AMRPA Magazine | January 2020

January 2020 • Vol. 23, No.1

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.

January 2020 • Vol. 23, No. 1

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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Robert Krug, MD Chair, AMRPA Board of Directors, President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line

Medicare Improper Payment Rates Drop But CMS Targets IRFs for Medical Necessity Errors

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Section GG Frequently Asked Questions

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John Ferraro, MS AMRPA Executive Director

Leading for a Lifetime: Dr. Alberto Esquenazi

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AMRPA Responds to Department of Health and Human Services’ Request for Information on Ways to Modernize Medicare Program Integrity While Safeguarding Patients

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New Hospital Price Transparency Requirements Finalized for 2021

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CMS Releases Final 2020 Physician Fee Schedule Rule With Changes to Outpatient Therapy Services

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MedPAC Discusses Latest Research on Post-Acute Care Spending in Medicare Shared Savings Program Accountable Care Organizations

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AMRPA Submits Comments to Congressional Request for Information on Rural and Underserved Communities

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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 23, Number 1

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.

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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 / January 2020

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Letter from the Chair

Robert Krug, MD President and CEO Mount Sinai Rehabilitation Hospital Medical Director, PM&R Service Line

Looking Back on 2019 It is my honor to start the 2020 year as incoming chair of the board for the American Medical Rehabilitation Providers Association. In the new role, I look forward to working with our volunteer leaders, members and staff to successfully advance the association in the midst of a rapidly evolving post-acute care landscape.

First and foremost, I want to take an opportunity to commend Dr. Richard Kathrins for his tireless work as chair over the past two years. Under his unparalleled leadership, AMRPA has successfully engaged with regulatory policymakers in the face of major changes to our payment system, zealously advocated for inpatient rehabilitation coverage and payment issues on Capitol Hill, and initiated a number of new policy initiatives that I look forward to helping carry on. We are all very thankful for Dr. Kathrins’ many contributions to our association, and I am personally grateful that he intends to take on an active role as immediate past chair.

Looking to the future, I find it fitting that my chairmanship aligns with the adoption of a new AMRPA mission statement: advancing the field of medical rehabilitation through advocacy, education, and the promotion of access to care. I believe our association’s efforts to educate policymakers on the distinct value of medical rehabilitation and our advocacy for improved patient access and patient outcomes truly set us apart, and I intend to embrace this mission statement in my leadership role.

As an industry, we will be bracing for a number of critical challenges in the months and years ahead. To that end, AMRPA will continue to advocate for regulatory relief, work to ensure robust patient access to medical rehabilitation in both traditional Medicare and Medicare Advantage, and closely examine how our industry would be impacted under any unified post-acute care prospective payment system proposals. We will also continue to seize upon all opportunities to advance our policy agenda, as we enter the next session of Congress actively engaged on a number of bills that would advance some of our highest priority legislative asks.

One of the things I’ve always found most impressive about our association is the dedication of its members. From conference presentations to committee leadership to workgroup participation, the collaboration and tireless work of our membership has propelled our advocacy efforts. If you would like to learn more about any of our committees or expand your committee participation in the new year, please visit our website for more information and contact our Washington office.

On behalf of the AMRPA leadership, we truly look forward to working with you and your team. If you would like to talk to me directly, please do not hesitate to email me at RKrug@TrinityHealthOfNE.org. As we head into the new year, AMRPA stands ready to help you successfully prepare for all the challenges and opportunities that lie ahead.

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AMRPA Magazine / January 2020

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

Our 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 Associate, at ekatsion@amrpa.org or 202-207-1102.

AMRPA Magazine / January 2020

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Legislative Update

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

Highlights: »»

»» »»

»»

»»

fter two Continuing Resolutions, A Congress finalizes Fiscal Year (FY) 2020 Appropriations by passing two large “minibuses.”

The House takes historical vote to impeach President Donald J. Trump on December 18.

On December 12, the House passed Speaker Pelosi’s drug pricing legislation (H.R. 3), by an almost party-line vote of 230-192.

Despite an agreement reached on surprise billing legislation between the Senate HELP Committee and the House Energy and Commerce Committee, the House Ways and Means Committee still intends to mark-up its proposal, which ultimately delays consideration until 2020.

On December 12, the Senate voted to confirm the nomination of Stephen Hahn to serve as Commissioner of the Food and Drug Administration (FDA).

The First Session of the 116th Congress Concludes with Some Progress on Health Care Priorities Congress had several intense, busy weeks in December as the final days of 2019 came to a close. Negotiations were ongoing around finalizing a proposal to fund the government past December 20, the expiration date of the current Continuing Resolution (CR). On December 12, top Senate and House Appropriators announced an agreement “in principle ” on $1.37 trillion in discretionary spending for FY 2020. As we go to print, the long-awaited bipartisan agreement on 12 appropriations bills will likely be passed via two large packages, known as “minibuses.” It is expected that the House will take up the funding bill on Tuesday, December 17, and the Senate will follow suit.

Although the president has not officially endorsed the agreement, it is expected that he will ultimately sign the bill into law.

On December 9, Senate Health, Education, Labor & Pensions (HELP) Committee Chair Lamar Alexander (R-TN) and House Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ) along with Energy and Commerce Republican Leader Greg Walden (R-OR) announced they reached a bipartisan, bicameral agreement on surprise medical billing legislation. The bill would require the insurer to pay at minimum the market-based median in-network rate for the service in the geographic area where the service was delivered. If the median in-network rate payment is above $750, the provider may elect to go to a “baseball-style” binding arbitration. The bill also aims to increase prescription drug competition and create price transparency, funds public health programs (including grants for maternal health and rural health initiatives and Community Health Centers), and increases the purchasing age of tobacco to 21. It does not appear that Leadership has signed off on the package, but Chair Alexander and House E&C leaders are pushing for the revised bill to be included in a year-end health package.

The House Ways and Means Committee subsequently released their surprise billing package a few days later on December 11. Their proposal sets the patient cost-sharing for out-of-network bills at the in-network rate and also calls for a “robust reconciliation process” with clear criteria for payment resolution and pre-determined thresholds. At this time, specific legislative language has not been released. Although hospital and physician stakeholders support the Ways and Means proposal, there appear to be low expectations that all the involved parties will come to an agreement before the first session of the 116th Congress concludes. Surprise billing and drug pricing will likely become priorities for the first quarter of 2020.

On December 12, the House passed Speaker Pelosi’s drug pricing legislation (H.R. 3), by an almost party-line vote of 230-192. The legislation includes a provision that would allow Medicare to negotiate up to 50 Medicare Part D drugs annually and place a cap on out-of-pocket drugs costs for beneficiaries. The Congressional Budget Office (CBO)

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AMRPA Magazine / January 2020

estimated that the legislation would lower federal spending by $456 billion over 10 years. These savings were used to expand Medicare coverage of dental, vision and hearing benefits, along with funding for the National Institutes of Health (NIH) and opioid epidemic efforts. H.R. 3 now heads to the Senate, but it is not expected that Leader McConnell (R-KY) will take it up for consideration.

MedPAC Continues to Recommend Cuts to PAC Sector On December 5-6, the Medicare Payment Advisory Commission (MedPAC) hosted a public meeting. MedPAC discussed the following recommendations to Congress for the upcoming fiscal year: Inpatient rehabilitation hospitals and units (IRF): For FY 2021, the Congress should reduce the Medicare payment rate for IRFs by 5 percent.

Skilled nursing facilities (SNF): The Congress should eliminate the FY 2021 update to the Medicare base payment rates for SNFs. Long-term care hospitals (LTCH): The Secretary should increase the FY 2021 Medicare base payment for LTCHs by 2 percent.

Home health agencies (HHA): The Congress should reduce the calendar year 2021 Medicare base payment rate for HHAs by 7 percent.

The recommendations will receive a vote during MedPAC’s January session, but all are expected to be approved and finalized. MedPAC staff expressed concerns with the IRF payment system, specifically noting how IRFs assess their patient's functional status affects their payments. MedPAC’s projected Medicare margin for IRFs in 2020 is 12.7 because it expects cost growth to exceed payment growth in 2019 and 2020. Commission staff state that payment growth will be limited because payment updates for fiscal years 2019 and 2020 were set in statute at below-market basket levels, 1.35 percent 10 and 2.5 percent respectively. The draft recommendation will also include a reiteration of 2016 recommendations. The first one addresses concerns about coding. MedPAC recommends that CMS ensure payment accuracy through focused medical record review, and encouraged the Secretary to reassess provider integrator reliability across IRFs. The second recommendation addresses differences in the profitability of case mix groups. MedPAC recommends again that CMS pay for a higher share of the cost of outlier patients who are extremely costly by expanding Medicare's IRFs' high-cost outlier pool. These outlier payments would tend to go to hospital-based and nonprofit facilities.

A Presidential Election Year Cometh We are now one year away from the 2020 presidential election, with the Iowa caucuses (February 3, 2020) and the New Hampshire primary (February 11, 2020) fast approaching. While these two states’ contests are important, in 2016 President Donald Trump and former Senator Hillary Clinton did not become their party’s presumptive presidential nominee until May and June, respectively.

// The President is polling at upwards of 90 percent for the Republican nomination, and five states have cancelled their Republican primary contests.

Health insurance coverage expansion, drug pricing, transparency and surprise medical billing, rural health, mental health and substance use disorder, and maternal health are key themes addressed in many of the candidates’ health care plans".

As these first contests approach and primary debates intensify, many of the Democratic presidential candidates are spending more time talking about their health care visions and priorities.

We expect that presidential candidates will adopt policy proposals from others as the pool of candidates eventually narrows.

Although President Trump has primary challengers, these candidates have gained little ground. The president is polling at upwards of 90% for the Republican nomination, and five states have cancelled their Republican primary contests. Health insurance coverage expansion, drug pricing, transparency and surprise medical billing, rural health, mental health and substance use disorder, and maternal health are key themes addressed in many of the candidates’ health care plans.

Lawmakers from the House will return on January 7, to commence the second session of the 116th Congress. The Senate has not yet established its January schedule due to the unpredictability of a likely pending impeachment trial. As noted above, this is a high-stakes presidential election year and you can expect it will be a wild ride. Health care costs remain a top concern for American voters, and lawmakers will want to respond.

An election year certainly makes politically contentious policies harder to pass, but it is likely that Congress returns to surprise billing and drug pricing negotiations early on in the new year and attempts to come to a compromise.

AMRPA Magazine / January 2020

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If you have the chance to meet with your members of Congress as we look to the new year, please 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 to certain types of providers, including inpatient rehabilitation hospitals and units. Specifically, please encourage your Members of Congress 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 plan to come to AMRPA’s Spring Conference and Congressional Fly-In, March 22-24, 2020, in Washington, D.C. You will have a chance to meet with your Representatives and their staff face-to-face and educate them on AMRPA’s key legislative priorities. We look forward to working with you in 2020!

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AMRPA Magazine / January 2020

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AMRPA Magazine / January 2020

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Medicare Improper Payment Rates Drop But CMS Targets IRFs for Medical Necessity Errors

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

On November 18, 2019, the Centers for Medicare and Medicaid Services (CMS) released new Fiscal Year (FY) 2019 data reflecting improper payment rates for Medicare, Medicaid and the State Children’s Health Insurance Program (CHIP). The updated numbers, included in the annual Financial Report for the Department of Health and Human Services (HHS), show a significant ($7 billion) decrease in improper payments for the Fee-ForService (FFS) program (which includes Medicare Parts A and B), and the lowest overall rate since FY 2010. Despite this decrease, CMS identified inpatient rehabilitation hospital/ unit (IRF) claims as one of four major drivers of improper Medicare payments. CMS will continue to target IRF payments for ongoing corrective action, as detailed further below.

Background The Improper Payments Information Act of 2002, and subsequent amendments, requires HHS and other agencies to periodically review the programs administered by the federal government, identify programs susceptible to improper payments, and estimate and report on such payments and efforts to reduce them. The data collected by CMS is issued annually within the HHS Agency Financial Report, released in November 2019. The report covers a wide range of information regarding HHS’s financial performance and strategic goals. Details on the Payment Integrity Report can be found starting on page 186 of the document.

Within CMS, the Office of Management and Budget (OMB) has identified five major programs as potentially susceptible to significant rates of improper payment. These include Medicaid, CHIP, Medicare fee-for-service (FFS) Part C, and Part D. In FY 2018, CMS estimated improper payments for the FFS program at 8.12% of all program outlays, or approximately $31.62 billion. In FY 2019, that rate decreased to an estimated 7.25%, or $28.91 billion. These rates are derived from CMS analysis of claims submitted from July 1, 2017, through June 30, 2018. Not surprisingly, there is a lag in the data analysis.

The decrease in improper payments has led to the lowest rate for the Medicare FFS program since FY 2010. CMS attributes this decrease to corrective actions taken by the agency, specifically in the home health (HHA), durable medical equipment (DME), and other Part B service areas. CMS also highlighted decreases in improper payment rates in the Medicare Part C and Part D programs, reflecting decreases of $1.18 billion and $710 million, respectively. CMS reported year-over-year increases in the improper payment rates for Medicaid and CHIP, but cautioned that FY 2018 and FY 2019 were not directly comparable due to changes in the measurement tool.

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“Improper” Payments for IRFs Although overall improper payments for the Medicare FFS program decreased in FY 2019, CMS again this year highlighted improper payments for IRF claims as a “major contributing factor” to the improper payment rate. CMS cited medical necessity (i.e., the agency determined that the services provided did not meet the requirements for medically necessary care under the IRF payment system) as the major error contributor for improper IRF payments. As AMRPA members are aware, CMS has considered a significant proportion of IRF admissions to be medically unnecessary (a position that AMRPA has strongly and consistently contested). In FY 2019, CMS states that the improper payment rate for IRFs was 34.87%, down from over 40% in FY 2018, and down from a high of over 60% in the recent past. Across all improper payments in the Medicare FFS program, approximately 19% were identified as such due to medical necessity errors.

While these numbers may seem high, it is important to understand the full meaning of “improper payment” as defined by CMS. In the report, the agency clarifies that “improper payments do not necessarily represent expenses that should not have occurred.”

Instead, the category includes instances with insufficient or no documentation, which are considered a subcategory of “unknown” payments. Across the full Medicare FFS program, more than 55% of “improper” payments were coded this way due to insufficient documentation, almost three times the proportion of improper payments due to medical necessity claims. Of the approximately $2.5 billion in “improper” IRF payments for FY 2019, about a quarter were due to insufficient documentation, while the majority of the rest were due to medical necessity errors.

As has been previously reported, CMS and the HHS Office of Inspector General (OIG) have frequently stated concerns about payment error rates as determined by the Comprehensive Error Rate Testing (CERT) contractor in previous years. Members may be familiar with the September 2018 OIG report claiming an 84% error rate in IRF payments, which is significantly higher than error rates identified by the CERT, even in the same year the OIG and CERT investigated IRF claims (i.e., 2013).

In the 2019 report, CMS acknowledges that improper payments to IRFs have decreased from FY 2018 levels and outlines (as required by law) the agency’s corrective action plans to address these improper payments (detailed below). AMRPA will continue to implement its own action plan to respond to potential repercussions from the OIG report and ongoing CERT analyses.

We will share additional developments with the membership as they become available.

Of course, the global IRF settlement offered by CMS earlier this summer undermines the accuracy of these high error rates for IRFs. In that settlement, CMS offered the highest percentage settlement figure for any global settlement in the recent past of claims in the administrative appeals process. They settled for 69% for most IRF claims and 100% for certain claims involving the so-called “three hour rule” and claims where group therapy was involved. These high percentage repayments to providers indicates that CMS tacitly acknowledged their reviews of IRF claims in the recent past have been overly restrictive.

Key IRF Corrective Actions In its report, HHS outlines three ongoing strategies to address the identified rate of improper payments for IRFs. These reviews are implemented as both preventive and detective measures to reduce improper payments to IRFs and reduce the overall improper payment rate.

1. T PE IRF Reviews: Under the Targeted Probe and Educate (TPE) Program, HHS conducts medical review, through Medicare Administrative Contractors (MACs), of IRFs, focusing on those identified as having high error rates for additional rounds of auditing. The MACs conduct up to three rounds of review, covering 20 to 40 claims per round, and provide oneon-one provider education at the end of each round. In FY 2019, approximately 600 IRF providers (out of approximately 1100) were reviewed under the TPE program. For context, TPE reviews were also conducted for approximately 1,000 SNF providers, 5,500 HHA providers, and 1,400 hospital outpatient providers.

2. SMRC IRF Reviews: The Supplemental Medical Review Contractor (SMRC) initiates medical review activities related to post-payment review of IRF claims. The contractor then shares these results with the MACs in order to adjust claims.

Providers impacted by SMRC reviews receive result letters from the contractors, as well as demand letters from the MACs to recover overpayments. These letters also include educational information for the providers regarding errors or incorrect documentation in the original billing of the claim.

3. RAC IRF Reviews: Recovery Audit Contractors (RACs) conduct post-payment reviews of Medicare services, identifying and collecting improper payments relating to several factors, including medical necessity and insufficient documentation. In FY 2019, HHS approved the Medicare FFS RACs to once again audit IRF claims. Of the total RAC collections in FY 2019, approximately 5% were collected from SNFs and 35% from HHAs due to overpayments identified during claim reviews.

HHS has implemented similar strategies to address high rates of improper payments in the other identified “driver” service areas, including SNFs, HHAs and hospital outpatient services. In addition, HHS identified key corrective actions in other service areas, including prior authorization for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) and ambulance transport services and RAC reviews for DME items and services.

Finally, the report outlines corrective actions to address the root causes of administrative and process errors (mainly coding errors) and insufficient documentation, which can be found on page 209 of the report.

Impact on IRF Providers The focus on IRFs as a source of major payment error in the Medicare program is unfortunately nothing new. As a result, most IRFs likely can expect to see a steady level of auditing activity from the various CMS contractors. For those IRFs that have not been targeted by the SMRC or a RAC in the past, the risk for future audits from these entities is high, especially if the IRF has been through all three rounds of a TPE audit and continues to have payment error rates that the MAC deems high.

AMRPA Magazine / January 2020 11

It remains important for IRFs to keep a close watch on the auditing activity, however, because of the risk for contractors to overstep the constraints on their authority (e.g., RAC record request limits) and the risk of overlapping claims review. Further, while CMS’ recent global IRF appeal settlement tacitly admitted that many IRF claims denied by contractors in the past were, in fact, appropriate for payment, to AMRPA’s knowledge and despite its

efforts to the contrary, no changes have been made to the criteria or guidance provided to the contractors in pursuing their ongoing IRF audits, setting the stage for continued denials on the same misinterpretations and disagreements regarding medical necessity and documentation criteria for IRF admissions.

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AMRPA: Working Together to To Preserve Preserve Access To Medical Rehabilitation AMRPA: Working Together Access to Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org

Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org, 202-207-1102.

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AMRPA Magazine / January 2020 13

Section GG Frequently Asked Questions As you might imagine, the eRehabData® Technical Support line typically receives many questions throughout the workday. With the switch to new Case Mix Groups (CMGs) based on the section GG/H items, the volume of questions is even greater. Many of these questions follow the same theme, so I thought I would share some of my thoughts on how to address these hot topics.

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

Below are some of the questions and my opinion on the best approach to scoring these scenarios.

QUESTION: Should both therapy disciplines assess the patient without a device, or if the physical therapist (PT) assesses a patient first, without a device, and recommends a device, does the occupational therapist (OT) then use the device? Or does OT also assess the patient without a device? Example: A patient is determined to be unsafe for transfers without a device, would OT then attempt a toilet transfer without a device? It seems like once one therapy discipline recommends a device, the next discipline would use it during treatment.

RESPONSE: In this example, if intervention is provided before OT sees the patient, then OT would not need to complete their own assessment for purposes of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI). If the OT elects to use the device that is recommended, then they are not really completing an assessment, so they would not need to provide a score. Per the IRF-PAI Training Manual, assessments should occur prior the patient benefitting from treatment interventions to capture the patient’s true admission baseline status. As such, I believe that once therapeutic intervention has been offered, it is not necessary to continue to gather scores. To provide a different example, if a nurse assessed the patient’s eating skills and identified that the patient required built-up handle utensils and issued them, the nurse would score the patient’s eating ability based on the assessment completed prior to introducing the built-up handle utensils. If each subsequent meal was eaten with the adaptive equipment, the other providers who are present for meals would not need to assess the patient’s eating ability since the intervention was provided and the task modified.

QUESTION: Can bed rails be considered an intervention if not used at home prior to admission?

RESPONSE: Bed rails are a device, not an intervention. If the clinician is explaining how to use the bed rails to help with rolling, then they are intervening. But use of the rails themselves would not be considered an intervention.

QUESTION: Can a bedside commode be used to assess a toilet transfer?

RESPONSE: Yes – it will make the transfer easier, so the patient’s score will likely be higher, but the scoring guidelines offered by CMS do not prohibit the use of any device.

The clinician’s role is to determine the need to use the bedside commode based on keeping the patient safe, rather than using the device because it is more convenient.

Scoring a toilet transfer on and off a toilet or a bedside commode are both considered methods for completing a toilet transfer, but it will be inherently easier for the patient to get on and off of a bedside commode.

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QUESTION: Is a shower chair considered a device that should not be utilized during the patient’s initial assessment?

RESPONSE: Using a shower chair for bathing would not lower the patient’s bathing score, but it might make it easier for the patient to complete their bath, so the bathing score would be higher. Use clinical judgment on what is safe and necessary.

QUESTION: Is it ok for staff to be scoring both Wheelchair and Walk on admission and discharge?

RESPONSE: Yes – you should score Walk if the patient walks during the admission assessment and Wheelchair if they are using a wheelchair to allow them to be more independent on the unit.

The same is true for discharge, but if the patient no longer uses a wheelchair at discharge, do not score those items. There is a lot of confusion over when to score the Wheelchair items. CMS training has indicated that Wheelchair should be tested when used.

However, if the wheelchair is only used to transport a patient from place to place, there is no need to provide a score. Since the typical use of a wheelchair in an inpatient rehabilitation facility is to allow the patient greater independence as they mobilize on the unit, the wheelchair does not fit the definition of transportation purposes only. Therefore, if the patient did not use a wheelchair at home, will not go home with a wheelchair, and does not have wheelchair goals, but the patient is using the wheelchair within the facility to promote independence, you should score the Wheelchair items.

QUESTION: For those patients who have the potential to walk but may require wheelchair for functional mobility or community distances, should both scores be entered? Which scores are used to calculate the patient’s CMG when both are used?

RESPONSE: Yes – both walk and wheelchair should be tested when the patient is doing both. The CMS calculations for the patient’s CMG are based on the Walk score in every case. With the FIM™ instrument, the calculation for the CMG was based on the patient’s most frequent mode of locomotion, but that is not the case with the CMGs as of October 1, 2019.

QUESTION: If I enter that a patient uses a wheelchair at admission but not at discharge, does this impact the CMG? RESPONSE: No – the CMG is calculated based on the patient’s admission assessment just like in prior years. The IRF-PAI instructions indicate that if the patient no longer needs a wheelchair at the time of discharge, it is unnecessary to provide scores. The person completing the IRF-PAI will indicate that a wheelchair is no longer used so that the items can be skipped without a penalty for having an incomplete assessment.

QUESTION: Does the score of “88” default to “1-total assistance”?

RESPONSE: Yes – The value of the score “88” is the same as the value of total assistance in the CMG calculation.

QUESTION: How should I score items when the patient could not do the activity on day 1 or 2, but was finally able to do it on day 3?

RESPONSE: I would report “88” rather than a number when you feel that nursing/therapy interventions on day 1 or 2 enabled participation in the assessment on day 3. If the patient got stronger and could then complete the task on day 3 because of the compensatory

strategies taught on day 2, then the score is not a reflection of an assessment prior to intervention, so keep the “88”. Essentially, the PPS coordinator must validate the “88” before taking the score of day 3 by reading the nurses’ and therapists’ documentation. The struggle is how to make the EMR convey that the assessment was possible due to therapeutic intervention. One provider I worked with created a means to document when intervention occurred. Their EMR section GG flowsheet demarcates intervention, so the PPS coordinators know when to stop reviewing the scores because the scores no longer reflect assessments prior to intervention.

QUESTION: How would you score a patient when they were unable to complete the activity without equipment or intervention, but could complete the activity when a device or intervention was provided?

RESPONSE: If the therapist has to teach the patient how to use the equipment, the first score is the one to take. In the example, I believe the score would be “88”, but it could be a “1”, “2”, or more if the patient was able to complete the activity with help. If the patient needs no cues, set up, or instruction, I would use the score with the device, not the “88”. The difference as I understand it based on clarification from CMS is whether or not you intervened versus the patient naturally knowing how to safely complete the task.

QUESTION: If a patient requests to use a device (walker, dressing stick, reacher, etc.) during the initial evaluation, we give the device to the patient and score the task accordingly. We do not offer the device if the patient did not use it prior to the acute care hospitalization but we do not withhold it if they request to use it. If the patient used a device at home and requests to use it, is it considered intervention if we have to get the device for the person, adjust it, etc.?

RESPONSE: I believe one more step can be taken in this example.

The clinician should use their judgment about what the patient will require in the future. You know that in some cases, the patient progressed to needing a device just before admission and might be able to progress beyond that point. I believe the therapists should focus their efforts on encouraging baseline assessments rather than looking for an opportunity to provide a device or intervention. The nurses and therapists are the professionals.

They should use their professional judgment to determine what a patient needs in order to safely and effectively complete the task.

Remember that the CMS Help Desk also offers guidance on these topics. For questions about quality measure calculation, data submission deadlines, and coding data elements in the IRF-PAI, CMS directs providers to contact IRF.questions@cms.hhs.gov. You can also find other IRF-PAI and quality-related contact information at https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/IRF-Quality-Reporting/Help.

What is reflected here is my opinion on how to correctly score the section GG items in difficult situations. Make sure that you continue to educate clinicians on conducting accurate assessments as new information is provided by CMS and other sources. We are all working together to decide the most accurate methods to objectively document how much assistance a patient requires during their self-care and mobility assessments.

AMRPA Magazine / January 2020 15

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AMRPA Magazine / January 2020 17

Did You Know?

All of our webinars are available online!

Missed out on a recent AMRPA webinar? Not to fear!

All AMRPA webinars are available On Demand for purchase almost immediately following its recording.

W Eour B selection I N A here: R Browse https://amrpa.org/Education/Webinars/OnDemand-Webinars *AMRPA members receive a discount on all webinar recordings.

18 AMRPA Magazine / January 2020

Leading for a Lifetime: Dr. Alberto Esquenazi

Dedication. Care. Service. Leadership.

Inseparable from the work we do as medical rehabilitation professionals, these elements not only define our underlying vision to transform the lives of our patients through access to the best care possible, they are also key characteristics of our industry’s top achievers.

One of these achievers is Dr. Alberto Esquenazi.

A dedicated AMRPA member and an integral part of our Board of Directors, Dr. Esquenazi was honored last month by the American Academy of Physical Medicine and Rehabilitation (AAPM&R), of which he is also a member and past president, with the Frank H. Krusen, MD, Lifetime Achievement Award. This award recognizes our colleagues who have demonstrated vital contributions to our specialty on a number of fronts, including research, education and community service. Taking his commitment above and beyond, Dr. Esquenazi continuously seeks to provide care through a variety of unique touchpoints. In addition to his membership in AMPRA, AAPM&R and numerous other societies, he is MossRehab’s chief medical officer and the John Otto Haas Chair of the Department of Physical Medicine and Rehabilitation.

While serving in these positions, he has maintained a steady, patientcentered focus on technological advancements that have since changed the playing field for medical rehabilitation.

His ongoing research into prosthetics and orthotics led, in part, to the development of the first FDA-approved exoskeleton device for those with life-altering spinal cord injuries. These contributions and more came as a result of his unwavering service to those we work with and drive to reach a main goal of our specialty: keep patients moving and allow them to live healthy, independent lives.

In addition to his achievements on the ground, Dr. Esquenazi continues to prove himself as an industry thought leader, publishing and authoring more than 100 papers, articles and chapters to share his research and knowledge with his colleagues.

Recognition of Dr. Esquenazi’s leadership and focus on the patient is in no short supply. He is a Castle Connolly Top Doctor and on the Top Doctors in Philadelphia list, where his excellence in delivering quality care has placed him for many years at the forefront of the nation’s medical rehabilitation providers.

In our field, our success is measured by the success of our patients. Each step taken during a rehabilitation session is an equal step forward for our industry as a whole. It is leaders like Dr. Esquenazi — those who go the extra mile in ensuring that the human element is the guiding force in the care that we offer — that inspire both us and our patients to keep moving forward.

Congratulations to Dr. Esquenazi.

AMRPA Magazine / January 2020 19

2020 Fall Educational Conference & Expo

Renaissance Dallas Hotel • Dallas, TX • October

Abstract Deadline: April 27, 2020

4-7

What would you like to discuss this year?

Submit your abstracts for AMRPA’s 18th Annual Educational Conference & Expo!

AMRPA encourages you to share your knowledge, case studies, and experience in these 6 categories:  Business Operations and Leadership Development  Clinical Care Delivery — A Team Approach  Regulatory, Legislative and Accreditation Matters  Marketing and Relationship Management  New for 2020! Technology, Research and Innovation  Other: Topics Outside the Box

Submit your ideas today!

For more information about how to submit your abstract, visit the AMRPA website: https://amrpa.org/Education/Events/Fall-2020-Call-for-Abstracts For questions about submitting an abstract, contact AMRPA Education Specialist Kirsten Lew at klew@amrpa.org.

#AMRPA 20 AMRPA Magazine / January 2020

AMRPA Responds to Department of Health and Human Services’ Request for Information on Ways to Modernize Medicare Program Integrity While Safeguarding Patients

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

On October 21, 2019, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) soliciting feedback on ways to improve its program integrity efforts in light of both policy changes in the Medicare program and technological advances. The RFI followed President Donald Trump’s October 3, 2019, Executive Order, Protecting and Improving Medicare for Our Nation’s Seniors, which directs the Department of Health and Human Services (HHS) Secretary to “undertake all appropriate efforts to direct public and private resources toward detecting and preventing fraud, waste, and abuse, including through the use of the latest technologies such as artificial intelligence,” with the applicable regulations required to take effect by January 1, 2021.

In the RFI, CMS states its interest in improving program integrity by “acting in real time,” rather than “chasing” improper payments, and asserts particular interest in (1) learning how Medicare Advantage (MA) and other payers have implemented tools to achieve this objective, and (2) whether and how such tools could be implemented in the traditional fee-for-service (FFS) program.

The American Medical Rehabilitation Providers Association (AMRPA) has long championed CMS’ efforts to advance and improve its approach to program integrity, and looks forward to continued engagement with CMS as it considers how to integrate emerging technologies into its Medicare and Medicaid oversight. The Association raised concern, however, about CMS’ stated interest in looking to the MA program to help “inform” potential reforms in the FFS program – particularly with respect to prior authorization policies. AMRPA members have reported that prior authorization practices used by MA plans have resulted in harmful care delays and inappropriate denials for inpatient rehabilitation services. AMRPA’s comment letter urged CMS to focus on curbing these ineffective practices in MA – rather than expand such harmful policies to the FFS program.

AMRPA also cautioned against the use of proprietary clinical decision tools to generate more “timely” claim reviews in the FFS programs. MA plans often rely on certain proprietary guidelines to drive post-acute care (PAC) placement decisions, and these guidelines often result in MA beneficiaries being denied services that they are entitled to receive under Medicare statute. These proprietary guidelines also often contradict wellestablished standards and best practices in rehabilitation medicine, such as the American

AMRPA Magazine / January 2020 21

Heart Association and American Stroke Association’s guidelines for stroke recovery.1 As such, AMRPA asserted that broader adoption of these clinical decision support tools in FFS are likely to increase the number of claim appeals, while also jeopardizing patient access to clinically appropriate inpatient rehabilitation services. AMRPA provided a number of alternative MA-focused recommendations to make the claim review process more timely, such as requiring MA plans to have staff available 24 hours, 7 days a week to respond to prior authorization requests.

Finally, AMRPA urged CMS to consider certain reforms to its auditing process to increase the effectiveness and efficiency of file reviews, such as requiring auditors to have appropriate training and experience in the context of their reviews. With respect to inpatient rehabilitation reviews, AMRPA recommended that requiring a qualified rehabilitation physician to approve all denials issued on the basis of medical necessity could significantly improve the accuracy of inpatient rehabilitation reviews and cut down on appeals, in line with CMS’ stated goals.

With CMS expected to issue new program integrity-focused regulations in early 2021, AMRPA will engage with policymakers in the year ahead to ensure that any new policies achieve the tandem objectives of ensuring proper payments while protecting patient access to clinically appropriate care. AMRPA’s full RFI response is reproduced below and is also available at www.amrpa.org.

November 20, 2019 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Avenue, Southwest Washington, D.C. 20201 Delivered Electronically RE: CMS Request for Information re: Future of Program Integrity and Request for Information re: Advanced Technology in Program Integrity Dear Administrator Verma: The American Medical Rehabilitation Providers Association (AMRPA) appreciates the opportunity to provide comments in response to the Centers for Medicare and Medicaid Services’ (CMS) Requests for Information (RFIs) regarding ways to modernize program integrity in the Medicare program. AMRPA applauds CMS’ efforts to work collaboratively with stakeholders to “identify new tools, strategies, and other innovative approaches to minimize improper payments and reduce provider and supplier burden.” We have major concerns, however, about the agency’s interest in looking to the Medicare Advantage (MA) program to help “inform” potential reforms in the fee-for-service (FFS)

Medicare program – particularly with respect to claim review practices and prior authorization policies. AMRPA members find that certain tools used by MA plans have resulted in harmful care delays and denials for inpatient rehabilitation services, and we therefore call on CMS to address these practices in MA rather than expand such harmful policies to the FFS program. Our concerns and recommendations on these and other issues are provided in greater detail below.

AMRPA is the national trade association representing more than 650 freestanding inpatient rehabilitation hospitals and rehabilitation units of general hospitals (collectively referred to as inpatient rehabilitation facilities (IRFs, hereinafter referred to as IRH/Us) by the Centers for Medicare and Medicaid Services (CMS)), outpatient rehabilitation service providers, long-term care hospitals (LTCHs), and several skilled nursing facilities (SNFs).

The vast majority of our members are Medicare participating providers. In 2017, IRH/Us served 340,000 Medicare beneficiaries with more than 380,000 IRH/U stays.2 AMRPA members help their patients maximize their health, functional ability, independence, and participation in society so they are able to return to home, work, or an active retirement.

Our comments below are focused on three major issues included in the RFI: (1) the potential expansion of prior authorization in the FFS Medicare program; (2) addressing current program integrity issues in the Medicare Advantage program; and (3) ways to improve the accuracy of IRH/U audits while reducing provider burdens. AMRPA stands ready to work with CMS to identify reforms in these areas that can effectively improve claim reviews and curb improper payments, while also reducing significant provider burdens currently facing IRH/Us. I. Applying Prior Authorization in FFS Will Lead to Inappropriate and Harmful Care Delays and Denials AMRPA is highly concerned by provisions in the RFIs that indicate CMS’ interest in “learning from the forwardthinking [program integrity] tools” utilized by MA plans and considering how to incorporate such tools in the FFS program – including prior authorization. Specifically, the RFI poses a number of implementation-related questions focused on prior authorization in FFS Medicare, such as (1) whether prior authorization can be used in a way that protects “complete access to medically reasonable and necessary covered services for beneficiaries;” (2) whether clinical decision support tools can play an appropriate role in prior authorization; and (3) if CMS can apply prior authorization in FFS without adding to provider and beneficiary burden. AMRPA asserts that the answer to all these questions is a resounding “no,” based on the current regulatory landscape facing our industry and the adverse impact that such policies currently impart on inpatient rehabilitation access in the MA program.

1

Winstein, C. J., et al. (2016). Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. (46)6. 98-169.

2

Medicare Payment Advisory Commission (MedPAC), “Chapter 10: Inpatient Rehabilitation Facility Services,” Report to the Congress: Medicare Payment Policy, March 2019.

22 AMRPA Magazine / January 2020

As an initial matter, prior authorization policies are particularly misplaced when applied to IRH/Us. Before a beneficiary can ever be admitted to an IRH/U, Medicare regulations require a qualified physician to evaluate the patient against objective pre-admission criteria. Among other requirements, the beneficiary must be able to tolerate and benefit from intensive therapy, at least three hours per day, with extensive documentation to confirm this. Due to the rigor of existing IRH/U admission criteria, our members report that they decline admission for a substantial portion of patients referred to their hospital – essentially creating a “de facto” prior authorization policy that is based on the physician’s clinical judgment and tailored to specific patient needs.

With respect to whether prior authorization policies can “protect complete access” to necessary services for beneficiaries, the experience of IRH/U beneficiaries in the MA program shows that these policies produce the opposite result. Our members report that, based on their direct experience with prior authorization practices in MA, these policies lead to improper denials, referrals to inappropriate care settings, and lengthy delays in care that cause irreversible clinical harm. MA plans take one to three business days to respond to a prior authorization request for IRH/U admission, and even longer when accounting for weekends. These initial requests are denied at a very high rate, and then the hospital must engage in the days-long appeals process. All the while, the patient’s acute stay has been unnecessarily extended up to a week, and the patient is without the comprehensive rehabilitation services needed. Often times, acute-care hospitals are left with no practical choice but to discharge the patient to a lesser-intensity setting of care, and by the time a favorable appeal determination is reached, it can be a difficult decision whether to move the patient yet again. Even in the increasingly rare cases when an MA patient is successfully admitted to an IRH/U, the administrative burden and resources expended are taxing and detract from care.

Supporting the stark lack of access for MA beneficiaries needing inpatient rehabilitation, CMS data demonstrates that MA enrollees are admitted to IRH/Us at one-third the rate of FFS beneficiaries - due largely to prior authorization policies that drive patients to lower-acuity settings.3 Expanding prior authorization to the FFS program would therefore devastate access to IRH/U services throughout the entire Medicare program. To further illustrate these access issues, AMRPA notes that there is strong bipartisan agreement in Congress to reform components of the prior authorization policies that have unfairly impeded access to reasonable and necessary 3

4 5 6 7

covered services for MA beneficiaries. Specifically, the House Appropriations Committee’s FY 2019 Report cautions against the use of prior authorization to inappropriately delay needed care and directs CMS to issue guidance to restrict these practices.4 In addition, 132 bipartisan members of the House have sponsored legislation that would fundamentally overhaul the way MA plans administer prior authorization.5 AMRPA similarly opposes the use of the currently marketed, proprietary clinical decision tools in the FFS program, based again on our members’ experience in the MA program. Many MA plans use clinical decision support tools – specifically proprietary guidelines (such as Milliman and InterQual) – that result in MA beneficiaries being denied services they are entitled to receive under Medicare statute. For example, while Medicare regulations clearly require MA plans to provide “all Medicare-covered services,”6 plans often apply these guidelines to make coverage decisions that run afoul of Medicare coverage rules and improperly deny coverage of inpatient rehabilitation. These guidelines also often contradict well-established standards and best practices in rehabilitation medicine, such as the American Heart Association and American Stroke Association’s guidelines for stroke recovery. 7 The net effect of these practices is to divert many enrollees who qualify for inpatient hospital rehabilitation to less appropriate, lower-acuity settings, such as nursing homes and homecare – inevitably decreasing their prospects for optimal recovery. AMRPA is alarmed, therefore, that CMS expresses interest in the RFI as to how MA plans use prior authorization “to closely monitor whether claims meet payer guidelines,” as such guidelines often work to deny beneficiaries access to covered and clinically necessary services. Therefore, rather than looking to expand the use of such clinical support tools, AMRPA urges CMS to reexamine the use of all proprietary guidelines used by MA plans and prohibit their usage when they run afoul of Medicare coverage criteria.

Finally, AMRPA underscores the administrative and financial burdens that prior authorization creates for providers, particularly the way that such policies are currently structured in the MA program. MA plans’ prior authorization polices often require providers to submit extensive documentation and spend time challenging inaccurate reviews of IRH/U prior authorization requests, diverting time and resources away from patient care (as more fully detailed in the next section). This is especially true for treating physicians, who must rearrange their schedules to participate in “peer-

Medicare Payment Advisory Commission (MedPAC), “Chapter 10: Inpatient Rehabilitation Facility Services,” Report to the Congress: Medicare Payment Policy, March 2017.

H.R. REP. NO. 116-62, at 139 (2019).

H.R. 3107, 116th Cong. (2019).

42 C.F.R. § 422.101(b)(2).

“In-patient rehab recommended over nursing homes for stroke rehab,” American Heart Association/American Stroke Association Scientific Statement, May 4, 2016, available at http://newsroom.heart.org/news/in-patient-rehabrecommended-over-nursing-homes-for-stroke-rehab. See also AHA/ASA, GUIDELINES FOR ADULT STROKE REHABILITATION AND RECOVERY: A GUIDELINE FOR HEALTHCARE PROFESSIONALS FROM THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION (2016), available at http://stroke.ahajournals.org.

AMRPA Magazine / January 2020 23

to-peer” discussions at the convenience of the MA plan.8 Introducing prior authorization and clinical decision support tools into FFS would add harmful new administrative and financial burdens for providers of FFS patients, in contrast to the stated burden reduction goals of this Administration.

AMRPA remains eager to work with CMS to identify new tools and technologies that could improve pre- and postpayment claim reviews, but we staunchly oppose using prior authorization as a means of improving program integrity in the FFS program.

II. Addressing Program Integrity Issues in the Medicare Advantage Program As outlined in the preceding section, AMRPA believes that any expansion of prior authorization policies poses a serious threat to beneficiary access to timely and clinicallyappropriate services, particularly IRH/U services. As an equally important policy issue, AMRPA also calls on CMS to focus its immediate attention on curbing the abusive and burdensome prior authorization policies that currently operate in the MA program. One of the major issues that providers face with respect to prior authorization is the variance in prior authorization requirements and processes among plans, which in turn create significant confusion for both providers and their patients. Therefore, in response to CMS’ request for the “specific changes [it] should consider as part of its program integrity strategy in the MA program,” AMRPA urges CMS to consider the following measures:

8

 Establishing a clear and uniform process for providers to submit prior authorization requests, such as through an electronic medium that facilitates faster and more easily reviewable determinations  Requiring plans to ensure that the contractors reviewing prior authorization requests have appropriate clinical background and experience on the claims at issue. This is particularly important for inpatient rehabilitationrelated claims, given the intricacy of IRH/U admission criteria and the medically complex nature of IRH/U patients  Mandating that prior authorization policies be consistent with Medicare coverage criteria and clinical guidelines.

This would prohibit, for example, the use of proprietary guidelines that contravene established clinical guidelines for stroke patients and often attempt to place stroke patients in a lower-acuity setting rather than an IRH/U  Creating new requirements to ensure plans have staff available 24 hours, 7 days a week to respond to prior authorization requests, given the need for immediate review of IRH/U admission requests and other treatment decisions in the PAC setting  Requiring plans to establish clinically appropriate and targeted documentation requests. This would curb the current practice of MA plans delaying prior authorization

determinations via requests for excessive documentation that often have limited relevance to the PAC placement decision at issue These reforms would significantly enhance the administration of MA program and the patient experience of care.

Collectively, these reforms would significantly reduce administrative burden for providers and better ensure that patients are receiving timely access to clinically appropriate services – directly in line with CMS’ goals outlined in this RFI. AMRPA stands ready to work with CMS to help implement these types of reforms to improve program integrity in the MA program, including the identification of appropriate timeframes for PAC-related prior authorization determinations.

III. Reforms to Improve Inpatient Rehabilitation-Focused Audits In addition to addressing the aforementioned pre-payment issues involving inpatient rehabilitation services, AMRPA calls on CMS to improve its program integrity oversight through key changes to the way its auditors intersect with IRH/Us. There are numerous entities that audit IRH/U claims – including Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractors (SMRCs), Recovery Audit Contractors (RACs), the Comprehensive Error Rate Testing Contractor (CERT), and the Office of Inspector General (OIG) – and all of these entities interpret IRH/U coverage criteria differently, often producing time-intensive and inaccurate audit results. In addition to the time spent on the audits themselves, hospitals spend countless hours appealing denials, which are overturned at a very high rate.

AMRPA supports needed reforms to improve audit practices, reduce provider burdens, and produce audit results that are more educational and instructive for both providers and the Medicare program.

AMRPA has long supported establishing a standing Medical Rehabilitation Advisory Board to ensure that Medicare medical necessity standards and enforcement reflects the real-world practice of rehabilitation medicine. This Advisory Board could advise CMS and its audit contractors on ways to accurately review medical necessity determinations as applied to IRH/U services, given the aforementioned complexity of both the IRH/U compliance criteria and IRH/U patient mix. Such an Advisory Board would interface with both providers and auditors to ensure that all parties maintain parallel medical necessity expectations. This effort would significantly improve IRH/U audits and significantly reduce the burdens currently created by the different audit contractor reviews and processes.

Furthermore, to advance CMS’ goals of improving provider

IRH/Us find the term “peer-to-peer,” as used in the context of prior authorizations for admissions, to be a misnomer. Hospitals rarely find that the MA plan is utilizing a physician trained in rehabilitation medicine to make prior authorization admissions determinations. This situation is exacerbated by the fact that sometimes rehabilitation physicians at the IRH/U do not have standing to participate in peer-to-peer discussions while the patient is in an acute care setting.

24 AMRPA Magazine / January 2020

education, CMS should require auditors to make their instructions and guidelines available for public feedback and discussion. Doing so would help make audits more educational and less punitive, and potentially result in fewer appeals. Relatedly, in the case of denials, CMS auditors should be required to explain how and why specific facts led to the conclusion that the patient did not meet the coverage criteria. This would help the provider refine its admission and documentation practices to address deficiencies that are clearly identified and explained by the auditor and understood by the provider. More detailed denials would also help educate providers and reduce the occurrence of similar errors in future audits.

AMRPA appreciates the opportunity to participate in CMS’ important efforts to improve program integrity in the Medicare program. We are eager to provide any technical assistance or further information on our recommendations and look forward to continuing to collaborate on ways to improve IRH/U claim reviews and protecting patient access to vital inpatient rehabilitation services. If you have any questions, please do not hesitate to reach out to Kate Beller, AMRPA Executive Vice President for Policy Development and Government Relations (202-207-1132, kbeller@amrpa.org) or Jonathan Gold, Director of Government Relations and Regulatory Counsel (202-860-1004, jgold@amrpa. org).

Sincerely,

Lastly, and consistent with our recommendations related to prior authorization, AMRPA urges CMS to require auditors to have appropriate training and experience in the context of their claims reviews. Currently, contractors often use non-physicians, or physicians who do not meet Medicare’s qualifications of a rehabilitation physician, to make medical necessity determinations of IRH/U services. To improve the accuracy of IRH/U reviews and significantly cut down on appeals, CMS should require that only a physician who meets the Medicare requirements of a qualified rehabilitation physician, with current experience in IRH/U practice, review and approve all denials issued on the basis of medical necessity.

Richard Kathrins, PhD Chair, AMRPA Board of Directors President and Chief Executive Officer, Bacharach Institute for Rehabilitation

AMRPA Magazine / January 2020 25

New Hospital Price Transparency Requirements Finalized for 2021

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

Highlights:

»» »»

All payer-negotiated rates must be included along with gross charges Minimum of 300 shoppable services must be posted in consumer-friendly format

In November 2019, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will require hospitals to make public their standard and negotiated charges for all items and services. These requirements, which are detailed further below, stem from a proposed rule CMS included in this year’s Outpatient Prospective Payment System (OPPS) Proposed Rule. Although originally proposed to go into effect in 2020, CMS delayed implementation of these requirements until January 2021. These new requirements will apply to all types of hospitals (specifically, all facilities operating as hospitals under state or local law), regardless of whether the hospital participates in Medicare.

In promulgating these new regulations, CMS relied on language from the Affordable Care Act (ACA) that requires each hospital to make public a list of the hospital’s standard charges for items and services provided in that hospital. In 2015, CMS first began telling providers that they would need to either post their chargmasters online, or make public their policies for how it would provide standard charges to the public. In 2018 rulemaking, CMS required that all hospitals post a list of their standard charges on the internet in a machine-readable format, effective January 2020. CMS permitted this requirement to be satisfied by publication of the chargemaster for the hospital.

CMS permitted this requirement to be satisfied by publication of the chargemaster for the hospital.

In June 2019, President Trump issued an Executive Order that required the U.S. Department of Health and Human Services (HHS) to propose regulations requiring hospitals to publicly post additional standard charge information. The new requirements that result from this Executive Order and the subsequent OPPS proposed rule go well beyond the current requirements and will require payer-specific negotiated and other types of rates to be posted. These prices will need to be displayed prominently on a publicly available webpage, and must be easily accessible to the public as well as digitally searchable.

CMS adopted a very broad interpretation of the range of items and services that must be posted by hospitals. The agency is requiring that each and every item and service, as well as any “service packages” that the hospital might charge certain payers, be posted online. This includes all services provided by hospital-employed physicians and other employed clinicians. However, CMS is not requiring hospitals to post charges for services of non-employed physicians and other non-employed clinicians.

The final rule also requires a very wide assortment of types of prices for all of these items and services. The final rule requires the following charges to be posted for each item and service:

26 AMRPA Magazine / January 2020

Payer-specific negotiated charges for every third-party payer, including Medicare or Medicaid managed care plans.

This does not include fee-for-service Medicare or Medicaid payments.

Discounted cash price that is available for individuals who pay cash for an item or service.

The de-identified minimum and maximum negotiated charge defined as the highest or lowest charge the hospital has negotiated with a third-party payer.

The gross charge, defined as the price reflected on a hospital chargemaster without any discounts reflected.

In addition to the requirement to post prices for all items and services for most payers, CMS is imposing additional requirements for certain “shoppable” services. CMS is requiring that these shoppable service charges must be posted in a consumer-friendly display. Although CMS did not proscribe a specific format, it does specify required information elements including “a plain-language description of each type of shoppable service,” along with the previously described payer-specific and cash prices for each service. The hospital will also be required to identify all ancillary items and services that the hospital customarily provides with the shoppable service, as well as ensure this tool is also digitally

searchable for consumers. In the final rule, CMS defined shoppable service as any service that a patient could schedule in advance. This includes 70 specific services designated by CMS in the final rule, as well as additional 230 as chosen by the hospital. If a hospital does not provide 300 shoppable services, they will be required to list information for as many shoppable services as they provide.

In the final rule, CMS finalized that it will enforce these requirements through audits of hospitals’ webpages. CMS has authorized itself to require non-compliant hospitals to undergo corrective action plans and can also impose civil monetary penalties of up to $300 per day for non-compliance. The agency also says non-compliant hospitals will be identified on the CMS website. All types of charges posted must be updated at least annually by the hospital.

AMRPA Commentary AMRPA strongly opposed these requirements and recommended to CMS in a comment letter that the agency pursue other, less burdensome means of accomplishing price transparency for consumers. Following the publication of this final rule, several organizations filed a lawsuit, arguing that CMS and HHS had exceeded its statutory authority as well as that these requirements are violations of the First Amendment of the U.S. Constitution.

AMRPA Magazine / January 2020 27

CMS Releases Final 2020 Physician Fee Schedule Rule With Changes to Outpatient Therapy Services

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

Highlights:

»» »»

CMS details application of payment reduction for use of therapy assistants Potential overhaul of Merit-Based Incentive Payment System

On November 15, the Centers for Medicare and Medicaid Services (CMS) released the Physician Fee Schedule (PFS) final rule for calendar year (CY) 2020 in the Federal Register.

The rule contains a number of noteworthy changes for both therapy and physician services. CMS has finalized its policy for applying a payment adjustment for the use of therapy assistants (TAs), and has also completed its overhaul of outpatient physician visit billing. Additionally, the final rule takes steps to expand the use of care management services by physicians, and also discusses a possible major overhaul of the Merit-Based Incentive Payment System (MIPS). This article reviews key provisions in the final rule of relevance to AMRPA members. As always, members who are seeking more information or have questions on these new policies are invited contact the AMRPA policy team.

Reduction in Payment and New Modifiers for Therapy Assistants As part of the repeal of the therapy caps for outpatient therapy services, the Balanced Budget Act of 2018 required that CMS institute a reduced payment rate of 85% of the otherwise applicable Part B payment for any outpatient therapy services provided in whole or in part by a TA. While the reduced payment rate will not take effect until January 1, 2022, the Act requires that use of the modifier to indicate TA involvement begin by January 1, 2020. In this final rule, CMS finalized its policy that requires providers to use the modifier “CQ” if a physical therapy assistant provides the services in whole and in part, and a “CO” modifier will when an occupational therapy assistant provides the services in whole or in part.

CMS dedicated considerable attention in this year’s rulemaking to defining when an outpatient therapy service is provided “in part” by a TA. Based on feedback in this and last year’s rulemaking, CMS finalized what it calls de minimis threshold, which requires the modifier when more than 10% of the billed service is provided by the TA. CMS emphasizes that only the therapeutic portion of the services count toward this threshold.

The agency provides examples of activities that would be considered non-therapeutic portions of service, such as gowning patients or cleaning equipment that non-skilled personnel could perform.

In this year’s proposed rule, CMS proposed that for purposes of determining whether the de minimis threshold was breached, providers would need to count minutes spent independently by the TA, as well as minutes spent concurrently by both the TA and the therapist. AMRPA and other stakeholders pushed back on this proposal, arguing that minutes spent concurrently by both the TA and therapist should not count toward the de minimis threshold, since in these instances it is the therapist providing the services. CMS agreed, and reversed its position in the final rule. The agency finalized that only minutes

28 AMRPA Magazine / January 2020

spent independently by the TA will count toward determining whether the de minimis standard has been exceeded.

CMS proposed and finalized two ways for providers to determine whether the TA has provided more than a de minimis amount of services. The first method is to divide the applicable TA minutes by the total minutes spent on any one unit of service, and then multiply that number by 100, and round to the nearest whole number. If the result is 11 or more, the de minimis standard is exceeded. The other method CMS proposed and finalized is to divide the total time of the unit of service by 10, round to the nearest whole number, add one, and that result is the number of minutes needed to have exceeded the de minimis threshold.

After establishing the basic methods of determining whether the de minimis threshold is exceeded, CMS also finalized additional policies on how providers should apply the modifier in various clinical and billing scenarios, including when multiple units of the same or different codes are billed for one session of services.

CMS will require the modifier for both timed and untimed service codes when the de minimis threshold is reached. For untimed service codes, CMS says providers will need to apply the above methodology by comparing the total time spent on the untimed service with the time spent by the TAs independently of the therapist providing that service.

For timed service codes, the finalized application of the modifier is less straightforward. Originally, CMS proposed that providers would need to continue to bill all service codes of the same type on the same claim line. Further, CMS proposed that the de minimis threshold determination would be made by combining all the time spent per service type per day, and calculating whether the TA was involved in more than 10% of the services. If the TA was involved in more than 10% of that type of service, then the modifier, and subsequent payment reduction, would apply to all units of that type billed that day, even if the therapist provided several units completely independent of the TA. However, due to AMRPA and other stakeholder’s feedback, CMS again reversed itself in the final rule. CMS finalized that providers can break up multiple units of the same service codes onto different claim lines to avoid applying the TA modifier on units of service in which the TA was not involved.

This will allow providers to minimize the number of units that will face a payment reduction.

Physician Evaluation and Management (E/M) Visit Code Payment and Documentation Last year, CMS put forward significant changes to the Evaluation and Management (E/M) codes used by physicians and other advanced practice clinicians to bill office and other outpatient visits (CPT Codes 99201-99205 and 99211-99215). These changes were scheduled to go into effect in 2021. However, in this year’s proposed rule, CMS said it no longer planned to implement the changes for 2021 that it had put in place last year. Instead, CMS proposed new changes for outpatient E/M code requirements and payment rates, to be effective 2021. CMS has now finalized these new, updated changes.

Current policy dictates that a physician will bill one of five E/M codes for outpatient visits. There are currently two distinct sets of five codes for outpatient E/M visits: one for new patients (9920199205) and one for established patients (99211-99215). The level of code generally increases as time, resources or the complexity of the patient’s condition increases, with level 1 being the lowest and level 5 being the highest. There are unique payments for each of the ten codes, and payment increases as the level of the visit increases.

According to CMS, these E/M codes account for approximately 20% of all charges billed under the PFS. Practitioners currently determine which level of visit to bill based on guidelines from the American Medical Association (AMA). The AMA guidelines instruct physicians to choose one of the five levels based on a combination of three factors, including history of present illness (HPI), physical examination and medical decision making (MDM).

As part of last year’s rulemaking CMS said that effective 2021, it will consolidate payment amounts for visit levels 2-4 for both new and existing patients. CMS stated this would allow for simplified documentation requirements, reducing burdens on clinicians billing these relatively similar visits. However, CMS has proposed and now finalized a different approach to updating current E/M codes, effective 2021, that will replace its policy change from last year. In this year’s rule, CMS has finalized that it will retain separate payment levels for all E/M visit levels. CMS also adopted updated work values for these codes that will significantly increase the payment amount for these codes. In addition, the agency is eliminating level 1 visits for new patients, which it says is sparsely used. The chart below provides an estimate of the updated values of the E/M codes for CY 2021, assuming CY 2020 finalized conversion factor and practice expense values.

AMRPA Magazine / January 2020 29

In addition to consolidating payments, last year CMS also finalized changes to how physicians would determine which level to bill.

Rather than continuing to consider three factors (HPI, physical, MDM), CMS put in place a policy that said physicians could choose a level of visit based solely upon MDM or time, or continue using the existing framework using all three factors (HPI, physical and MDM). Building upon this, CMS has finalized in this year’s rule that it will adopt recommendations from the AMA that would change the standard way outpatient E/M visit levels are chosen (Full AMA recommendations available at https://www.ama-assn.org/practicemanagement/cpt/cpt-evaluation-and-management). Under this new policy, HPI and exam would no longer be used to determine visit level. Instead, physicians will choose the level of visit based upon either MDM or based upon the total time spent during the day of the visit on that patient. In addition, new, updated typical time values will also be adopted for each of the E/M codes.

Last year CMS also adopted a reduced documentation threshold, so that physicians would only need to document at level 2 requirements for all 2-4 level visits, consistent with the consolidated payment rate. CMS is no longer adopting this change. Instead, physicians will be required to provide documentation for the corresponding visit level, but only for the element used to justify the visit level, which would be either MDM or time. When selecting a visit based on time, the physician will need to document the total amount of time spent with the patient.

Given the proposed consolidation of E/M payment levels last year, CMS proposed in that rule several add-on codes for physicians that may find themselves undercompensated for treating particularly complex or resources-extensive patients. Now that CMS is walking back its consolidation of payment rates, it is also altering its new add-on codes. CMS has finalized that it will use two distinct add-on codes for outpatient physician visits. The first will be for prolonged services, when the time spent on the day of visit exceeds the level 5 floor time by at least 15 minutes. This code can only be used when time is used to determine visit level. CMS is also eliminating the use of codes 99358-9, which are currently used as add-on codes for prolonged time spent without patient contact, since the redefined E/M and add-on codes will allow for counting extended time without patient contact.

The second add-on code CMS has created is a complexity addon code, which will be used for primary care physicians devoting additional resources to services such as time spent coordinating care. The second permitted use of this code will be for specialists treating particularly complex patients. Notably, unlike last year’s proposed add-on, CMS is not specifying certain specialties in this code descriptor, and intends for the code to be available for all types of physicians.

To summarize, CMS is implementing the following, effective CY 2021: Four levels of outpatient E/M visits for new patients and five levels of outpatient E/M visits for existing patients, all with separate, distinct payment amounts.

Adopting increased values for these codes consistent with AMA recommendations.

30 AMRPA Magazine / January 2020

Level of visit will be determined by MDM or time, and the current process for determining visit levels using three factors (MDM, exam and HPI) will be eliminated.

Require physicians to provide documentation sufficient to support the level of visit billed.

Creation of two new add-on codes: One for prolonged time when billing based on time, and one for visit complexity.

It should also be noted that the physician fee schedule is budget neutral. Any increases in overall value of codes are offset by a budget neutrality factor applied to all services. It is anticipated that, due to the large increase in value for these E/M codes, as well as these codes making up 20% of all fee schedule services annually, there will be a large budget neutrality factor put in place for CY 2021. Therefore, some specialties that do not bill E/M visits as frequently may see notable decrease in payments. In the final rule, CMS provides estimated changes in payments as a result of these E/M code changes. The estimate shows physical medicine and rehabilitation receiving a 2% overall payment reduction. Physical and occupational therapy is estimated to receive an 8% payment reduction, likely due to the fact these therapists cannot bill E/M codes. CMS says it is aware of concerns from certain specialties, and will examine ways to avoid such cuts in next year’s rulemaking.

Care Management Services CMS has made several changes that it says will expand the ability of physicians to bill for management of patients with chronic conditions. First, CMS is lifting the restriction on physicians billing transitional care management (TCM) codes concurrently with other codes such as care plan oversight or complex chronic care management services. TCM is used for the management of a patient who has recently been discharged from a facility. CMS says lifting this restriction on concurrent billing of other codes will hopefully encourage more use of the TCM codes. CMS has also slightly updated the value of the TCM codes in this final rule.

In addition, CMS has made changes to chronic care management (CCM) codes, which physicians can bill for non-face-to-face management of a patient with multiple chronic conditions. CMS has added an add-on code for these services that can used for each additional 20 minutes of CCM services provided. Previously, physicians could only bill for the initial 20 minutes of service time. The final rule also revises some requirements for billing of CCM codes, including eliminating the requirement for some of the codes that there must be a substantial revision of the care management plan.

CMS also addressed concerns in this final rule that there was no equivalent CCM code for patients with just one chronic condition.

Therefore, CMS has finalized new codes it calls Principal Care Management services. These codes would mirror CCM codes, but only require the patient to have one chronic condition. As a condition of billing this code, CMS is requiring documentation from physicians of the coordination between the billing physician and other clinicians involved in the patient’s care.

Supervision and Scope of Practice of Physician Assistants CMS currently requires general supervision of physician assistants (PA) by a physician. General supervision is defined as having the PA services under the overall direction and control of the physician, but the physician’s presence is not required during the performance of services by a physician assistant. Due to the evolving nature of state rules for scope of practice, CMS says it wishes to provide flexibility to clinicians to adhere to state rules. To accomplish this, CMS has finalized that PAs must be supervised in accordance with the state law in the state in which they practice, rather than a specific CMS standard. In the absence of a state law, providers must document the way in which the PA is supervised by medical staff for the services delivered. CMS says this will align the PA scope of practice in Medicare with those used by nurse practitioners.

Physician Documentation Requirement Changes Last year, CMS finalized a change that would eliminate the requirement that teaching physicians redocument items that were already entered into the medical record by a nurse, resident or another physician. Now, CMS has expanded this policy to all physicians and physician extenders billing under Part B, regardless of whether the clinician is acting in a teaching capacity. CMS says that now physicians and physician extenders will be permitted to enter a signed notation that they have reviewed the information entered by another individual, rather than redocument that same information again.

Overall Payment Changes Overall, changes to payments in the PFS must be undertaken in budget-neutral manner, so CMS does not estimate a positive or negative change in total payments for CY 2020. However, due to shifts in the relative values for services, and a small change in the standard conversion factor, CMS estimates overall payment changes by specialties. CMS estimates that there will be a 1%

increase in payment to the physical medicine specialty for 2020.

CMS also estimates no overall change for payments to physical and occupational therapists due to this year’s changes. However, as previously noted, CMS has estimated a bigger change for both specialties for 2021, when the new E/M policies take effect, due to the PFS budget neutrality adjustment.

Potential Redesign of the Merit-Based Incentive Payment System In this year’s rulemaking, CMS discusses a potentially large-scale overhaul of MIPS to make the program more accessible and less burdensome for clinicians. MIPS adjusts Part B payments to eligible clinicians based on four performance categories: quality, cost, promoting interoperability and improvement categories. Currently, measures for each of these categories are separately reported, sometimes with little nexus to one another.

CMS discusses in this year’s proposed and final rule the possibility of creating what it terms MIPS Value Pathways (MVPs). The agency explains MVPs would create the ability for a clinician to have an option to participate in MIPS based on their specialty. A MVP would be created for different specialties that have measures relevant to that type of clinician and that potentially cut across the four categories. This, according to CMS, would make the program both more relevant to physician practices, as well as less burdensome to participate in.

In the final rule, CMS indicated it plans to continue working toward creating MVPs, potentially introducing MVPs as early as 2021. It says it will work with stakeholders to further develop the pathways, and is still considering whether to make MVPs voluntary or mandatory, as well as what type of transition there will be from current MIPS protocols to MVPs.

AMRPA Magazine / January 2020 31

MedPAC Discusses Latest Research on Post-Acute Care Spending in Medicare Shared Savings Program Accountable Care Organizations On November 8, the Medicare Payment Advisory Commission (MedPAC) held the public meeting session Post-acute care spending under the Medicare Shared Savings Program. The session focused on post-acute care (PAC) spending within Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), and how PAC services could be a potential opportunity to lower spending within ACOs. In a prior session, MedPAC reported that reductions in PAC services, and not acute-care hospitalizations, have been the primary source of savings for Medicare’s ACO programs.1 Since that time, MedPAC has continued to develop research specific to MSSP ACOs (the largest of Medicare’s ACO programs), and the updated research was the basis of this meeting.

Background MedPAC staff presented data from 2012 to 2016, primarily focused on home health agencies (HHAs) and skilled nursing facilities (SNFs), and the impact of MSSP ACOs on Medicare spending and PAC utilization. Staff reported that approximately 40% of acute-care hospital discharges are followed by a PAC stay in any of the four settings (SNF, HHA, inpatient rehabilitation hospitals/ units [IRFs], and long-term care hospitals [LTCHs]). Staff went on to explain that spending varies widely based on geographic location, with a greater variation compared to other Medicare services. Staff stated that ACOs may be an opportunity to address PAC spending due to overlap between PAC settings in both services and patient population.

MedPAC staff reported that some studies have found that MSPP ACOs had a modest reduction on Medicare spending compared to traditional fee for service (FFS). Specifically, staff cited one study which found that lower spending growth for acute-care hospital and PAC services within an ACO was equivalent to an approximately $197 savings per beneficiary, or approximately 2% of the average Part A and B spending per beneficiary in 2014.2

Comparatively, in its June 2019 report, MedPAC reported that all-services spending growth for MSSP ACO beneficiaries was 1-2% lower than FFS between 2012 and 2016.

MedPAC staff explained that their latest research utilized an “intent-to-treat” model to compare spending growth between beneficiaries assigned to an MSSP ACO and a control group (traditional FFS) not assigned to an ACO. The model followed the ACO beneficiary group and the control group from 2012 to 2016 (i.e., no new beneficiaries enter the sample after 2012), to mitigate any effects that may be due to changes in ACOs’ attributed beneficiaries from year to year. Staff expected average spending to increase for both groups every year due to the beneficiaries aging.

The control group was sampled from the same market as the MSSP ACOs, and were weighted to demographically and clinically match the ACO population.

Staff measured ACO impact by comparing the growth in expenditures for these two groups, examining both acute-care hospitalizations and PAC use. Over the four-year period, MSSP ACOs had 1% to 2.8% lower spending growth than the comparison FFS group for hospital or PAC services. The data showed that ACOs slowed the growth of PAC encounters (defined as IRF, LTCH, or SNF stay or HHA episode) relative to FFS; however, the difference between ACOs and traditional FFS was negligible.

Specifically, the traditional FFS group had an 18.0 increase in PAC encounters per 100 beneficiaries, while MSSP ACO beneficiaries had a 17.8 increase in PAC encounters per 100 beneficiaries, for a difference of -0.2 encounters for all PAC services. With regard to PAC use, staff pointed out that MSSP ACOs have not significantly reduced the frequency of SNF use, and furthermore, the decline in SNF spending was due to reduced Medicare SNF days and not fewer SNF admissions. More detailed data can be found on the next page.

1

MedPAC Report to Congress: Medicare and Health Care Delivery, Medicare accountable care organization models: Recent performance and long-term issues, 230. (June 2018)

2

McWilliams, J. M., Gilstrap, L. G., Stevenson, D. G., Chernew, M. E., Huskamp, H. A., & Grabowski, D. C. (2017). Changes in postacute care in the Medicare Shared Savings Program. JAMA internal medicine, 177(4), 518-526.

32 AMRPA Magazine / January 2020

Increase in per-beneficiary spending between 2012 and 2016

Relative differences per beneficiary for MSSP ACOs between 2012 and 2016

Comparison group

2013 MSSP ACO beneficiaries

Relative difference in spending per beneficiary

Difference in spending as a percent of average

$1,337

$1,268

-$69

-2.3%

Skilled nursing facilities (SNF)

$655

$632

-$23

-2.8%

Home health care

$402

$396

-$6

-1.0%

$2,394

$2,296

-$98

-2.2%

Inpatient acute hospital

Total

Note: Positive differences represent higher growth for the MSSP ACO group. Negative differences indicate lower growth for the MSSP ACO group. Expenditures do not include MSSP shared savings payments. Data are preliminary and subject to change.

Source: MedPAC analysis of beneficiary-level spending data from the CMS Chronic Condition Warehouse.

Increase in PAC encounters per 100 beneficiaries between 2012 and 2016

Relative difference per 100 for MSSP ACOs between 2012 and 2016

Comparison group

2013 MSSP CO beneficiaries

Difference in encounters

Difference in encounters as a percentage of average between 2012 and 2016

All PAC services

18.0

17.8

-0.2

-0.8%

Skilled nursing facilities

4.9

4.9

Less than -0.1

-0.9%

Home health care

12.4

12.2

-0.2

-1.0%

Note: All PAC services includes skilled nursing facilities, home health care, inpatient rehabilitation facilities, and long-term acute care hospitals. Positive differences represent higher growth for the MSSP ACO group. Negative differences indicate lower growth for the MSSP ACO group. Data are preliminary and subject to change.

Source: MedPAC analysis of MedPAR and home health claims.

Increase in hospitalizations per 100 beneficiaries between 2012 and 2016

Relative difference per 100 beneficiaries for MSSP ACOs between 2012 and 2016

Comparison group

2013 MSSP A CO beneficiaries

Difference in hospitalizations

Difference in hospitalizations as an average between 2012 and 2016

Hospitalizations with PAC

6.5

6.4

Less than -0.1

-0.7%

Hospitalizations without PAC

4.6

4.3

-0.3

-1.9%

Note: All PAC services includes hospital discharges followed by skilled nursing facilities, home health care, inpatient rehabilitation facilities, and long-term acute care hospitals. Positive differences represent higher growth for the MSSP ACO group. Negative differences indicate lower growth for the MSSP ACO group. Data are preliminary and subject to change.

Source: MedPAC analysis of MedPAR and home health claims

AMRPA Magazine / January 2020 33

MedPAC’s Latest Findings  MSSP ACOs appear to have slightly slowed spending growth in acute hospital and PAC services over a four-year period relative to traditional FFS. Most of the slowdown was in acute hospitalizations, and reduced PAC spending accounted for a relatively smaller share of the impact.  While ACOs have modestly reduced the rate of hospitalizations for beneficiaries, the reduction is due to a slowdown in hospitalizations that were not followed by PAC. MSSP ACOs have not reduced the growth in PAC use after hospitalization to a meaningful degree.  MSSP ACOs marginally reduced PAC use and the greatest impact is from reduced SNFs days. Most of the savings have come from shorter SNF stays and not less frequent SNF admissions.

Staff acknowledged that their analyses do not include the shared savings payments made to ACOs; if they were included, ACO spending growth would be higher than FFS spending growth.

In concluding their presentation, the staff sought feedback from commissioners regarding: 1) why ACOs have not had a more significant impact on PAC spending; 2) what changes could be made to encourage ACOs to reduce unnecessary PAC utilization; and 3) will the shift toward two-sided risk in MSSP sufficiently improve incentives for PAC program savings.

Commissioner Discussion For a significant portion of the conversation, commissioners discussed the role that social determinants of health (SDoH) may play in PAC spending and utilization; both in the traditional FFS and ACO settings. Commissioners commented that there is a general assumption that beneficiaries have access to all PAC settings of care in an “equal and available manner,” and that family support plays a role in beneficiaries’ PAC use. He questioned if there are other similarly unmeasured social risk factors that may impact ACO’s PAC utilization and spending.

Additionally, commissioners stated there may be “real differences” in family supports, income, and other unobserved patient factors influencing PAC use. MedPAC staff concurred that SDoH may drive unexpected effects with PAC use.

Commissioners also questioned if data for Medicare Advantage was available and that it may present different PAC spending and utilization data in comparison to traditional FFS or ACOs. MedPAC staff explained that MA encounter data still lacks the necessary integrity and completeness that would make a comparative analysis possible, but that it is clear that MA has utilization management tools to curb PAC and other service use, which are unavailable in FFS.

34 AMRPA Magazine / January 2020

In addition to considering factors such as SDoH and various Medicare programs, commissioners discussed the impact that provider behavior and knowledge may have on PAC spending and utilization. Specifically, commissioners expressed concern that some providers may not be as engaged within an ACO as they should be, and asked MedPAC staff to investigate if engagement could be a factor in the savings variability seen between ACOs. Commissioners also suggested that staff examine MSSP ACOs by performance strata, and if this would lend greater resolution and possibly pinpoint the factors that differentiate successful ACOs from less successful ACOs. MedPAC staff explained that anecdotally some physicians may be more engaged within their ACO than others, and added that there are some ACOs where physicians may not even know their hospital is in an ACO. Commissioners commented that there is currently a lot of variability across the country with regard to PAC use, and questioned if staff had considered that in their analysis.

Suggestions were made to stratify ACOs by those with high PAC spending at baseline and then evaluating ACO impact on PAC spending. MedPAC staff replied that distribution of PAC spending had not been specifically considered, but overall spending had been evaluated and it appears that the areas with higher PAC spending are doing “a little bit better” than average.

Commissioners concluded their discussion with how current data may change and its potential relevance in the future. There was also a general consensus among commissioners that ACOs may not lead to sustainable or significant cost savings.

Commissioners asked what is known in the comparison of upside versus downside risk, and if there is an analysis of differences in performance available. MedPAC staff explained that the Next Generation ACO (Next Gen) program includes both types of risk and hence MedPAC’s evaluation of the Next Gen program will cover the comparison and analysis. He added that a 1% to 2% change seems to be “directionally consistent” for other, non-MSSP ACOs as well.

There was general consensus among the commissioners that, based on the data provided by MedPAC staff, ACOs do not have a profound effect on PAC spending despite the Commission’s previous expectations. Some commissioners commented they were not surprised by the “largely confirmatory” results of the modest 1-2% ACO savings, and that the commission should consider if the observed MSSP savings will continue to be achievable going forward. Comments were also made that the method used by MedPAC to evaluate ACOs contained a significant potential for bias, and could open MedPAC up to criticism. Questions were also raised if spending was conditionspecific, and if there is a payment differential when comparing BPCIs and ACOs. A commissioner noted that bundled payments may have more targeted provider involvement compared to ACOs. He added that ACOs may be “too nebulous” for physicians to understand and subsequently consider the financial impact of their PAC decisions.

It was stated that ACO PAC spending will ultimately be a result of how much an ACO prioritizes modifying their use of PAC. Commissioners specifically encouraged the exploration of areas of overlap between BPCIs and ACOs, caveating however, that results within bundled payments can have significant variation within conditions. Additionally, commissioners expressed the view that ACOs may not be the appropriate entity to address PAC spending, as ACOs are primarily a non-hospital based mechanism and the “majority of PAC opportunity” seems to be in post-hospital care.

While the discussion did not provide a timeline of next steps, AMRPA expects MedPAC staff to refine their ACO analyses based on the guidance commissioners provided in this meeting and present updated work in the coming months, including analysis of Next Generation ACO programs. AMRPA will continue to monitor the commission’s attitudes towards PAC spending/use in ACOs and other alternative payment models.

A complete transcript of the discussion and presentation slides are available at http://medpac.gov/-public-meetings-.

During the meeting, ommissionecrs and staff did not directly discuss the perceived incongruence between the most recent findings of ACOs having only a marginal impact on spending utilization, and prior conclusions of PAC being the primary source of ACO savings. Instead the commissioners appeared to view the former as a more refined analysis.

AMRPA Magazine / January 2020 35

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AMRPA Submits Comments to Congressional Request for Information on Rural and Underserved Communities Editor’s Note: On November 29, 2019, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to a Request for Information (RFI) from the House Ways and Means Committee Rural and Underserved Communities Health Taskforce on issues that affect health status and patient outcomes. Launched in July, the taskforce is the committee’s forum to convene members and experts to discuss the delivery and financing of health care and related social determinants in urban and rural underserved areas, and identify strategies to address the challenges that contribute to health inequities.

Reps. Danny Davis (D-IL), Terri Sewell (D-AL), Brad Wenstrup (R-OH) and Jodey Arrington (R-TX) serve as the taskforce co-chairs.

November 29, 2019

This RFI solicited input on priority topics for future consideration and discussion as the taskforce works to identify bipartisan policy options to improve the care delivery and health outcomes within rural and underserved communities. The complete letter is provided below and is available at www.amrpa.org.

Dear Rural and Underserved Communities Health Taskforce Co-Chairs:

The Honorable Danny Davis US House of Representatives 2159 Rayburn House Office Building Washington, DC 20515 The Honorable Terri Sewell US House of Representatives 2201 Rayburn House Office Building Washington, DC 20515 The Honorable Brad Wenstrup US House of Representatives 2419 Rayburn House Office Building Washington, DC 20515 The Honorable Jodey Arrington US House of Representatives 1029 Longworth House Office Building Washington, DC 20515

On behalf of the American Medical Rehabilitation Providers Association (AMRPA), the national trade association representing more than 650 freestanding inpatient rehabilitation hospitals and units (IRFs), we write in response to the Rural and Underserved Communities Health Taskforce Request for Information (RFI) on issues specific to postacute care (PAC) services in rural and other underserved settings (RFI question 8).

The predominant concern regarding the delivery of health care in rural areas is the lack of access to care, and particularly PAC. AMRPA believes that policy reforms related to telehealth expansion can help alleviate some of these access concerns and deliver improved utilization of clinically necessary rehabilitation services for rural patients. To that end, AMRPA has supported recent efforts in Congress – particularly H.R. 4932, the CONNECT for Health Act of 2019 – that would take steps such as expanding telehealth and remote patient monitoring. Of note, the bill would allow the Department of Health and Human Services to issue waivers to allow therapists and other specified PAC

AMRPA Magazine / January 2020 37

providers with new authority to provide telehealth services, which would help ensure patients are able to remain engaged with their provider despite geographic barriers. We encourage this Taskforce to identify other legislative opportunities to incentivize a greater number of specialties, including rehabilitation physicians and therapists, to utilize telehealth services.

AMRPA also recognizes that PAC providers (including those in rural and underserved communities) face unique challenges and burdens, with Medicare Advantage (MA) and the prior authorization (PA) policies utilized by MA plans being of particular concern. PA policies place undue financial and administrative burdens on rural providers, where resources are already limited. PA policies often force providers to shift (already scarce) time and resources toward completing PA requests and fighting inappropriate denials, when such resources could otherwise be devoted to patient services.

To address these issues, AMRPA strongly supports H.R. 3107, the Improving Seniors’ Access to Care Act, and encourages Taskforce members to support the advancement of this legislation in the 116th Congress. AMRPA additionally encourages Congress to develop policies that go further in addressing the utilization management policies employed in MA (such as the use of proprietary guidelines that run afoul of Medicare coverage criteria), as we believe such reforms would significantly improve patient outcomes in rural and underserved areas.

38 AMRPA Magazine / January 2020

AMRPA appreciates the opportunity to participate in the taskforce’s efforts to ensure all patients, regardless of geographic location, have access to high-quality post-acute care. AMRPA welcomes the opportunity to provide technical assistance and further recommendations related to PAC and IRF access. If you have any questions, please do not hesitate to contact Kate Beller, AMRPA Executive Vice President for Policy Development and Government Relations (202-207-1132, kbeller@amrpa.org) and Martha Kendrick at (202) 887-4215 or mkendrick@akingump.com.

Sincerely,

Richard Kathrins, PhD Chair, Board of Directors President & CEO, Bacharach Institute for Rehabilitation

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