Updated as of November 4, 2021
Recently published from Inside Health Policy on the RCD:
Rehabilitation and hospital provider associations want CMS to withdraw its proposal to create an inpatient rehabilitation facility review choice demonstration, saying the system would impede patient access to care and impose an inordinate burden on IRF providers. If the demonstration must continue, CMS should make significant changes including allowing only rehabilitation doctors to determine medical necessity for claims, ensuring contractors provide timely determinations and offering more specific details in another proposed plan, organizations say.
The IRF review choice demonstration is a five-year project that’s set to begin in Alabama before expanding to Pennsylvania, Texas and California and eventually other states in several Medicare Administrative Contractor jurisdictions. It would require IRFs to submit all Medicare fee-for-service claims for review throughout the demonstration or until they have a 90% claim approval rate. At that point, they could forgo the pre- or post-review but would still be subject to so-called spot checks on 5% of their claims. IRFs would be able to decide throughout the demonstration whether they’d like claims reviewed before a patient is admitted or after payment is received.
CMS first announced the idea in December 2020, and the American Medical Rehabilitation Providers Association, the American Academy of Physical Medicine & Rehabilitation, the Federation of American Hospitals, the Coalition to Preserve Rehabilitation and others opposed the idea at the time. But the agency doesn’t seem to have taken these comments into account, the groups say.
CMS again asked for comments on the project in September after making some small changes to its proposal, and rehabilitation provider groups are again asking CMS to pull the demonstration.
“We therefore urge CMS to withdraw this proposal in its entirety and discuss with stakeholders other, less problematic ways to achieve its program integrity goals,” a letter from CPR reads.
While CMS has pushed forward with a review choice program in home health, AMRPA says IRFs operate differently and the agency should work with stakeholders to figure out what would be most appropriate for IRFs specifically. The home health program, which began in 2019, also received backlash from providers. It was effectively paused during the beginning of the COVID-19 public health emergency but resumed last summer.
The home health demonstration is focused on improved documentation, but the IRF version is also targeted at medical necessity, AAPM&R adds.
“A professional environment where rehabilitation physicians will be second-guessed by CMS’ contractors on every IRF admission they approve, leading to a debate and a need to justify every case that is denied is a recipe for disaster that will not end in rehabilitation physicians embracing the program,” AAPM&R says.
If the demonstration is implemented as CMS has proposed, it could compromise patient access to IRFs, the organizations say. Past trends of IRF denials indicate the demonstration would cause IRFs to accept fewer patients – especially those with certain conditions often denied by reviewers – because they assume a claim is likely to be thrown out and they don’t want to go through the burdensome appeals process, commenting groups say.
“Without an expeditious appeals system, where a neutral third-party adjudicator can resolve medical necessity disputes, rehabilitation physicians will be placed in the unenviable position of either denying IRF admission to patients they believe meet the medical necessity criteria or continuing to accept such patients and placing their IRFs at serious financial risk over time if these stays are denied,” AARM&R says.
CPR also says the demonstration would affect other health sectors, as patients turned away from IRFs would still need care.
“This influx of patients into settings inappropriate for their medical needs will also serve to further exacerbate existing caregiver shortages, which will negatively impact not only those patients denied from IRFs but patients across the post-acute care spectrum,” the group says.
Some groups posit that the demonstration also could effectively change standards of coverage, even though CMS must change coverage requirements through rulemaking rather than through actions of its contractors.
“One-hundred percent review of IRF claims in the states in which the IRF RCD is implemented will, over time, fundamentally alter coverage standards. IRF physicians will have no choice but to reject admissions of certain patients the MACs refuse to validate as acceptable in an IRF," FAH’s comments say.
Moreover, groups say the demonstration would dramatically increase provider burden, even though CMS predicts that would not be the case. FAH says submitting claims for review takes about twice as long as CMS has allocated in its cost estimate, and CMS doesn’t account for the time it would take to appeal a claim or communicate with contractors.
Stakeholders say that if CMS moves forward with the demonstration, it should be delayed for at least one year after the end of the COVID-19 public health emergency. Not only will IRFs likely not have the staffing capacity to comply with the demonstration any time soon, but waivers and temporary regulatory changes for the PHE have made big differences in medical necessity and documentation required for IRF care for the past year and a half, AMRPA says in its comment letter.
“Beginning a demonstration and reviewing claims based upon temporary medical necessity criteria will do little to determine IRFs’ expected compliance with the standard medical necessity criteria,” the organization writes.
AMRPA and others also want the scale of the demonstration to be altered and say requiring 100% claim review for five years exceeds CMS’ authority, as the agency is looking to improve fraud investigation methods without first identifying fraud.
The proposed qualifications, oversight and training of reviewers in the demonstration also concern its opponents. Specialized rehabilitation doctors are supposed to be the only ones allowed to approve IRF admission under Medicare guidelines, but CMS proposes allowing less trained clinicians to override rehabilitation doctors’ determinations.
Nurses or therapists with IRF care experience might be able to review documentation to make sure everything is filled out correctly, but rehabilitation doctors should be the only ones determining medical necessity, AMRPA says. FAH adds that using people other than rehabilitation physicians to deny claims could reduce the admission of patients that contractors might not typically consider requiring IRF care.
Some groups say a medical rehabilitation advisory board should be created to give guidance on interpreting IRF coverage requirements. They say contracted reviewers also should be trained and regularly audited, and AMRPA adds that transparency is necessary around this training.
Commenters also emphasize that contractors should be specific and quick in their denial determinations, though AMRPA says IRF determination requests should receive responses within six hours, while FAH and AAPM&R say contractors should provide a coverage decision within 24 hours for pre-claim reviews.
CMS in its September proposal for the demonstration reduced the amount of time a contractor may take to respond to a pre-claim review from 10 days to five days, but that’s still an untenable timeframe, organizations say. Groups also want contractors to be available for conversations about determinations, and appeals to be expedited.
AMRPA also has questions about how CMS will evaluate the success of the demonstration. Current plans just say the demonstration will begin in Alabama and then be expanded to other states, but don’t mention how CMS will grapple with the demonstration’s impact on patient and provider experience or whether the demonstration will actually prevent fraud. Expansion of the demonstration should be contingent on public reports that show the program isn’t negatively affecting patient care, AMPRA says.
Additionally, CMS needs to put out more specific details on the proposed demonstration – including how to submit determinations and redeterminations, how long the program will last in each state and more – and allow another opportunity for comment on that information, AMRPA argues.However, an AMRPA staff member told Inside Health Policy that, based on discussions with CMS’ Center for Program Integrity, she doesn’t expect another procedural comment period.
The next step is likely to be the demonstration’s final approval, and if that moves ahead, CMS would then announce a start date for the demonstration. --Maya Goldman
Updated as of October 12, 2021
CMS proposed to implement a “Review Choice Demonstration” for IRFs, which would subject selected IRFs to 100% pre-claim or post-claim review of their Medicare claims. We believe that this RCD would add significant burden to physiatrists working in IRFs and fundamentally alter the patient population by allowing MACs to overrule admitting physician decisions and curtail access to IRFs for patients under Medicare coverage if the MAC determines the IRF care is not appropriate for the patient. Thank you to everyone who used our template to submit your own, individualized letter to CMS opposing this proposed IRF RCD. Read our full comments to CMS that we submitted last Friday, October 8.
Originally published on February 16, 2021
On February 16, AAPM&R delivered comments to The Centers for Medicare and Medicaid Services (CMS) in response to the proposed information collection on a Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services (CMS-10765).
CMS proposes to implement a “Review Choice Demonstration” for IRFs, which would subject selected IRFs to 100% pre-claim or post-claim review of their Medicare claims. While this demonstration would begin with all IRFs in Alabama, CMS proposes to expand the RCD to all providers in four Medicare Administrative Contract (MAC) jurisdictions, covering 17 states, three U.S. territories, and the District of Columbia.
We have significant concerns with this proposal, which would dramatically increase physician burden in a field already subject to onerous documentation requirements. It would also serve as an unprecedented intrusion by CMS contractors in the exercise of independent physician judgment. As such, we are urging CMS to withdraw this proposal and work to develop a less onerous alternative that meets CMS legitimate need to only pay for medically-necessary care, while preserving patient access to vital inpatient rehabilitation hospital services.
We also asserted in our comments that if CMS is concerned about IRFs admitting patients who do not medically need IRF care, CMS should consider requiring physiatrists to be in the position of rehabilitation physician to ensure that appropriate patients are being admitted to and treated in IRFs. AAPM&R consistently advocates for the role of the physiatrist and the definition of a rehabilitation physician in the IRF setting.
However, if CMS decides to proceed with this demonstration, we urge the agency to significantly restructure the demonstration program in a manner that reduces physician burden and maximizes patient access.
Read our full comment letter here.
On February 19, AAPM&R and the American Medical Rehabilitation Providers Association (AMRPA) released a joint statement urging CMS to withdraw its proposal to implement the demonstration.
Read the full joint statement here.
During this initial comment period, many key rehabilitation stakeholders, including AAPM&R allies and patient-centered coalitions, echoed our concerns about the potential consequences of moving forward with this demonstration.
Read the comments made by our allies here.
We will keep our members informed about the final outcome via the Academy's communication channels.
To learn more about our advocacy efforts, we invite you to attend AAPM&R Advocacy: Advancing PM&R on Capitol Hill and Beyond, an informational webinar hosted by our advocacy committees on Thursday, March 4, at 7 pm (CT).
Our advocacy committees look forward to receiving input from AAPM&R members during this session on our ongoing and upcoming advocacy priorities, including physician reimbursement, telehealth, scope of practice, COVID-19 and post-acute COVID syndrome, social determinants of health and Medicaid expansion.
Learn more and register for our March 4 webinar today.