care items and 18.90 for the mobility items. The average discharge subscale is 70.63.

What does that mean for you? It seems that we have an opportunity to capture a higher reimbursement for Medicare patients. In order to determine if the CMG change has been positive for you, compare your CMI for 3rd Quarter 2019 to your CMI for October 2019 discharges. Hopefully, your numbers will be favorable. Regardless of your findings, it is important to capture scores on the IRF-PAI that accurately reflect the care involved in managing your patient’s needs.

When examining items, break down the self-care element first. The scoring of self-care items changed the most from the FIM™ scale to the section GG/H items. For example, GG/H eating does not incorporate the burden of care with tube feeding. Toileting, dressing and oral hygiene scores are based on the amount of care overall, rather than steps like in the FIM™ instrument. Medical devices such as braces and compression hose are considered items of clothing. Because all these changes can easily be forgotten by nurses and therapists, continue to review these items with staff.

Review the mobility elements. Make sure that patients are assessed based on their prior level of function where possible. While ensuring that the safety of the patient is never compromised, consider the necessity of using a device or the amount of assistance required based on the way the patient would have performed the task prior to admission.

Be sure you can identify the difference between completing an assessment and providing intervention. If the patient is unable to complete the task without intervention, then consider what is safest for the patient and provide the amount of assistance that the patient requires. If necessary, abort the task.

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Review the individual scoring of items by analyzing the functional scoring comparison graph. Isolate where the nurses and therapists may not be completing an assessment. In your records, look for nursing involvement in scoring. As I have provided training to nurses and therapists, I focus attention on the nurses completing assessments of the patients’ bed mobility, bed to chair transfers, toileting transfers, toileting, oral hygiene, and eating prior to the therapy evaluations. Each nurse should carve out time to complete these assessments once during the shift when the patient is admitted and again on the night shift. This is not a task that should be left to the nursing assistants. Rather, the nurse should communicate with the nursing assistants to allow the nurse the opportunity to complete their own assessment when the patient calls for the bathroom. The bed mobility assessment can be completed in conjunction with the skin assessment when the patient is rolling from side to side. The lying to sitting and sitting to lying can be completed when the nurse sits the patient up to listen to their lungs or when they need to get out of bed to use the bathroom.

Review the IRF-PAI Manual decision trees and remind therapists and nurses of the nuances of scoring. Remember that the assessments should be completed prior to beginning interventions with the patient. According to CMS guidance, the admission

scores should reflect the patient’s baseline status. Once the treatment program has been initiated, the scores will reflect the treatment. Therefore, recording additional scores is unnecessary.

If your scores are vastly different than the national or regional benchmarks and you cannot figure out why, shadow your staff.

Look for assessments versus item completion that involves teaching and intervening. Provide feedback to the nurses and therapists when their cueing moved from a basic cue to teaching the patient how to complete a task. There is a difference between giving the patient step-by-step instructions and providing a few simple cues. Make sure the nurses and therapists know and are practicing the difference.

Have you compared your performance under the GG/H CMGs to the old CMI? Now is the time to correct behaviors before new habits are formed and change becomes more difficult. Spend time on shadowing and chart reviews, with a focus on continuing your education in a purposeful manner. Monitor your CMI. Aim for numbers higher than your 3rd Quarter 2019 benchmarks. Adjusting to the new requirements will take time. These suggestions will help your facility with implementing best practices and capturing higher reimbursement for Medicare patients.

AMRPA Magazine / December 2019 15

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18 AMRPA Magazine / December 2019

CMS Seeks to Refine Medicare Program Integrity Oversight via New Data and Advanced Analytics

Kate A. Beller, JD, AMRPA Executive Vice President for Policy Development and Government Relations

AMRPA Closely Analyzing CMS’ Proposals to Assess Impact on Inpatient Rehabilitation Claim Reviews, Patient Access In late October, the Centers for Medicare and Medicaid Services’ (CMS) Center for Program Integrity (CPI) released two Requests for Information (RFIs) that shed light on potential future CMS initiatives regarding its program oversight and provider education efforts. CMS cites several reasons for engaging in this type of outreach, including the fact that program integrity tools need to be reformed and modernized in order to effectively apply to the new value-based payment (VBP) models being tested throughout the Medicare program. Furthermore, and of particular interest to the American Medical Rehabilitation Providers Association (AMRPA), CMS states that it has reviewed program integrity and program vulnerability-related recommendations from the Government Accountability Office (GAO) and U.S. Department of Health and Humans Services Office of the Inspector General (HHS OIG), and that stakeholders “may have recommendations for us to better effectuate worthy recommendations.” AMRPA has consistently argued that federal oversight review of inpatient rehabilitation hospital/unit (IRF) claims could be improved through certain changes – such as reforms to qualification reviewer standards – and looks forward to engaging CMS on ways to improve the identification of improper payments.

The first “Future for Program Integrity” RFI is directed to provider and provider associations. CMS states that one of the key goals of this RFI is “to identify nextgeneration strategies, tools and technologies that will assist us in anticipating, assessing and acting in real time upon opportunities and vulnerabilities highlighted by our partner federal agencies rather than ‘chasing’ the recovery of improper payments.” To this end, CMS clarifies that it is looking for “innovative, but fiscally prudent and operationally feasible ways” to make its program integrity administration more effective and efficient.

CMS specifies that the agency looks particularly for technologies and approaches that CMS has not previously explored (such as biometrics and smartcards), and hopes to receive suggestions with respect to new technologies that can effectively detect/prevent fraud while limiting burdens for providers, suppliers and patients.

CMS outlines four major areas of focus tied to these objectives: 1. Program integrity for value-based arrangements; 2. Ensuring integrity of Medicare Advantage plan practices; 3. Use of prior authorization in the traditional Medicare program; and 4. Enhanced provider education.

AMRPA Magazine / December 2019 19

Additional detail on CMS’ current concerns and priorities within each of these areas is detailed below: Program Integrity for Value-Based Payment Programs CMS states particular interest in identifying new program integrity approaches that are more tailored for emerging value-based payment models. CMS specifically notes that because “these [newer] models mitigate the incentive to provide unnecessary services to maximize payment, existing medical review protocols aimed at identifying overutilization may need to be modified or re-engineered.” CMS acknowledges that while concerns about overutilization in these payment models may diminish compared to the traditional fee-for-service (FFS) structure, new program integrity concerns arise under these models – such as concerns regarding care stinting and inappropriate beneficiary attribution. AMRPA has raised these concerns to CMS in certain value-based payment model contexts, such as with respect to inpatient rehabilitation access in certain accountable care organization (ACO) structures.

CMS seeks stakeholder input on a range of issues, including the use of advanced analytics, the reporting of alternative (e.g., nonclaims-based) data, or other mechanisms to identify improper payments, beneficiary safety issues, and other program integrity related concerns. CMS adds that it will further determine whether innovative new strategies, tools and technologies presently exist that can increase data accuracy and integrity and consequently reduce improper payments. CMS poses a number of questions to stakeholders on this issue including, but not limited to: What useful improper payment detection or prevention controls have private sector payers employed to protect against improper payments in a value-based environment?

How can payers ensure that payments in VBP programs accomplish the goals of improving the value of the care provided?

What additional data should CMS collect or examine to evaluate coverage, appropriateness of care, and beneficiary assignment?

Integrity of Medicare Advantage Practices In the context of Medicare Advantage (MA), CMS primarily focuses on the use of contract-level risk adjustment data validation (RADV) audits by MA plans. CMS notes that these audits are “not only expensive and time-consuming for CMS but also expensive and burdensome on plans and providers/suppliers who must submit voluminous patient records for review.” To that end, CMS seeks stakeholder feedback on ways to perform claim reviews in ways that are lower cost and carry substantially less burden for plans and providers, potentially integrating the use of artificial intelligence or other new technologies. CMS asks a series of questions designed to advance this goal, such ways to incorporate innovative program integrity approaches that private plans use in their commercial, Medicaid and MA line of business.

20 AMRPA Magazine / December 2019

Prior Authorization in FFS Medicare Of particular concern to AMRPA, the RFI expresses interest in exploring the use of prior authorization or other types of new claim review processes in FFS Medicare. A provision in the FY 2020 HHS Budget proposed a prior authorization program in FFS Medicare, and AMRPA zealously advocated against the implementation of such proposal.

In the RFI, CMS states concern that more than 99% of Medicare claims are processed and paid “without any medical review,” compared to the “aggressive use” of tools such as prior authorization by private payers. CMS asserts that “more reviews

by CMS could reduce improper payments,” but states that certain requirements – such as having a clinician personally review the patients’ charts – is “very costly.” As such, the agency is seeking input on “new and innovative strategies and technologies, perhaps involving artificial intelligence and/or machine learning that are more cost effective and less burdensome to both providers, suppliers and the Medicare program.” CMS seeks the most feedback from stakeholders on this issue, asking for input on the following specific questions: What program integrity activities should CMS consider to ensure that items or services are provided as approved through the prior authorization process?

Can clinical decision support tools play a role in prior authorization? If yes, how?

How can CMS apply prior authorization without adding to provider and supplier burden?

How can CMS apply prior authorization while maintaining timely and complete access to medically reasonable and necessary covered services for our beneficiaries?

While prior authorization helps ensure that services or items to be furnished comply with all applicable coverage and coding rules at the time of the prior authorization request, some requirements cannot be assessed until after care delivery. What information cannot be captured by a prior authorization process, and does this limit or restrict prior authorization?

Are there other issues with respect to prior authorization that CMS should consider?

AMRPA will be carefully considering whether and how the use of these new technologies, such as artificial intelligence, could impact inpatient rehabilitation claim review and engage with CMS extensively as it considers prior authorization-related reforms in FFS Medicare.

Provider Education On the issue of provider education, CMS states support for its Targeted Probe and Educate (TPE) program, noting that this type of “personalized education” has helped providers “evolve beyond the ‘pay and chase’ paradigm” and “improve compliance and reduce appeals.” CMS states, however, that provider education through TPE has still been hamstrung by several factors, including the fact that a “significant percentage of providers and suppliers do not respond timely to the opportunity for TPE.” CMS also notes that it sees more opportunity to enhance providers and suppliers’ awareness of documentation requirements earlier in the claims process in order to improve billing practices. CMS states it is therefore calling on the private sector and the broader provider community for input on “whether new strategies, tools or technologies exist that we are not currently using to address and resolve these challenges.”

The second RFI – “Advanced Technology in Program Integrity” – is considerably more focused on how data/advanced analytics can help CMS improve its program integrity oversight. Specific issues/potential future measures for which CMS requests comment include, but are not limited to, the following: The development of a new tool or technology that would allow access to state and local business ownership and registration information that “could improve CMS’ line-ofsight to potentially problematic business relationships;”

Potential new “strategies, tools and technologies” that may be a preferable alternative to RADV audits in Medicare Advantage; Identifying the types of data that can effectively “evaluate coverage and the appropriateness of care, and monitor other factors, such as beneficiary attribution” under new payment models; and The strategies, tools, or technologies that exist to help providers and suppliers become more aware of the necessary documentation requirements earlier in the claim process.

The RFI also includes a series of questions related to the specific use and implementation of artificial intelligence, documentation requirement repositories, advanced analytics, and other specific tools CMS may consider using in its program integrity modernization efforts. **** AMRPA will be providing substantive comments on these RFIs and will carefully monitor how new program integrity tools – such as prior authorization reforms and the use of artificial intelligence – may impact inpatient rehabilitation reviews and patient access in the future.

Potential use of artificial intelligence or machine learning tools as a potential “cost effective” and “less burdensome” alternative to prior authorization for claim reviews in FFS Medicare;

AMRPA Magazine / December 2019 21

CJR Second Annual Evaluation Report Continues to Find Reduced IRF and SNF Use in CMS’ Mandatory Joint Replacement Bundles The Centers for Medicare and Medicaid Services (CMS) recently issued the second annual evaluation report on the Comprehensive Care for Joint Replacement (CJR) model.

This report, again prepared by The Lewin Group for CMS, presents findings from the first two performance years of the model, which spans from April 1, 2016, through December 31, 2017. For comparison, the first CJR evaluation reflected the model’s first performance “year” (April through December 2016).

Mimi Zhang, AMRPA Director of Payment Innovation, Quality and Research

The report finds that CJR continues to significantly reduce the use of institutional postacute care (PAC). Specifically, reductions in payments for both elective and non-elective lower extremity joint replacement (LEJR) episodes were largely driven by reducing the use of inpatient rehabilitation hospitals and units (IRFs) and skilled nursing facilities (SNFs).

More CJR patients were first discharged to an HHA; however, there was no statistically significant change in HHA payments.

Highlights:

This article summarizes key findings of the second CJR evaluation report, and highlights those findings of interest to rehabilitation hospitals and AMRPA members.

»»

Background Implemented in 2016 by the Center for Medicare and Medicaid Innovation (CMMI), CJR is intended to test whether episode-based bundled payments and quality measurement for LEJR can lower payments and improve quality. CJR holds acute-care hospitals in certain markets accountable for the cost and quality of a 90-day bundle of elective and non-elective LEJR episodes. To date, CJR remains CMS’ sole mandatory care delivery alternative payment model (APM). As such, it is a significant marker on CMS’ roadmap to shift from volume-based to value-based payment via APMs.

»»

»»

JR reduced LEJR episode costs by C changing PAC use to shift away from IRFs and SNFs to using less intensive settings.

A smaller proportion of CJR patients were discharged to an IRF and a larger proportion to HHAs. Lewin reports that CJR “maintained” quality outcomes such as readmissions, mortality, and emergency department use. However, for those patients using PAC, a smaller proportion of CJR patients improved their functional status than control patients while in the PAC setting.

After accounting for reconciliation payments, CJR has resulted in a net savings of 0.5% to Medicare in its first two years.

22 AMRPA Magazine / December 2019

This second evaluation report covers the first two CJR performance years during which 147,932 LEJR episodes were initiated by 733 acute-care hospitals located in 67 metropolitan statistical areas (MSAs) across the country. CJR participation was mandatory in this timeframe; in 2017 however, under the leadership of then-HHS Secretary Tom Price, M.D., CMS scaled back the mandatory nature of the model so that, starting in 2018, only the 34 highest-spending MSAs were mandated to finish out the remaining three years of the five-year demonstration model. Hospitals in the 33 other MSAs were no longer required to participate, but were given a one-time opportunity to continue. Similarly, rural

or low-volume hospitals in any of the 67 MSAs were given the same option to discontinue participation.

Payment and Performance Reconciliation CJR participant hospitals are financially responsible for the quality and cost of an episode of care beginning with the LEJR surgery through 90-days post-discharge. All Medicare-covered items and services provided during the episode (with some exclusions) are included in the episodic cost bundle. All providers involved in the episode continue to be paid under Medicare’s existing fee-for service (FFS) payment systems.

At the beginning of each performance year, a 3% discount is applied to a hospital’s historical payment amount. CMS uses a target pricing approach that incorporates historical hospitalspecific and region-specific pricing and a quality adjustment.

CMS also stratifies elective versus non-elective fracture LEJRs into separate spending targets.

At an end-of-year reconciliation process, CMS assesses whether participant hospitals have achieved the established financial and quality targets. Participant hospitals may earn reconciliation payments if they meet those metrics, and face repayments to Medicare if they do not. Hospitals must achieve (1) LEJR episode payments below the target price, and (2) a threshold performance on quality measures in order to be eligible to earn a reconciliation payment from Medicare. Hence, any hospital that meets or exceeds those benchmarks may be subject to the full 3% discount.

The quality composite score is based on hospital performance on the total hip arthroplasty/total knee arthroplasty complications measure, a Hospital Consumer Assessment of Healthcare Providers and Systems survey measure. Hospital can also report a patientreported functional status outcome measure on a voluntary basis to earn additional points on their quality score.

CJR Hospital Strategies Lewin interviewed participant acute-care hospitals for feedback on how CJR has impacted their approaches to managing care. Of the 196 survey respondents:  8 9% reported implementing same day post-surgery ambulation and physical therapy  8 1% reported scheduling follow-up appointments for all LEJR patients prior to discharge  6 5% reported implementing repeated telephonic follow-up during the entire 90-day episode  6 1% felt that physician engagement in care redesign activities had improved since the CJR model  A ccording to Lewin, orthopedic surgeons and other clinicians interviewees were “consistent in their view that home was the best place for most patients to recover and that with time, CJR patients would achieve the same level of functioning after their surgery.”

“Decreases in payment were due to shifts from more to less intensive PAC. CJR participant hospitals discharged a relatively smaller proportion of patients to an inpatient rehabilitation facility (IRF) and a relatively larger proportion of patients to a home health agency (HHA) than control group hospitals. Furthermore, CJR patients with a skilled nursing facility (SNF) stay spent relatively fewer days in a SNF than control group patients did. These shifts in utilization resulted in statistically significant decreases in IRF and SNF payments, which drove the decrease in average episode payments.”

The mandatory nature of CJR is the major distinction between it and similar CMMI APM demonstrations such as Model 2 of CMMI’s Bundled Payments for Care Improvement (BPCI) initiative.

Key Takeaways on CJR Impact Lewin found that CJR participant hospitals responded to the model incentives by changing PAC service use. Hospitals shifted patients to less expensive PAC settings, and this was the main source of the savings generated under the model. Hospitals also implemented different strategies to manage care episodes.

Payment Impact During the first two performance years, the CJR model reduced the average cost for LEJR episodes. CJR episode payment decreased by 3.7% more ($997) in the first two years of the model, representing $146.3 million in gross savings.

(See Exhibit 3) After accounting for $128.9 million that CMS distributed in reconciliation payments to hospitals, CJR produced net savings to Medicare of $17.4 million, or 0.5% of baseline payments.

Lewin directly attributes the cost reduction to PAC use, stating that:

AMRPA Magazine / December 2019 23

Impact on PAC Use and Case-Mix Cost reductions were largely driven by reducing the use of IRFs and SNFs. (See Exhibits 11, 12 and 13) CJR participant hospitals discharged 27.4% fewer patients to IRFs. This resulted in a relative decrease in IRF payments of $357 for CJR episodes. During the baseline period, a greater proportion of CJR patients were discharged to an IRF than control group patients. The proportion of patients discharged to an IRF declined for both groups, although more so for CJR patients, so that during the intervention period, a smaller proportion of CJR than control patients were discharged to an IRF (Exhibit 13). Lewin did not find changes in the average IRF length of stay (LOS), and states this is not unexpected given that Medicare pays IRFs on a per-discharge basis.

There was a relative decrease of $508 in SNF payments, driven by a 2.3 day relative decrease in the number of SNF days. Lewin remarks that hospitals have an incentive to influence SNFs to reduce LEJR days to reduce overall episode costs.

Although more CJR patients were first discharged to an HHA, there were no significant changes in HHA services over the entire LEJR episode. Because some patients receive home health care following discharge from institutional PAC, Lewin examined the proportion of patients who received care from an HHA at any time during their episode. There was no statistically significant difference in the proportion of patients who had home health care at any time during the episode.

Lewin concludes that the decrease in patients discharged to IRF and the increase in the proportion discharged to HHA suggest that the CJR model resulted in shifts in care from more intensive to less intensive PAC settings. Lewin additionally comments that this result “is consistent” with their expectations for how participating hospitals would respond to CJR by “reducing the use of a costlier institutional PAC and replace it with less expensive HHA services to reduce payments during the episode of care.”

Given the shifts from more intensive to less intensive PAC settings, Lewin says it expected patient complexity to increase in the IRF, SNF and HHA settings. It found evidence that complexity increased in IRF LEJR patients, some evidence to suggest this may have occurred in SNFs, but no evidence that it did in HHAs. Impact on Quality Outcomes: Lewin concluded that CJR maintained quality of care in the first two performance years. Lewin reported that it did not find statistically significant changes in the quality of care for CJR episodes relative to control group episodes. The outcomes measured were readmission rates, emergency department visits, and mortality.

24 AMRPA Magazine / December 2019

By the end of the episode, CJR and non-CJR control patients reported making similar gains in functional status from before their hospitalization. Self-reported pain did not differ between the two groups.

Notably however, Lewin found that for those patients discharged from the hospital to an IRF, SNF or HHA, a smaller proportion of CJR patients improved their functional status than control patients while in the PAC setting. CJR and

Findings on Unintended Consequences: There is some evidence that the population of CJR patients receiving elective LEJR without major complications or comorbidities became healthier on average relative to the control group, which could indicate patient selection or induced demand (cherry-picking).

The CJR model had no statistically significant impact on payments for services provided during the 30 days following the episode. This indicates that CJR participant hospitals did not shift services until after the end of the 90-day post-hospital discharge period to lower average episode payments.

The CJR model did not have a statistically significant impact on the volume of elective LEJR discharges.

Report Conclusions Lewin concludes that the CJR model “continues to be a promising approach” to reduce Medicare LEJR episode costs. Evidence suggests that CJR participant hospitals may have better targeted where their patients were discharged, reserving institutional PAC for patients with greater needs. Changes in functional status and pain outcomes during the shorter term, however, indicated a reduction in the proportion of CJR patients discharged to PAC who improved their functional status during their PAC stay, relative to control patients.

Future reports will continue to evaluate whether the lower episode payments translate into savings for the Medicare program, and the impact of changes in PAC on longer-term patient outcomes.

The next annual report will also examine the impact of the CJR model on the hospitals that remained mandatory participants and on all hospitals that ever participated in the CJR model. Lewin also intends to further investigate whether CJR’s payment dynamics creates patient selection or induced demand incentives for acutecare hospitals.

The complete report and accompanying materials are available at https://innovation.cms.gov/initiatives/CJR. control respondents reported similar satisfaction with their overall recovery and care management and had similar care transitions experiences, although CJR respondents reported more reliance on caregiver help during their recovery.

Less than 10% of CJR patients were discharged to an IRF during the baseline period. IRF stays averaged 11 days. For CJR patients first discharged to an IRF, the average change in mobility score during their IRF stay improved by 0.2 points from baseline to intervention (from 10.7 to 10.9). In comparison, for control group the average change in mobility score improved by 0.6 points (from 10.2 to 10.8). See Exhibit 20). As a result, the average change in mobility score for CJR patients was lower than for the control group. However, as noted above, IRF CJR patients were also more clinically complex than non-CJR IRF patients in the control group.

*** From a purely financial perspective, early results of CJR demonstrate that it has delivered on reducing the cost of LEJR care. But it still remains to be seen if the model will actually improve the value of patient care and deliver high quality and durable functional outcomes that fully enhance patients’ quality of life. CJR’s dramatic reduction of institutional PAC utilization remains concerning, especially given the lack of evidence on the model’s longer term impact on patient well-being and outcomes.

AMRPA will continue to advocate for the critical need to maintain patient access to medically necessary rehabilitation hospital services in bundled payment and other alternative payment models.

AMRPA Magazine / December 2019 25

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HHS OIG and CMS Propose Changes to Modernize Anti-Kickback and Self-Referral Rules

Jonathan M. Gold, JD, AMRPA Director of Government Relations & Regulatory Counsel

In October, the U.S. Department of Health and Human Services Office of Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) proposed an array of changes to the Anti-Kickback Statute (AKS) and Physician Self-Referral (Stark) Law regulations. The proposed rules focus on creating additional or modifying existing safeharbors under the AKS and exceptions under the Stark law. The intent of these proposals is to lift barriers to value-based arrangements that may exist due to the current regulations under both laws. This article will provide a high-level overview of the proposed changes.

The proposed rules were published in the Federal Register on October 17, and comments on the proposed rules are due by December 31, 2019.

Anti-Kickback Statute The OIG has proposed seven safe harbors under the AKS related to value-based care.

Most of these new proposed safe harbors would protect different types of value-based arrangements. There are a number of proposed definitions that are key to these new safe harbors, as explained below. The definitions presented here are not exhaustive, and a complete list of proposed definitions can be found on page 55700 of the proposed rule.

A Value-based Enterprise (VBE), would be defined as two or more VBE participants that are party to a documented, value-based arrangement. The VBE must have an accountability body and a governing document.

A VBE participant may include any individuals or health care entities unless expressly excluded. OIG proposes to exclude pharmaceutical companies, laboratories, and manufacturers, supplies, or distributors of durable medical equipment, prosthetics, and orthotics.

A Value-based Arrangement would be defined as arrangements that have at least one Value-based Activity for a target patient population.

Value-based Activities would be defined as a provision of an item or service, or refraining from an action, designed to achieve a value-based purpose (VBP).

However, the Value-based activity cannot incorporate referrals.

The definition of a VBP would be defined as a goal of coordinating or managing care, improving quality of care, reducing cost or cost growth or maintaining quality, or transitions to quality-based reimbursement.

The first proposed safe harbor using these definitions is the Care Coordination Arrangements to Improve Quality, Health Outcomes, and Efficiency Safe Harbor. This safe harbor protects value-based arrangements that include in-kind remuneration between VBE participants directly tied to care coordination efforts. These care coordination efforts

AMRPA Magazine / December 2019 27

must be measured with evidence-based outcome measures.

Like all of the proposed safe harbors, the remuneration may not be for limiting medically unnecessary items or services, and the remuneration may not come from entities that are not members of the VBE. There are a number of other proposed elements to this Safe Harbor, on which CMS seeks comments, which can be found on page 55708 of the proposed rule.

The second proposed Safe Harbor is the Value-Based Arrangements With Substantial Downside Financial Risk Safe Harbor. This proposed Safe Harbor would protect both monetary and in-kind remuneration. The VBE would need to assume downside risk of at least a repayment obligation of 40% of any shared losses, an episodic or bundled payment arrangement with a repayment obligation of at least 20% of any losses, a prospective payment for a total cost of care, or a partial capitated payment that reflects a discount of at least 60% from the otherwise applicable fee-for-service payment amount. The value-based arrangement would need to be targeted to serve a particular patient population for which the value-based activity would apply. There are also specific thresholds of downside risk that each VBE participant must assume, which are detailed more in the proposed rule. Further details on this proposed safe harbor and requests for comments can be found beginning on page 55716 of the proposed rule.

The next safe harbor proposed is the Value-Based Arrangements With Full Financial Risk Safe Harbor. This safe harbor would protect a value-based arrangement when a VBE receives a capitated payment for a target patient population, and assumes responsibility for the cost of all items and services for those patients. This safe harbor would also protect both in-kind and monetary remuneration, and would need to bind the VBE to full downside risk for at least one year. No additional payments can be received by any VBE participants from the payer for the items or services covered by the value-based arrangement. Additional details and requests for comment on this proposed safe harbor can be found beginning on page 55719 of the proposed rule.

The fourth safe harbor directly related to value-based care is the Arrangements for Patient Engagement and Support to Improve Quality, Health Outcomes, and Efficiency Safe Harbor. This safe harbor would permit providing in-kind items or services, technology or tools, or other supports and services if they have a direct connection to the coordination and management of care of a target patient population. These protected items or services must be provided directly to patients, and cannot be in the form of cash, gift cards, or any other cash equivalent. The in-kind remuneration would also be limited to a value of $500 per year, per patient, unless there is demonstrated financial hardship.

Additional information and requests for comments on this proposed safe harbor can be found beginning on page 55721 of the proposed rule.

In addition to the broader safe harbors, OIG also proposed a safe harbor specifically for remuneration provided as part of a CMSsponsored payment model. This would avoid the need for waivers to be issued for every CMS-created model, but would only protect the CMS portion of the model, and would not extend to private

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payers who may be operating a model alongside the CMS model, although those arrangements may be eligible for one of the other proposed safe harbors. Additional information on this proposed safe harbor and requests for comment can be found beginning on page 55730 of the proposed rule. OIG also proposed a safe harbor specifically for accountable care organizations (ACOs) providing beneficiary incentives. This proposal would put into regulation a safe harbor that was created by statute, and OIG does not propose to expand on the statutory defined protections.

The next safe harbor would protect the donation of non-monetary remuneration of cybersecurity technology, as well as services to support that technology. The proposed rule is vague as to who may be the recipient of this technology can be, seemingly proposing to allow both patients and providers to accept remuneration. More information on the cybersecurity safe harbor can be found beginning on page 55734 of the proposed rule.

OIG also proposed to modify a number of existing safe harbors.

Most notably, for arrangements protected under the Existing Personal Services and Management Contracts Safe Harbor, compensation would no longer need to be set in advance.

Instead, OIG proposes that only the formula for determining compensation be set in advance. OIG is additionally proposing to update the existing Local Transportation Safe Harbor to allow for longer distances for patient transports than under the current rules. The proposed modifications to existing safe harbors and request for comment can be found beginning on page 55743 of the proposed rule.

Physician Self-Referral (Stark) Law In its rulemaking, CMS has proposed three new exceptions to the Stark Law that are similar to the safe harbors proposed in the AKS proposed rule. CMS proposes to use the same definitions OIG proposes to use in the AKS safe harbors, and commits to keeping the definitions identical in the final rules. The proposed rule also contains provisions aimed at improving the adoption of electronic health records (EHR), a request for information on price transparency, and proposals to modify existing Stark Law exceptions.

The first exception CMS proposes is the Meaningful Downside Financial Risk Exception. Under this exception, a physician must be responsible for repayment of no less than 25 percent of the value of the total remuneration received under the valuebased arrangement, or the physician must be in a prospective payment arrangement and responsible for all costs of providing care for a defined set of items and services. CMS proposes that the remuneration cannot conditioned on referrals or for limiting medical necessity care, the downside risk for the physician must be in writing, and the methodology used to determine the amount of remuneration must be set in advance. Additional information on this proposed exception and requests for comment can be found beginning on page 55781 of the proposed rule.

CMS also proposes Full Financial Risk Exception where a VBE must be at full financial risk for the cost of all patient care for a specified period of time, such as through a capitated payment or a

global budget. Similar to the Meaningful Downside Financial Risk Exception, the remuneration cannot be conditioned on referrals or limiting medically necessary care, and must be for value-based activities. The financial risk must also be set in advance. Additional information on this proposed exception and requests for comment can be found on page 55779 of the proposed rule.

The third exception CMS proposes is a broad Value-Based Arrangement Exception. This exception requires a number of terms to be set in writing by the VBE, including the value-based activities to be undertaken and how those activities will further the value-based purpose of the VBE, the target patient population, the type of remuneration and method to determine remuneration, and the performance measures that will be used. Like the other exceptions, the remuneration cannot be for referrals or limiting medically necessary care. In addition, CMS proposes to require that the performance measures used must be objective and measurable, and can only be altered on a prospective basis.

Additional information on this proposed exception and requests for comment can be found on page 55783 of the proposed rule.

CMS also proposes a number of changes aimed at promoting the adoption of EHR. The first proposed change is a modification of the existing Electronic Health Records Exception. The updated exception would protect nonmonetary remuneration such as EHR software, update the exceptions requirements pertaining to information blocking, and potentially lessen the recipients’ minimum contribution threshold. The proposed rule also contains a proposal for a new Cybersecurity exception that would similarly

protect cybersecurity software and services used by providers.

Additional information on these proposed changes and requests for comment can be found on page 55822 of the proposed rule.

In addition to the new exceptions, CMS proposes to establish formal definitions or change existing definitions used for Stark Law exceptions. The first proposal would modify the definition of “commercially reasonable.” CMS seeks to define commercially reasonable as whether the arrangement makes sense in light of the entities’ goals, and would not require the arrangement to be profitable to fit under the commercially reasonable definition. CMS also proposes to define “volume or value of referrals,” which is the term used to determine whether an arrangement is inappropriate.

CMS’ proposal says that an arrangement will only be considered to take into account the “volume or value of referrals,” which is not permitted, if the methodology for remuneration includes number of referrals or the value of referrals. There are a number of additional proposed definitions, which can be found beginning on page 55790 of the proposed rule.

Finally, CMS also includes a request for information (RFI) on price transparency in this proposed rule. CMS seeks comment on how availability of prices and physician’s financial relationships may effect consumer choice of health care services. CMS states it is considering requiring an element of price transparency in all of its value-based arrangement exceptions for the Stark Law. This RFI can be found beginning on page 55788 of the proposed rule.

AMRPA Magazine / December 2019 29

AMRPA Hosts Successful Annual Fall Educational Conference & Expo in San Diego

The American Rehabilitation Providers Association (AMRPA) hosted the 17th Annual Fall Educational Conference and Expo in San Diego, October 13-16, at the Loews Coronado Bay Resort.

More than 400 attendees and 22 exhibitors participated in events that spanned three and a half days, including over 50 breakout sessions, two panel discussions, networking roundtable discussions and receptions, and more than 40 poster presentations.

Rehabilitation managers and medical directors of acute rehabilitation programs had the chance to attend two preconference events. The first, “IRF Boot Camp,” focused on providing background on key rules, regulations, reimbursement issues and management concerns for rehabilitation programs.

The session was well-attended with more than 60 participants. In addition to the IRF Boot Camp, attendees were able to attend the first ever “Congressional Outreach Boot Camp.” Participants learned how to successfully engage with their members of Congress, set up meetings and tours, and advocate on behalf of the medical rehabilitation field. The session was led by Martie Kendrick, Esq., Partner, Akin Gump Strauss Hauer & Feld LLP, and Kate Beller, JD, AMRPA Executive Vice President for Policy Development and Government Relations.

With a conference focus on continuing education, attendees participated in 50 breakout sessions within five tracks. The breakout sessions provided conference attendees the opportunity to concentrate their continuing education on topics most applicable to them and earn up to 15.25 hours of credit. This year’s conference sessions addressed diverse and timely topics including: “The Opioid Crisis and Rehabilitation Hospitals: Survival and Recovery,” “A Frank Discussion on Physician Burnout, Causes and Possible Interventions,” “BE-MAAAAD: Benefits Expertise for Medicare Advantage Advocacy Against Aggressive Denials,” “Impact of Yoga on Fall Risk, Function and Quality of Life for Chemotherapy-Induced Peripheral Neuropathy in Cancer Survivors,” and “K-9 Effect: How to Establish an Animal-Assisted Therapy Program at Your Facility.” Conference attendees had this to say about the well-received “BE-MAAAD: Benefits Expertise

30 AMRPA Magazine / December 2019

Continuing Education Breakout Session Tracks  B usiness Operations and Leadership Development  C linical Care Delivery: A Team Approach  R egulatory, Legislative and Accreditation Matters  M arketing, Relationship Management, and Employee Engagement  O utside the Box

for Medicare Advantage Advocacy Against Aggressive Denials:” “[The session had] fantastic speakers and provided invaluable information and insight. The return on investment on attending the 2019 AMRPA [Fall Conference] has been exceeded on this session on BE-MAAAAD alone! I can't believe I am looking forward to the next MA denial I get just to try this expedited fax appeal myself.”

The conference featured panel discussions focused on innovative and relevant topics facing the field of medical rehabilitation.

AMRPA National Leadership Excellence Award recipient, Christine MacDonnell from CARF International, moderated the Monday afternoon discussion on the direct role social determinants of health (SDoH) play in patient’s health. The panelists spoke on

What Are Some Social Determinants of Health (SDoH)?  E mployment  Z IP code  H ousing  T

ransportation  F ood Security  E ducation Level  C ommunity Engagement  H ealth Coverage  P sychosocial Support  W alkability and Safety of Physical Environment

how SDoH impacted rehabilitation and patient outcomes in their facilities, and innovative ways in which their organizations are working to better address patient’s SDoH. The floor was then opened for a question and answer session with the panelists.

In addition to Monday’s SDoH panel, Tuesday afternoon’s panel focused on emerging technologies in rehabilitation. The event was moderated by Leslie Stern, MA, CCC-SLP, Speech Pathology and Audiology Supervisor at Scripps Memorial Hospital. Panelists discussed their personal experience in the use of telerehabilitation, virtual care and assistive technology in the age of increasing technology utilization.

The annual conference provides attendees numerous opportunities to network with peers from across the country and discuss industry experience. Those opportunities included a networking breakfast with educational roundtables and several networking receptions. The networking breakfast educational roundtables covered topics related to marketing, legislative and regulatory issues, rehabilitation nursing, quality, and compliance.

One attendee had this to say about the educational roundtables: “This was an exceptionally helpful opportunity to share methods of managing challenges [in] our departments in our respective hospital systems.”

In addition to the networking breakfast, each evening was capped off with a networking reception offering attendees further opportunities to engage with one another.

This year’s conference hosted more interactive poster presentations than ever before. With over forty posters, attendees were able to interact with researchers and learn about an array of topics, including: “Bolstering Employee Engagement During Transition and Change,” “Development of a Caregiver Training Program to Prevent Falls in an Inpatient Rehabilitation Setting,” “Improving Length of Stay Efficiency,” and “Utilization Review: A Team Approach.”

The poster presentations provided researchers the opportunity to showcase their latest research in the field, and both attendees and presenters were eligible to earn continuing education credits.

AMRPA Magazine / December 2019 31

The exhibit fall featured over 20 vendors, and attendees were able to network and learn about the latest technologies available to rehabilitation providers. AMRPA thanks all of our conference sponsor and vendors: Allscripts, Bioness, Bionik, Expatiate Communications, Select Medical, Gorbel, Mary Free Bed Rehabilitation Hospital, Movendo Technology, Wellsky, CARF International, Casa Colina; and exhibitors: Angel Med Flight, Aretech, Atrium Health, Brooks Rehabilitation Institute of Higher Learning, Ekso Bionics, eRehabData™, Hocoma, Hope Network Neuro Rehabilitation, Indego, RKB Instruments, and Woodway.

Join us for next year’s AMRPA Fall Educational Conference and Expo which will take place at the Renaissance Dallas Hotel in Dallas, October 4-7, 2020. The request for abstracts for the 2020 conference will be posted in the coming months. For more information about future conferences and events, visit the AMRPA Upcoming Events page.

// As a member who happens to be a vendor, the receptions and breaks between classes gave me the opportunity to have meaningful conversations to understand how best to support [members].”

– Susan Price, Program Development Manager, Ekso Bionics

2020 Fall Educational Conference & Expo Renaissance Dallas Hotel Dallas, TX October 4-7, 2020

32 AMRPA Magazine / December 2019

AMRPA would like to offer a special thank you to the 2019 Education Committee for their part in planning and executing another successful Fall Educational Conference & Expo.

Kent Riddle, Chair Mary Free Bed Rehabilitation Hospital Bruce M. Gans, MD Kessler Institute for Rehabilitation Select Medical Richard Kathrins, PhD Bacharach Institute for Rehabilitation

Marcie Hurlbutt Spectrum Health Bob Krug Mount Sinai Rehabilitation Hospital Michael Long Vibra Healthcare Molly Mesibov CarePartners Rehabilitation Center

Russ Bailey Kindred Hospital Rehabilitation Services

Mallory Miller Brooks Rehabilitation Hospital

Bob Bianchi ClearSky Health

Ana Mieres Shriners Hospital for Children

Carolin Dohle Burke Rehabilitation Hospital

Peggy Seminara MossRehab

Alberto Esquenazi, MD MossRehab

Jane Snecinski Post Acute Advisors

Pamela Gambardella St. Anthony’s Rehab Hospital

Gail Solomon Kessler Institute for Rehabilitation Select Medical

Barbara Goodspeed Spectrum Health Julie Hensler-Cullen MossRehab

Specialty care deserves a specialty solution With Allscripts as your trusted partner, we can help your rehabilitation organization reduce variance, improve compliance and increase reimbursements. When the right information is in the right place, anything is possible.

Visit allscripts.com/rehab to better understand your rehabilitation solution goals.

AMRPA Magazine / December 2019 33

2019

Fall Educational Conference & Expo

Loews Coronado Bay Resort • San Diego, CA | October 14-16, 2019

A Profile in Courage: Retired Sergeant First Class Cory Remsburg Inspires at AMRPA Fall Conference The 17th Annual AMRPA Fall Conference and Expo kicked off with a truly inspiring opening keynote session featuring veteran and medical rehabilitation patient U.S. Army Ranger Retired Sergeant First Class (SFC) Cory Remsburg. Cory, accompanied on the stage by his father, Craig Remsburg, spoke of his military career, his injury, his experience with medical rehabilitation, and his ongoing journey of recovery.

Coming from a long line of family military service, Cory knew he wanted to serve his country from a young age. As an Army Ranger, Cory was in one of the first troops sent to Iraq in 2003. On October 1, 2009, during his 10th combat deployment, Cory and his squad were conducting a combat operation involving multiple enemy contacts. Cory’s father, Craig, explained that during the operation, Cory was caught in the explosion of an enemy improvised explosive device (IED). He was seriously wounded with injuries including near drowning, paralysis of the left side of his body, traumatic brain injury, damaged vocal cords, burns, and the loss of sight in his right eye. As a result of his injuries, Cory spent over three months in a coma.

Cory, and his father Craig continued their speech covering Cory’s transition from the Kandahar and Bagram Medical Centers in Afghanistan, to the military hospital in Landstuhl, Germany, and on to several rehabilitation hospitals and units in the United States. Following Cory’s stay in Germany, he was transferred to Bethesda Naval Medical Center in Maryland where he remained in a comatose state and received multiple surgeries. It was not until Cory transferred to the Tampa VA Polytrauma Center and had been in a coma for more than three months that he began to return to consciousness.

During his time in Tampa, Cory began an intensive and rigorous therapy schedule including physical, occupational and speech language therapy. Eight months after his

Visit: AMRPA.org/2019-Fall-Conference-Registration 34 AMRPA Magazine / December 2019

#AMRPA

Living Center. After over three and a half years in acute-care or rehabilitation hospitals, Cory was able to return home and participate in intensive outpatient therapy. He now lives in a home provided by the Jared Allen Homes for Wounded Warriors and Army Ranger Lead the Way Fund, for which he is an ambassador.

Because of the care provided by rehabilitation specialists and Cory’s sheer determination, Cory explained that he has participated in several sporting events at both the local and national level. Cory is currently training to join a Dragon Boat crew, and recently competed in both the 2019 Valor Games Far West in Alameda, California, and the 2019 U.S. Department of Defense (DoD) Warrior Games in Tampa, Florida. In the Valor Games, Cory won gold, silver and bronze medals and he won three bronze medals at the DoD Warrior Games.

The duo concluded their talk with several special moments Cory has participated in throughout his road to recovery. Cory has met with former President Barack Obama seven times, the most notable of which was being Mr. Obama’s guest at the 2014 State of the Union Address. Cory said, “My life changed dramatically when the President told my story. In my opinion, I had two options at that point in life: go under the radar and continue life as is, or use this moment to champion the cause of helping others battle through adversity.” Other special moments included being added to his high school’s Hall of Fame, and attending the 70th anniversary of D-Day in Normandy, France in 2014. injury, Cory began talking and challenged the “new normal,” making great strides in his recovery. As Cory continued to recover, Craig explained that they visited multiple rehabilitation hospitals to allow Cory to determine the best fit for him to transfer to following his time in Tampa.

Cory ultimately chose Casa Colina Rehabilitation Center in Pomona, California, where he had a 16-month in-patient stay.

It was here, with the help of numerous rehabilitation providers, that Cory relearned independent living skills, made great strides in his recovery, and was able to participate in the Transitional

Cory focuses on engaging with others about recovery and to “keep pushing on” when challenged by personal events. He continues to work toward further independence and relearning to drive, which he says is one of his biggest goals. Both Cory and Craig reminded the audience to keep paying it forward and giving to others, one of Cory’s major missions. Cory’s personality shone with his concluding remarks: “Thanks for having us join you today.

My new home is too close to my parents. I’m in a lifelong journey for my independence.”

AMRPA Magazine / December 2019 35

2019

Fall Educational Conference & Expo

Loews Coronado Bay Resort • San Diego, CA | October 14-16, 2019

AMRPA Honors Leaders in the Medical Rehabilitation Field During the 17th Annual AMRPA 2019 Fall Educational Conference and Expo, Board Chair Richard Kathrins, PhD, and the AMRPA Awards Committee announced the recipients of two esteemed awards, the Edward A. Eckenhoff Memorial Award and Lecture and the AMRPA National Leadership Excellence Award. The Edward A. Eckenhoff Memorial Award and Lecture was established in 2018 to honor a founding father of AMRPA and visionary leader in the rehabilitation field. The National Leadership Excellence Award recognizes an individual who has exemplified outstanding service and made significant contributions to the field of medical rehabilitation.

Christine MacDonell, Managing Director of Medical Rehabilitation and International Aging Services at the Commission on Accreditation of Rehabilitation Facilities (CARF) International, received the AMRPA National Leadership Excellence Award. MacDonell graduated from the University of Southern California and began her career in health care as an occupational therapist. She later transitioned into a health care administration role in which she was responsible for overseeing post-acute care. In 1991, she moved to CARF International, and it is through her contributions and dedication that the accreditation of medical rehabilitation programs and services have expanded to a global scale, helping to ensure patients receive consistently high quality programs, services and outcomes.

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#AMRPA

Felice Loverso, PhD, CEO and President of Casa Colina Hospital and Centers for Healthcare, was honored with the Edward A. Eckenhoff Memorial Award. Dr. Loverso is an AMRPA Board member who has been a tireless advocate for the field of medical rehabilitation. He has contributed invaluable leadership in the areas of research, education, public policy, and clinical excellence.

Additionally, he is a past chair of the AMRPA Board of Directors.

As part of the Eckenhoff Memorial Award, Dr. Loverso provided a keynote lecture to conference attendees. Dr. Loverso provided his insights on the history of AMRPA and discussed the transformation of Casa Colina over the years. Since Dr. Loverso’s arrival in 1998, Casa Colina has grown to its current 20-acre campus with state-ofthe-art facilities. The organization has increased its patient capacity to 219 beds dedicated to medical-surgical, intensive care, acute rehabilitation, residential rehabilitation, and long-term residential care. In addition, outpatient services have been expanded to include diagnostic imaging and physician-staffed clinics.

AMRPA also recognized Carolyn Zollar, JD, AMRPA Senior Policy Counsel, Richard Kathrins, PhD, Chair of the Board, and Bruce Gans, MD, Immediate Past Chair, for their hard work and dedication to AMRPA and the medical rehabilitation field. Zollar was recognized for her former role as AMRPA Executive Vice President for Government Relations and Policy Development. She has dedicated more than 30 years to AMRPA and its predecessor organizations, as well as to the field at large. Dr. Kathrins was recognized for his many contributions to AMRPA as the current Board Chair and he will transition to Immediate Past Chair. Dr. Gans was recognized for his membership on the AMRPA Board of Directors and former position as Board Chair. Dr. Gans will transition to Board Emeritus status, and remain involved with AMRPA as the Chief Policy Officer.

AMRPA Magazine / December 2019 37

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