By Peter W. Thomas, JD, Principal, and
Joe Nahra, Director of Government Relations
Powers Law Firm
On December 14, 2020, the Centers for Medicare and Medicaid Services (CMS) solicited public feedback on the agency’s intention to develop and implement a Medicare “Review Choice Demonstration” (RCD) for inpatient rehabilitation facilities. This demonstration would seek to ensure proper payment for inpatient rehabilitation hospital services by requiring IRFs impacted by the demonstration project to undergo 100% pre-claim or post-payment review.
In comments submitted on February 16, AMRPA strongly opposed this demonstration, asking CMS to fully withdraw the proposal and work with AMRPA and other stakeholders to develop more patient-centered methods to assure compliance with medical necessity requirements. AMRPA’s comments raised a number of alarming concerns with the impact of the proposed demonstration, which would present serious risks to patients and AMRPA member hospitals.
In particular, AMRPA noted that the demonstration would likely result in serious barriers to access for Medicare beneficiaries in need of inpatient rehabilitation, including high rates of erroneous denials and a potential “gatekeeper” effect restricting IRF admissions for certain categories of patients. AMRPA also cautioned CMS that the burden and cost to IRFs participating in the demonstration would be significantly higher than estimated, imposing time-consuming requirements and processes on IRFs already overtaxed with regulatory burdens.
During the preliminary comment period, many key rehabilitation stakeholders, including AMRPA allies and patient-centered coalitions, echoed AMRPA’s concerns about the demonstration. Although all of the comment letters submitted by the public are not yet available on CMS’ website, www.regulations.gov, a few key comment letters are worthy of mention.
The Coalition to Preserve Rehabilitation, which includes more than 50 patient and provider-centric organizations (including AMRPA) amongst its members, urged CMS to withdraw the proposal entirely to avoid a significant negative impact on patient access to care. CPR’s comments noted that patients in need of rehabilitation already face barriers to access, including the overuse of prior authorization and other utilization management techniques, the harmful incentives created by new models in the Skilled Nursing Facility and Home Health payment models, and restrictive coverage regulations already in place for IRFs. CPR also noted that the proposed demonstration would allow Medicare Administrative Contractors (MACs) to essentially dictate IRF admissions and overturn the judgment of treating rehabilitation physicians.
The American Academy of Physical Medicine & Rehabilitation (AAPM&R, representing physiatrists practicing in a number of care settings including IRFs) also stated its opposition to the proposal, which they noted would place private Medicare contractors in the position of practicing medicine and using trained nurses to overturn the medical judgments of experienced rehabilitation physicians. If CMS does proceed with the demonstration, AAPM&R outlined a number of additional recommendations to restructure the program, many of which mirrored AMRPA’s proposals to CMS.
The American Hospital Association (AHA) also requested that CMS withdraw the demonstration, primarily citing concerns about the timing of the demonstration given the ongoing COVID-19 public health emergency. In addition, AHA noted longstanding concerns with Medicare auditors lacking adequate knowledge of IRF-specific coverage criteria and clinical processes, and the administrative burden that would be imposed on IRFs. noncompliance.
The Fund for Access to Inpatient Rehabilitation (FAIR Fund) submitted comments that raised several legal issues challenging the authority of CMS to pursue this demonstration project altogether. Other organization such as the Federation for American Hospitals, UDSmr, and the American Physical Therapy Association also submitted comments raising serious concerns with this demonstration program.
AMRPA will continue to monitor any future developments with the IRF RCD and ensure that the patient and provider perspective continues to be at the forefront of any discussions around expanding IRF claim review requirements.