All right, welcome, everyone, to our session, AAP Menard Advocacy Update, Advancing Physiatry on Capitol Hill and Beyond. Just a few announcements. Please make sure your cell phones are on silent or off. There is an evaluation form for this session, as there are for other sessions, so we really encourage you to complete the evaluation forms, because that helps us planning for the future. And also, from the Academy, make sure you visit the PM&R Pavilion. There's great resources there for all of us physiatrists. And just make sure you pick up your T-shirt, as well, if you haven't done so. I can see a lot of people have already, but make sure you do that, as well. All right, so we're going to get into our session today, and no joy with this. No, are you able to advance it for me? Okay, that'll be great. Okay. All right. Yeah, no worries if you can go back a slide for a second. Thank you Okay, all right now you can go forward to the next slide I wasn't sure was that all right So we have three speakers today. My name is Prakash Jayabalam I'm physician scientist at the Shirley Ryan Ability Lab in Northwestern in Chicago I'm predominantly here as the chair of the health policy and legislation committee for the academy I do not have any disclosures The next speaker will be Dr. Matthew Grierson He owns his own practice at Seattle spine and sports medicine He's also the chair of the reimbursement and policy review committee for the academy as well And he does not have any disclosures and finally Peter Thomas who has been heavily involved with the academy for several years he is major advocate for PM&R He's our our federal policy consultant as well at powers law firm and he does not have any disclosures next slide So this is our agenda for today Dr. Grierson is going to be talking about physician payment advocacy I'm going to be talking about our committee and our advocacy priority and updating on that And then Peter will be talking last and he'll be talking about updates on federal elections and the landscape moving forward Obviously with the election just two days ago I'm sure many of us probably have some questions about what this means for us and our specialty as well And hope I know Peter won't have answers to all of those But he will be able to give some some guidance to us on on what to think about and what to be concerned about as well next slide So this is just a slide to show our priorities how does the academy Decide what to advocate on and I know you many of you have survey fatigue or even email fatigue, but some of these emails I encourage you to respond to this is Usually every year or every few years we send a Email to all members of the academy as you see there were 7 000 members. It was sent to sadly, we only had a four percent response rate, but It gave us some idea of what are the some of the issues that are impacting you as physiatrists and there was three major Areas that really came out from this survey. The first is a scope creep scope of practice creep from predominantly non-physician practitioners such as physician assistants and nurse practitioners the second being medicare reimbursements and prior authorization concerns And then finally the physician fee schedule, which we'll talk about as well Those seem to be the three major issues that are impacting our our membership But I certainly encourage all of you if you get these surveys in the future Please fill them out because it does impact what we do as committees And more widely within the academy of what we decide to focus our advocacy efforts on as well And with that i'll pass over to dr. Grayson Thank you, thank you, uh, we'll go to the next slide here Um, i'm, uh, matthew grayson, uh, my new clinic is sound spine and joint but um I've been in private practice for about a year. So these uh, physician payment advocacy issues are very near and dear to my heart because Um, it sort of affects whether or not I can keep my clinic door open I know that affects many of us in the room Others let other people sort of at your big hospital think about it, but it's actually really important for all Physicians to know kind of what happens behind the scenes Um, because it's a big part of um the work we do and access, uh to the treatment, uh that we want to provide So let's go to the next slide Um, i'm the outgoing chair of the rprc. That's the reimbursement and policy review committee and um Dr. Lauren shapiro is going to be taking over for me and uh, she's going to do a wonderful job. I'm also Uh the aapmnr member that sits on the ruck The ruck is the committee that values all of our cpt codes out there. So if you want to throw tomatoes Just realize i'm not allowed to actually speak on behalf of any of our actual codes That's kind of how it sets up if you're the one billing the codes. You don't get a participant Participate at that level, but there are other ways that we have physiatrists involved and we'll go over that in a second Next slide. So these are the main things that we're going to talk about today is our current efforts at the ruck and cpt We're going to talk a bit about medicare payments for 2025. The final rule was just published Um telemedicine coverage is a big part of that and we're going to talk about some advocacy work that we all in this room Can do on getting coverage for toxins next slide We've got some great volunteers who are working behind the scenes your academy members Um at both the cpt level where they create the codes and at the ruck level where we value the codes And so, uh, dr. Joe shivers and antigone argerio. They represent our academy as a cpt advisors um, and then Dr. Carlo milani and dr. Esther yoon are our Pmnr folks at the ruck who are able to advocate for our specialty So where are those issues that I can't speak on behalf of because i'm part of the ruck panel with my alternate. Dr. Clarice sin Um, drs milani and yoon are able to provide that advocacy work on behalf of our specialty so we do have a voice at the table Uh, let's go to the Next slide. So the big work Actually go back one slide. So the big work that we're um that we've kind of worked on over the last Year or so has been on telemedicine. There's a little bit of some updates to acupuncture codes And then we're going to talk about what's coming forward in 2026 So next slide in terms of acupuncture not too many of our physicians physiatrists, um Actually perform acupuncture but for those who do There's a little bit of a decrease in some of the codes one code does go up if you're using e-stem Much of that decrease. Yes. We did review those codes at the ruck but much of that Decrease in payment relates to how all of our services are decreasing over time and that's Kind of a big theme and we're going to talk about how we may sort of address that issue moving forward Because we have a 2.8 conversion factor cut that's currently projected to go unless Someone does something and so we'll talk about what that something could be here in a second Uh next slide So this uh, oh go forward one two slides, I guess We're going backwards in time There we go, ah wonderful Down this is forward. Okay. All right. Thanks Um, so for 2026 we have two new codes Uh, one is for percutaneous interlaminar lumbar Decompression also known as the mild procedure. So i'm not sure if anyone's trained here in the room Uh, actually you should have Many of you may have recently got a survey on that procedure And so if you did get a survey, i'm not sure if it's still open on that or any other ruck survey It's very important that you fill out. Uh, that survey does take some time Uh to fill out and complete but we rely on that data because that data goes directly into how we value the codes and so, um That's just sort of a plug that whenever you get that's one of those emails not to ignore If you get it um, and then there's another code for percutaneous decompression of the median nerve at the carpal tunnel and I know there's some Educational sessions here at this meeting about that code as well And so that's a brand new one that was just created that will go into effect both of these in 2026 and With the values that we created the ruck for it There's also some new codes for remote musculoskeletal therapeutic monitoring as well Coming down the pipeline In terms of the 2025 physician fee schedule that Final rule and just the cycle is every summer you get a proposed rule that comes out from cms people have time to comment and Give feedback to cms and then they create a final rule which comes out sometime in the fall this year It came out on november 1st And um, it does sort of finalize a 2.8 physician fee schedule cut And that will be implemented starting at the beginning of the year unless congress takes action and why is there a cut Well, there's one big pie and every year codes are revalued new codes are added and They're mandated from uh congress that you know, you can't add more money to the pie only congress can do that and so unless uh action is taken, uh by congress, uh that cut will go into effect and we'll talk about sort of Some fixes that are being proposed. Um actually right now that you can uh, lobby to your uh, congress Individuals for your state So the finalized conversion factor is 32 and 35 cents. Of course, this is not sustainable and you know we show this next slide year after year and certainly all of our our senators and congress Uh people out in the hill are very aware of this. It's something that the entire house of medicine is very uniform in terms of Letting them know that this is not something that is sustainable. So every year there's updates to hospital inpatient updates to hospital outpatient Hospice asc and those updates in terms of their physician the fees that they get for their services They go up with inflation and so you'll see 2.6 percent increases proposed for each of those for the next year Now inflation is a little bit higher for physicians just in the way They calculate it 3.6 instead of 2.6 because that's tied to the medicare economic index, which has a productivity adjustment But even with that increase in terms of what our costs are to provide services for our patients. They're actually You know think we should be able to do that for less money um Which of course is not sustainable. So the big push right now is uh, the medicare patient access and practice stabilization act Um, and the academy has endorsed that along with the rest of the house of medicine A pyramid is putting a lot of its advocacy resources into making sure that this moves forward as does the ama This would halt the latest round of scheduled payment cuts Um again, that's because of that budget neutrality requirement, which is um a statutorily imposed, you know requirement the nice thing about this act is it would not just um, I Eliminate that 2.8 bump, but it would Rather than give us You know, it doesn't it doesn't quite propose giving us this entire update but half of it which we think is um Reasonable that they at least give us um half of it back So we'll see it's it's um A newer bill and it's starting to gain some traction and this is one of those things where you may have gotten one There's emails from the academy asking you to contact your senators and congress uh people and um uh And send them an email tell them why this is so important they really need to hear from physician practices, especially if your practice is an area where uh, they're it's really hard to access, uh care because Many of the practices out of how it is in your city but many of the private practices and other practices are having to start to limit how many medicare patients they see because Quite simply they can't keep the lights on if if they continue, uh to take cuts year after year after year So here's how to join the fight. So everyone take your phones out scan that and um join me and uh the rest of uh The volunteers on our committees who have already reached out to our senators And representatives to advocate for medicare patient relief. It's actually pretty quick and easy You just put in you know your address and it it has a form letter that you can also edit But you don't have to and that's a really important piece of how you can get involved So the next thing that i'm going to talk about is telemedicine coding now telemedicine is a big issue since the pandemic Huh This is again one of these issues where it's an ongoing work in progress and right now cms has not um, Decided to move in the direction that the rest of the house of medicine has encouraged. So During the pandemic, uh, there was a special dispensation exceptions made to allow Medical services to be performed in a telemedicine environment um Because they waived certain rules one of those rules was like the patient would have to be like at a Separate clinic site, you know, they couldn't be at home Only certain services are allowed to be telemedicine And so we're actually going back to that world at least for cms starting, uh, january 1st unless something changes now one of the things that we were doing at the ruck to try and um Make telemedicine and that includes audio only visits is we created a whole host of new codes that the ruck did value but the medic medicare chose not to Finalize that final rule incorporating those new codes um So that's going to be a big issue moving forward In terms of how do we continue to advocate for telemedicine coverage? one of the hard things I would also say is Cms has its own idea for what it wants to do and all the other private insurance companies are also going to Make their own decisions about what they do So you're going to need to sort of be very aware if you are a practice that does a lot of telemedicine coverage That you're following whatever rules are set by each individual payer um And um So right now telemedicine is going to be limited to patients who are in health care professional shortage areas and again Telemedicine cannot be is not available to patients from their home They have to present to an ongoing to an approved originating site just like it was before the pandemic um, we did recently join the alliance for connected care, which is a group of You know other interested parties who are looking to expand our capacity for advocacy in this area And it's a big push also from again the entire house of medicine We work with all the other specialties at the ama level as well um, this is uh, my final slide here, which is um, Another way for you as individuals to get involved in your local community for um There are local determination, uh policies, uh that are created by all the medicare contractors and so one of the contractors out there um is uh I can never pronounce it. Is it novitis or novitas, but novitas and first co-star they're accepting comments for what to do about botulinum toxin coverage and so Uh, it's in an open comment period So if this is a big part of your practice or even if it's not and you know It's an important service provided to many of our patients and physiatry. This is another code that you can go in and leave comments um, and it is something that our academy is also very Involved with uh that process giving our own comments and also monitoring it and will continue to provide Uh education and feedback in terms of their decisions moving forward Those Draft policies, you know as they're written oftentimes they do limit the types of patients that can receive the toxin They often limit it based on diagnosis and and even how much of a toxin you can use Um in different settings, so this is something really important to get involved Uh, because it's a big thing for patients within our specialty. So With that i'm going to turn it back over to prakash All right, thank you so much, dr Grissin, so i'm going to be giving some updates on our health care policy and uh legislation committee And what we've been working on and some ongoing Sort of issues right now in dc at the hill that we're also Following as well. Um, the first part is I just want to say thank you to our committee. Um, this is Majority of the members of our committee when we were last uh at the hill or in dc visiting um congressional offices We have a great very active very energetic group representing different types of diversity also in terms of diversity of um practice private practitioners academic practitioners Sub specialties as well and geographical location as well as racial and ethnic diversity as well um First thing I want to say is that these are we so our committee meets on a quarterly basis We have zoom calls and then we meet in person twice one at this annual assembly and then we also meet at the hill Um, and we do some training there as well in terms of the different issues that are impacting physiatrists as I mentioned before many of our Many of our priorities are really um come from what we hear from you as members Um, particularly through some of these surveys surveys i'll talk about voter voice campaigns as well that we run Because those are also very telling as to what's impacting you and what you're concerned about Um at the last hill day where we were there as a committee In in april, there were really three areas that we focused on and similar to what I talked about before Fair medicare reimbursement for physicians Prior authorization reform and then we also talked about the three-hour rule as well, which i'll explain shortly And then obviously the academy also has a fantastic program the future leaders program And as their sort of capstone project they actually go to the hill Separately and they advocated for similar things, but also wanted to educate on what is pm and r which is unfortunate We're one of the few specialties that every time we meet congressional officers We have to spend the first 10 minutes explaining what we are doing and we're not a psychiatrist or a physical therapist So that's um, that's unfortunate, but it's so this is important work as well that we need to do um first thing to talk about is uh is sort of advocacy priorities reducing some of our burdens, so We've really advocated for reducing some of the legislative and regulation burdens, and trying to make sure that we are advocating for our patients to get timely access. When you're at the Hill, you're not just advocating for us as a specialty, you always have to come at it as like, what is impacting our patients as well? And so, that's a key priority for us. And we often see prior authorization, that's what we hear from all of our membership, majority of our membership, that that is a big burden, not only to the physician, but making sure our patients have access as well. And it's one of the leading causes of burnout, and that's probably why there's such high burnout in our specialty, as there are in other specialties as well. So, with that, I think one of the key legislative policies that are being introduced is the Improving Senior Timely Access to Care Act. And this is actually, in modern day politics, this is unusual, it's a bipartisan policy that would essentially review or reform prior authorization for Medicare Advantage programs. This would basically solidify many of the other regulatory gains that Congress has passed in the past. And this bill is actually, just with a new update, as of 6th of November, there have been 233 co-sponsors of this bill, and more than 55 co-sponsors in the U.S. Senate as well. And so, we are very supportive of this legislation. Sorry, I go the other way. So, the other thing that was really stalling this in the prior Congress was that the initial, the original legislation was going to cost, from the congressional budget of it, several billion dollars but they have now managed to work it out where it's actually gonna be zero dollars, which is incredible. But we anticipate, and I'll let Peter talk to that, how this has gone from 16 billion dollars to zero dollars within a few years, and how that actually worked. But we anticipate that this will get a lot more support because of that as well. It was very close to being passed, and then the CBO came out with a bill for it, which was 16 billion dollars, and that stalled it. So, hopefully this will move forward as well as a result. As Dr. Grissom mentioned with these QR codes, if you scan any of these QR codes, they go to a website where you'll see all of our legislative priorities, and what we need from you as members of the academy to send as letters to your congressional offices. Again, it's really helpful because when we see a certain number of letters, we can then say that this is really impacting our practitioners. One major thing as well, it's just very, very simple. So, if you scan this QR code, you put your zip code in, it automatically goes to your house representative or your senator's office, and it's as easy as that. So, you don't need to edit the letter unless you really want to, and I would highly encourage you to do this in the future. I know it's annoying to get, now my name is tied to those emails, so I'm sure a lot of you are like, goddammit, another email from Prakash. I apologize, but I would highly encourage you to do some of these things as well. Another thing to also talk about with the prior authorization reform is the Gold Card Act. And the Gold Card sounds really cool because it's called the Gold Card Act, but it's essentially the idea that if you have done prior authorization with Medicare Advantage plans, and more than 90% of what you've been asking for in prior authorization has been approved, then you could be exempt for the next 12 months from having to do prior authorization for those. So, we've really pushed this, and it would also allow electronic prior authorization as well. And so, we are highly supportive of this resolution that's currently being discussed, and I think the academy's been front and center in sort of advocating for this policy as well. And then the other part that we also discussed in terms of our priorities is scope creep. And we've been working with the House of Medicine, predominantly the AMA, to pose some of these federal legislation that would expand the scope of practice for nurse practitioners and physician assistants. There are a couple of bills here that we would talk about. One of them, the first one here, would essentially inappropriately expand the scope of practice for nurse practitioners and physician assistants in the federal workers compensation program. And then the second one here is, similarly, in Medicare and Medicaid programs, again, expand their scope without any oversight by physicians. And we continue also to monitor the VA system as well, where they have this federal supremacy project. And this would basically establish national standards for professions in the VA system. And we're just monitoring that currently. One other thing that we're seeing more and more, certainly in some members from the state advocacy committee are here, is that at the state level, there are certain things that are being pushed, or certain agendas that are being pushed as well. The first one here was from the state of Missouri, which essentially would expand the scope of practice for prosthetists and orthotists, and initiate treatment on a patient without any prescription for many of us as physiatrists or other physicians. That failed to pass. And certainly the academy, that was one of our major wins, because we significantly advocated against that legislation. Similarly, in the state of Washington, and this would, essentially there was a proposal that it would expand the scope of practice for naturopaths, where they would be able to prescribe schedule three and schedule four medications. So that would include opioids, fentanyl, and ketamine. And there would be no educational or training requirements for that prescription. Not to show my bias, I'm glad to say that did not pass. Yes, so again, the academy was front and center in sort of advocating against that legislative session. But what we're seeing more and more is that at the state level, there are differences, and our state advocacy committee has been very busy as a result. And then I want to talk about the three hour rule. This was one of our priorities at the Hill visits this past year, mainly because of the timeliness of it, because it was being introduced. This bill essentially is this idea that currently, as you know, for three hours of inpatient rehab, you have to have physical therapy, occupational therapy, or speech therapy, or those are the covered entities. The three hour rule basically would give the physician autonomy to prescribe, change the type of therapy someone receives during their inpatient rehabilitation stay. And that would also include respiratory therapy, and also recreational therapy as part of a prescription of rehabilitation. It was reintroduced in Congress, and bipartisan bill, and we can talk about the update on that with Peter as well. We've worked with local stakeholders, we've worked with the recreational therapy organizations, and to engage with federal agencies on this specific bill, which we think is really important as physiatrists to actually give us the autonomy to prescribe the right type of therapy to the patient at the right time in their stay. And then another advocacy priority has been long COVID. We've endorsed a lot of legislation pertaining to this. The Care for Long COVID Act was the one bipartisan legislation that we've also advocated for. And further to that, we've also had Academy members be leaders in this. Obviously it's an area that we have led as a specialty in this era. And Dr. Vidasco-Gutierrez, she was recently appointed to the HHS Secretary's Advisory Committee on Long COVID. I'd be interested to see with the new Congress how far long COVID goes. And so certainly again, this may be a question for Peter coming up as well on that as well. So with that, certainly happy, we'll take some questions, we'll have some Q&A at the end, but I'm gonna pass it over to Peter Thomas from Powers Law Firm. Good morning, everyone. Thank you so much for coming. I'm Peter Thomas, I'm with the Powers Law Firm and have been working with the Academy since the 1990s. So I'm going to be talking a little bit about some of the key issues that the Academy has been working on this past year or so, and then touch on the election. I figured I'd save the election till last. And by the way, I hope you enjoy and like my long red tie. I heard it's trending these days. So I wore it in honor of our new incoming president. Let's start by talking about, oh, well, this is kind of a slide that kind of, where do I, how do I change it? This thing? Thank you. Pardon me. This is a slide that just says that I do represent the Academy of Physical Medicine and Rehab, but also work with other rehabilitation constituency groups including the Rehab Hospital Organization, the AMRPA, the Federation for American Hospitals, the Coalition to Preserve Rehabilitation, which is a coalition of about 53 national organizations of which many of the organizations you would imagine would be in that coalition are in it. And we work in many ways to try to preserve access to rehabilitation care in a variety of settings. The Independence Through Enhancement of Medicare and Medicaid Coalition, which is all about access to assistive devices and technologies. And finally, the Disability and Rehabilitation Research Coalition, which has been in existence since 2008 and has been really focused on NIH, NIDILRR, CDC, VA, agents, federal agencies that both fund and support rehabilitation science and building the evidence base for rehabilitation, disability, and independent living. I also happen to have personal experience with prosthetics. I was in a car accident when I was 10. I went to Craig Rehab Hospital for two and a half months and learned how to walk again. I've been walking on artificial limbs ever since. And so I have a physiatrist and I must tell you that I greatly respect and appreciate all the work that you do every day. It means so much to the patients you serve. So I'm quickly going to recap some developments in the Review Choice Demonstration Program, which is being implemented in a couple of different states right now and is expected to be expanded. The OIG has the Office of Inspector General of the Department of Health and Human Services, has a new audit underway, a nationwide audit of inpatient rehab hospital care. I'm going to speak about the therapy caps under the Affordable Care Act. The MedPAC, most recent things coming out of MedPAC. Telehealth and tele-rehabilitation and pick up from where Dr. Jayabalan left off. I'll talk a little bit about technology access and some of the more recent developments in that area and then get into the election. So first off, the Review Choice Demonstration sprang from one of the recommendations in the 2018 OIG report. The Office of Inspector General did a 220 case audit of patients in inpatient rehab hospitals. It actually was admissions from 2013. It took them five years to draft and publish the report. But the outcome of the report was that 84% of the patients that were admitted in that 220 case sample, they determined were overpayments, meaning were errors. They didn't comply either with the documentation requirements or they weren't considered medically necessary to be treated in an IRF. I can assure you that the Academy strongly opposed that finding. We think that that was a completely inaccurate finding and not credible on its face. We went to the OIG, we went to HHS, we went to CMS, we drafted a 20-page paper in response to the report. We developed a relationship with the Office of Inspector General and ultimately I'll talk about that on the next slide. But one of the recommendations from that report was that CMS conduct much more auditing of inpatient rehab hospital claims. And so they did. They created something called the RCD, the Review Choice Demonstration Project. And you might think, well, what does the choice mean? The choice is an IRF gets to decide whether they want to have 100% of their admissions reviewed by their contractor pre-claim or post-payment. That's the choice that you get to make. And so think about that. 100% of the claims that an IRF admits, of patients that an IRF admits have to be reviewed by a contractor. You either get an affirmation to move forward with providing care and billing the program or you get a non-affirmation, which essentially is a denial. You do have an opportunity to submit additional documentation to try to meet whatever standard they feel you're not meeting. But ultimately, it's kind of like Big Brother looking down and assessing exactly who you're admitting and who you're not. The big question is whether this is really going to have an impact on the types of patients that gain access to inpatient rehab care. And is CMS essentially doing an end run around a regulatory process that would restrict medical necessity instead of doing that, which can get controversial and messy. They just put it out to their contractors to do 100% claim review. And after a while, IRFs get the message, well, every patient that we admitted that looked like that patient in terms of their comorbid conditions and their primary diagnosis was non-affirmed, so we better not admit them now. And over time, what that does, of course, is change the referral patterns, the admission patterns, and really, it amounts to practicing medicine. So we've got very significant concerns with this program. It was rolled out last year in Alabama, and it then rolled out in the state of Pennsylvania. It is expected to go next to Texas, and then California, and then in the end, when fully implemented, about half the states will undergo 100% claim review of IRF claims. How they're going to be able to do that and pay for that is a little bit questionable, but they are planning on moving forward with that. Right now, the best data we can find is that about 90% of these IRF claims are being affirmed, whether they're being affirmed on the first go-round or whether they're being asked to submit additional documentation. It's about a 90% affirmation rate, which is great. And that largely conflicts with the findings of the Office of Inspector General in 2018 that said that 84% of these claims shouldn't have been paid. So that's a really interesting dynamic. What it says is that there is a bunch of subjectivity in these reviews. There is some real kind of condensing down to checklists, something that's a very complex and nuanced provision of rehabilitative care along with medical management, and we're trying to get to the bottom of that. We do think that this very much could mean some changes at the margin to who is admitted to IRF care, and that's just something we're continuing to push back on and work through. So I mentioned that we developed a relationship with the Office of Inspector General, which is not easy because they're the top cop for HHS, and they oversee these programs, and their role is to point out where they should not be paying claims and how their contractors are doing, how providers are doing in terms of servicing the program, is there fraud and abuse in the program, or if not fraud and abuse, then overpayments. And ultimately that report of 2018 was pretty devastating. We've been pushing back on that ever since. But that kind of has, that's what led to the RCD. That's what will lead to additional restrictions and additional audits in this field. So about two years ago we were invited to the table. The OIG decided to do another nationwide audit of IRF care to follow up on their 2018 report, which is completely understandable. You don't get an 84% error rate and then just walk away. They're coming back to see where the field is now. And they invited the AAPMNR along with the AMRPA and the Federation of American Hospitals to work with them in real time to review the sampling methodology they planned on using, to review what they call the medical review instrument, which is how they're going to assess these claims. They made significant changes to the sampling methodology based on our feedback. We're now in the mode where they've reviewed 200 claims and we are going to be given access to the patient files. And we have compiled about close to 25 physicians and non-physician clinicians who work in the IRF space who have volunteered to assist us with these reviews of these claims. We're only going to be looking at denials and we're going to be looking at the patient files and the reasons that the OIG found errors. And we're going to try to inform them why we disagree or if we agree we will tell them that too. But we're going to have a two-day meeting in the spring, in March. We're going to sit down with them along with CMS and we're going to have our physicians there. And we're going to try to reach a better meeting of the minds on why there's such a disconnect on the high error rate for IRF claims. And many, many of these claims tend to be physician-driven. It's, you know, there wasn't a need for supervision by a rehabilitation physician. You know, all of the medical necessity reasons for denial tend to reach back to and are affiliated with physician involvement in the claim. And so the AAPM&R takes this very seriously. We're going to be working with OIG throughout this audit. we will have an opportunity to submit a written report that they will publish as an addendum to their report that they publish verbatim. They will not change the report that we submit at all. So we'll be able to say whatever we want to say in the report itself. And so we're hoping that this will lead to additional changes to the regulations, improvements in the process, reductions in the error rates. We don't expect that report to be actually finalized and out for the public to see until 2026. These reports tend to take a fair amount of time. You know, therapy caps were a big issue for Medicare for quite some time. They were actually passed in the 1997 Balanced Budget Act, but they were only implemented for a three-month period, one year. Congress always came back and punted, never really implemented the caps, denying Medicare beneficiaries rehab therapy services, outpatient rehab therapy services after a certain period of, after a dollar cap was reached. So only a very short period of time did those caps ever go into effect, but they constantly made Congress go back and, along with the physician fee schedule, make adjustments to both of those for about a 20-year period. And finally, in about 2016 or 17, there was enough political will to change that. As you know, they passed the exceptions process. There's now a pretty robust exceptions process under the Medicare program for beneficiaries to receive outpatient therapy services over and above the previous caps if they meet a series of exceptions, and that's got to all be documented. But it may not be the best way to do it. It may not be the most efficient or streamlined process, but it seems to be working. I don't hear a lot of people complaining about access to therapy anymore under the Medicare program. But under the ACA plans, the Affordable Care Act plans, all the state-regulated private insurance plans that serve ACA beneficiaries, those plans routinely implement caps and limitations in therapy benefits, outpatient therapy benefits. Now, they can't do it based on dollars. The Affordable Care Act says you can't have a dollar limit, but you can have a visitation limit. So it's essentially the same thing. And you know, I see some nodding heads around the room, oftentimes these caps will be quite low, 20 visits of PTOT and speech combined. And for a person, a 65-year-old tennis player who has a joint replacement, maybe that's just a fine benefit. There's no problem there. But for a person with a brain injury or spinal cord injury or major multiple trauma or a neurological condition, 20 visits is just not at all adequate, appropriate, sufficient to meet the needs of that beneficiary. Over and above, understanding the fact that those therapy, that requirement for therapy is medically necessary. We're not talking about kind of superfluous therapy. We're talking about medically necessary therapy. So the CPR coalition led by the AAPMNR has been working with CSIO, which is the Center for Consumer Information and Insurance Oversight. They're within CMS. They administer the ACA plans. They put out a regulation every year. We have made some good progress. They've now said that you can't have the same limitation or cap on habilitation services that you have on rehabilitation services. They've added new modifiers to make sure that providers can track their claims and make sure that those limitations are not going into effect. And that way, they also have said that you've got to have separate benefits. So the cap for PT is separate from OT is separate from ST or SLT. So that's all good. But the caps are still in effect and they're routinely working to preclude additional coverage for therapy services that are deemed medically necessary by the rehab team. So we have been working with them to try to get that changed. We have not made much progress in terms of the written word. But I will say that we met in August, or rather in September, with CSIO again. And the two people we happened to meet with who we'd been meeting with for a few years and talking with them about this for a while, both had instances in their family. One of them was dealing with a knee injury and he was being denied therapy and he needed more therapy and he was paying out of pocket and he was going through appeals and he was getting frustrated and he related this to us. And the second person had a daughter who needed significant therapies and was being completely denied and she said, I wouldn't wish the appeals process on my worst enemy. And it was a much different meeting. I can tell you that, than it had been before. Unfortunately, the Notice of Benefit and Payment Parameters proposed rule, which is the rule where they put those regulations into effect, came out only three weeks later. So they didn't have enough time to impact that. But these are career officials at CMS. These are not political appointees. And we do hope, this is a bipartisan issue. The timely Access to Care Act is completely bipartisan. Dr. Jai Balan mentioned that a moment ago. So I think we can make some progress on this. Obviously, it's going to be more challenging under a Trump administration than it would have been under a Harris administration. But we're not going to give up on this one. We're going to continue to push the envelope. So there is a new report out that the Government Accounting Office published on limb loss. It involves rehab services and outcomes for beneficiaries. It was just published on the 23rd of October. So it's fairly hot off the press. We have a link there for you if you want. I'm not sure how you get to that link. That makes no sense. My apologies. My apologies. But the report describes the characteristics of Medicare beneficiaries who lost a limb in 2016. They did a deep dive into the Medicare database. The percentage of those who received rehabilitation services or prosthetic limbs, the percent of those who experienced selected health outcomes and challenges in obtaining rehab services and prosthetic limbs. All 50,000 Medicare beneficiaries who lost a limb that year received at least one rehabilitation service according to GAO's analysis and CMS fee-for-service claims data from 2016 to 19. Now here is really, this is interesting, only 41% received a PM&R physician service, 89% received OT, and 96% received PT. The devastating statistic here in this report is that only 30% of Medicare beneficiaries in this sample who lost a limb had any subsequent claim for a prosthesis. 30%, which is just an unbelievably devastating number. And as someone who uses artificial limbs to get around, I can't imagine, I mean, what do you do? I guess you just sit in a wheelchair and there's nothing wrong with wheelchairs. You know, wheelchairs are critically important to people who cannot otherwise ambulate. But when you have the availability of the technologies that the prosthetics field and PM&R provides to people with limb loss today, and you only have 30% of Medicare beneficiaries who lose a limb receiving a limb, an artificial limb, that's a real problem and deserves some real attention. MedPAC just met this morning and I got a, and they talked about the physician fee schedule and I got kind of an update from my staff back in Washington. The commission again recommended for fiscal year 2025, the 2024 IRF base payment rate be reduced by 5%. That's their typical kind of, I just saw Bruce Gans respond in horror. They typically say that every year. I think last year or the year before they went down 3% instead of 5% because of COVID. But ultimately, these are recommendations. They don't go into effect. The Congress has to pass this if they are going to rebase or give any kind of a cut to the IRFs or any other post-acute care provider. And they did make payment reduction suggestions and recommendations for all the post-acute care provider settings. But ultimately, the commission, you know, those rate reductions don't go into effect unless Congress acts. The commission ultimately did not move forward with the UPAC, the Unified Post-Acute Care Payment System that they'd been contemplating for several years. Do you remember the IMPACT Act of 2014 that was designed to collect data across LTACs, IRFs, SNFs, and home health, normalize the data between the settings, and then develop one big fat post-acute care payment system, which we were very, very concerned about, frankly, because the people who need care the most likely would have fared the worst under that payment system. And in the end, the commission gave up. They said, we can't. This is too complex. We can't do this. We're not recommending that CMS move forward with this. Then they thought about site-neutral payment between IRFs and SNFs. They actually had on the table a proposal to take all the 40% of the 60% rule cases, so all the what they called non-qualifying cases, which was a complete mischaracterization of what that 40% represents, and we brought that up to them. But they were contemplating paying IRFs for those 40% that didn't meet the 60% rule, the SNF rate for IRF care. That was one of the proposals that they were thinking about. In the end, they also decided they would not make a recommendation on that, and they've largely moved on. I mean, this is a victory. They were very seriously thinking about watering down and underfunding IRF care and removing a really key aspect of post-acute care, a very specialized setting of care, for many beneficiaries, and they chose not to do that. So kudos to the Academy for its strong advocacy on this for several years. I also need to inform you that Lori Feinberg is with MedPAC now. She is the principal analyst. Does anyone know Lori by any chance? Yeah, there's a few folks in the room. Lori is a PM&R physician. She practiced or did a residency, I believe, at National Rehab Hospital. She went to CMS. She was there for quite some time. She is largely the person who fashioned the CMS-13, which used to be called the HCFA ruling 85-210 conditions. She turned it into 13 conditions. Ultimately, we have a checkered history there, but we will do our best to work with everyone we possibly can to achieve our objectives. How is that for subtle? Okay. This is about as subtle as I could get. Okay. Pardon me? Thank you for pointing that out. She was a member of the HP&L committee, and we worked fairly closely together for some time. All right, telehealth and tele-rehab, it was mentioned a moment ago. The Consolidated Appropriations Act of 2023 extended most telehealth flexibilities during COVID-19 through December 31st, 2024. That's obviously coming up very quickly. Congress needs to act. It's on their end-of-the-year to-do list, along with potential physician fee schedule, you know, kind of lessening the harshness of the cut. But I must tell you, I think if there's a trifecta, as they're calling it, if Republicans control all three branches, House, Senate, and the White House, there's really not an incentive for them to move forward with a big healthcare package at the end of this year. They probably will push as much as they can into the following year, so they have a lot more control over what they pass and what they don't. The other countervailing point to that would be they may not want to have that on their watch, that they're spending money on various types of healthcare things. I don't know what they're going to do with the appropriations. You know, the federal government runs out of money on December 20th. They have to pass either a continuing resolution into 2025, or they have to pass an omnibus spending bill. They may want to try to clear the decks to get ready for the new Congress and the new administration and just get that done and not have that hanging over their head as soon as they come back into office, or they may want to say, no, we're going to reshape that whole bill and do what we want to do. So it's really unclear at this point. It's only been a couple of days, and we still don't know what the House will bring in terms of leadership, but the fact is that I think it's considerably less likely than it was on Monday of this week that Congress will come back and have a fairly robust lame duck session and get a bunch of things done. That's what a lot of people had planned for. There's a lot of bills that are kind of teed up in the Finance Committee and the Energy and Commerce and Ways and Means Committees, and they're kind of waiting for the smoke to clear, but my personal view, and this is validated with a number of other conversations with my clients, is that this really puts a bit of a damper on expectations about a post-election healthcare package. They'll probably do some things that have to be done, but I think it'll be very slim and fairly narrow. Telehealth may or may not be in there. That's one of the must-dos. So everyone recognizes telehealth, the value of it, but it is expensive, and if they can find a pay-for, there's a chance that they can get it included at the end of the year. All right, real quick, and I want to move to the election. I know I'm running late here. So PM&R has been very, very supportive of a lot of the new developments to try to get new Medicare coverage. We've got Dr. Anjali Shah has been really instrumental in working with the item coalition. Ultimately, there's been really kind of a new approach at CMS, I think, over the last several years. I think it stems out of the whole push toward health equity that the Biden administration really led. I think that's probably going to be curtailed dramatically under the new administration, but they did publish the Transitional Coverage for Emerging Technologies Regulation. That essentially allows a more streamlined path to a national coverage determination under the Medicare program for what the FDA deems as breakthrough technologies. They covered seat elevation and power CRT wheelchairs. That's a huge new Medicare benefit. So if you have beneficiaries, patients who need wheelchair access, have power wheelchair needs, they can get seat elevation systems where they could not previously. You need to follow the documentation requirements and if it's appropriate for that person, but it's actually a very, very generous policy. It's for improving reach and for performing mobility-related activities of daily living in the home. And if you have a lift system or something along those lines, that doesn't matter. You can still have that and still get a seat elevation system in a power wheelchair. So that's a huge advantage. We're still working on standing systems, power wheelchairs that ultimately will extend into a standing position. You don't have to transfer into a stander. There's all kinds of metabolic benefits to that and we're waiting for CMS to open up that NCD. In terms of microprocessor technology for prosthetic knees, CMS expanded that technology to K2 amputees. These are limited community ambulators based on the fact that there's pretty ample evidence that microprocessor technologies, fluid and pneumatic prosthetic knees all help in fall reduction and limiting fall risk and the fear of falling, which really constrains an amputee or person walking on a limb to be as functional as they can be. If you're constantly worried about falling, you don't take nearly the kinds of risks that you otherwise would. All of that you can find out in the DME MAC publications that they put out and I would encourage anyone that treats amputees to lower limb amputees to give that policy a really close look. There's a lot of new, interesting and good things in that. They also determined that power applied to a brace is defined as an orthosis. It's a covered benefit under the Medicare program. So I don't want to mention brand names, but I kind of have to because there's certain categories that there's only one real brand. But you've heard of the Myomo or the MyoPro devices. You've heard of the ReWalk or the exoskeletal devices. Those now are considered powered orthoses and they have codes and they have reimbursement levels, which are actually quite significant. So if you have patients who are good candidates for those technologies, by all means, you should examine what they're doing with that in terms of CMS coverage, Medicare coverage. And finally, there's new coding for catheters. For years, the catheter field and the patient groups have been trying to get CMS to code separately hydrophilic catheters. These are catheters where there's a substance that's impregnated onto the catheter, whether it's a straight tip or a coude tip. And when that becomes wet, it immediately provides a lubricant. There is no separate lubrication process. And with people with spinal cord injuries or dexterity issues, that becomes very difficult. It's been proven through the literature to reduce urinary tract infections. So they're finally creating three new codes for hydrophilic catheters. The price is the same, so there shouldn't be any barrier to getting access to those. So I highly encourage you to take a look at that if you have patients who need urinary catheters for their urinary health. All right, election. So now that the election's behind us, I must have sent 50 stop messages on my texts to get out of all of the political stuff. So Donald J. Trump was elected to a second non-consecutive term, only the second person in history to do that. I heard that on CNN. I thought he was the first. I'm still trying to figure out who it was. Does anyone know? Cleveland, all right. Thank you for that. Now I'm getting educated. So that was a surprise to many. Clearly, the polls, many of the polls, did not reflect that. So like in 2022, when there was kind of a blue wave that was unnoticed in the polls, by and large, and other previous years, the polls tended to miss. Really, Trump making inroads in every Democratic constituency, the youth vote, the senior vote, the Latino vote, the black vote, the labor vote, virtually every area, Donald Trump excelled beyond expectations. And it's one of the reasons that he beat Kamala Harris by about 5 million votes in the popular vote, which is really a pretty astounding performance. So we don't exactly know what is in store, because much of what has been said, and I want to be as delicate with this as I can be, you don't know really what is real and what's not. You don't know what to trust and what not to trust. Was it just some blustering thing that was said at a podium, or whether it's a real policy that they plan on pursuing? So it's difficult to kind of figure out where they're going. But I think I'm going to try to handicap it and try to give you some sense of it. I will say that the transition is already in place. It's already working, moving forward. It's going to be down in the Mar-a-Lago area. And there'll be a number of people that flock to South Florida for various positions and interviews and all kinds of things. I think there'll be a big emphasis on tax policy. There's no question there'll be a big tax bill when the Trump tax cuts expire. They'll want to extend them and probably go farther. I doubt they're going to increase the corporate tax rate. I think there'll be a big increase in tariffs across the board, because Trump has said that. And that is kind of the basis of his economic plan. That means increased prices, but it's designed to try to get better deals from foreign companies. We'll see how that plays out. The goal, of course, has been to resolve conflicts around the world. On day one, I'm very pleased to say that on January 21st, the Ukrainian-Russian war is going to be resolved. So that's great news. You know, that is good news. Immigration, I heard Stephen Miller talking about when the first person would be deported. And he said January 20th. So I do think there's going to be a fair amount of immigration focus on this administration. That's, in large measure, one of the key issues that got him elected. And I think there'll be a lot of pressure on the Affordable Care Act, in particular the subsidies that were added under the COVID era that were really have is one of the reasons why last year the Affordable Care Act covered more Americans than it ever has before. 15 million people received coverage under the Affordable Care Act. And I think that's going to dramatically start to decrease once those subsidies start to be decreased. The subsidies won't go away, but the added subsidies that were provided under the COVID era are up for refinancing. And under a Harris administration, I expect that that would happen. I don't think that's going to happen under the Trump administration, but we'll see. They may not want to be tagged with losing 5 million people, you know, in terms of health insurance. So we'll have to play that out and see how that goes. Trump has pledged not to cut Medicare and Social Security, but he's got, he maybe has no third term. So he doesn't have a third term, but the question is whether he will push to get a third term. And that's not beyond the pale, right? I mean, there is a chance that he says, well, it wasn't consecutive, so now I can do a third, right? So without that worry about a third term, I don't know whether he'll stick to his pledge not to cut Medicare or Social Security, especially if the Elon Musk kind of approach of this efficiency commission that he's talking about and gutting government in large measure, doing what he did with Twitter to the federal government, I don't know where they get the money. I mean, Medicare and Social Security is the key place to go. I may be overstating the case, because those are third rail programs, and traditionally, if you've touched them, you've been burned. But we'll have to see how that goes. And then the legal troubles that Trump has got, he's supposed to be sentenced on November the 20th in one of his trials. I just can't imagine that those don't go away. They'll figure out some way to make them go away, and I highly doubt they'll pursue them after he's out of office. But again, we'll have to see. All right, real quick, and then I'll sit down or take questions. The whole panel will take questions. So the battle for the House is still up in the air, but it's leaning Republican, clearly leaning Republican. There's about 35 seats that have not, 37 seats somewhere in there that have not been resolved. It depends on who you ask and what source you find. They're being called almost every hour. So the most recent date I had was 206 Republicans, 192 Democrats, and about 37 races that have yet to be called. But many of those races are being led by Republicans, very, very small margins, or they would already be called. So you can't really call it, you can't really make that statement. But it would be very surprising to me if all of a sudden you had a blue wave at the last week of vote counting, given what we've seen thus far in the trends. So I do expect there to be a Republican House for them to retain their majority, but not by many votes, but by enough for them to have a working coalition. In the Senate, it also depends on who you talk to and what source you, the most conservative is that it's 52-45 at the current time, with three races undecided. The race in Pennsylvania is most concerning personally to me, because Bob Casey is really viewed as the disability advocate in the Senate, on the Hill. He is the most invested in disability policy. And if he loses that race, he's down now. His opponent is up, and they've counted 98% of the vote. If he loses that race, I don't know who replaces him on disability policy. So it's a very concerning situation there. But ultimately, the Senate has flipped. It will no longer be run by the Democrats. Chuck Schumer, presumably, will become the minority leader. The two people are, two senators are vying for majority leader, Chuck, I'm sorry, John Thune and John Cornyn. Thune is from South Dakota. Cornyn is from Texas. The betmakers have Thune is likely to become the next majority leader. No telling, that could change. The flips in the Senate included Montana Tester, who opens up a big new leadership post on both Veterans Affairs and Appropriations Defense spending, because he was the chair of both of those. Ohio, Sherrod Brown, was not able to maintain his seat. He's been there for a long time, certainly both in the House and the Senate. But ultimately, Ohio continues to trend red. And Brown lost his seat. And then West Virginia, Manchin retired. And of course, a Republican easily won that race. There probably will be a couple of others. But at this point, it's too early to tell. I think I, OK. So a couple of other things about the Finance Committee. The new chair is likely to be Mike Crapo from Idaho. Doesn't have a lot of background or interest in health policy. He's a former Banking Committee chair. So he will be instrumental and focused on the tax bill. And that's the key committee that will do that. The new ranking member on that committee will be Ron Wyden, who's currently the chair. In terms of the HELP Committee, that's the Health, Education, Labor, and Pensions Committee. The new chair will be Bill Cassidy. He is a physician from Louisiana. He cranks out an incredible amount of work. He is not a darling of the right. A number of the more conservative senators don't particularly jibe with him. But I think he'll be a formidable chair of the HELP Committee. And then Bernie Sanders will become the ranking member. He's currently chair. And then I've already gone through the Democratic losses. Last slide. OK, the lame duck session I've already kind of talked about a little bit. I don't need to repeat that. And by the way, I made this slide yesterday morning. And things have been changing. And I think I would change the slide around a little bit at this point. Because I really think that the policy priorities there, partial physician fee schedule fix, passing the Improving Seniors' Timely Care Act, and the telehealth extension, they clearly were all in the mix. They still are. I just think the likelihood of getting those things across the finish line are considerably less than they were earlier this week. Because especially if there's a trifecta, especially if the House stays Republican. I think I'll end there. Thank you very much. Thank you. All right. We have time for questions. We're going to go a little long, just because I think it's a really important discussion. When I was thinking about this session after the election, if you're very positive about the new administration, good for you. If you're of another persuasion, then you're probably seeing this as a therapy or counseling session. So I did see it as something that we need to discuss, because there's a lot of unknowns with the new administration, as Peter alluded to. One of my questions to you was using, I think a lot of us are concerned, particularly you mentioned Bob Casey and other advocates for disability rights within the Hill. Is treatment of individuals with disability and disability rights going to be a focus of this administration? Probably not a focus, I would say, but something that they value? If we take into account the prior time that they were in office, what do you think? Well, I mean, traditionally, some of the best disability leaders in the Congress have been Republican. Bob Dole, Lowell Weicker was Republican. He was quite moderate, but he was on the ADA when it passed. There's been some good Republicans that have led on disability rights and disability issues. But in the end, I think generally the Democratic Party is better aligned with the goals and the priorities of the disability community than the Republican Party is. Having said that, it's not as though they will, no one ran against disability, and no one has it out for the disability community. I just don't think it'll be as easy a sell, and I think there will be some additional work that will need to be done. Well, certainly, if we do lose Bob Casey, we'll have to work hard to try to develop additional champions, especially in the Senate. I have a follow-up question, but I'll hold it. That's on Swami. Great session. I think that's on. Yeah, great session. Thank you. Two questions. One, we've done a lot of work in the committees on principles of the unified post-acute care. Now that the Impact Care Act has sunset, and any unified sort of system is probably also, like you said, dead in the water, is there an opportunity to take a proactive approach that would serve the best interests of the inpatient rehab community? Or is that something that we are not pursuing at this point? Is there an advantage to sort of creating a framework of a model that will be sustainable, and people may have bipartisan support around it? And my second question, it's a shorter one. What are we doing about the whole FAA possibility of the wheelchair seating in airplanes? Go ahead, Peter. I'll answer the first one first. We just submitted comments on that very issue. And there's a lot of activity around that, including both legislative and regulatory. I think you might have seen just last week, one of the major airline carriers had a big settlement on wheelchair repairs and damage. I expect other airlines to do the same. I think it's going to take quite a while for airlines to be building airplanes that will assume that people remain in their chairs and are sufficiently safely secured. But that's clearly a goal of the Academy. It's a goal of the disability groups. And they're most definitely making progress on airline transportation for people who routinely use wheelchairs. Getting the planes actually retrofitted or modified from scratch when they come off the assembly line is a longer-term approach. But I think Academy's been very active on this. And I'm hopeful that they'll move in that direction. It certainly seemed that way under the Biden administration. We'll see what happens under the next. Now, on the other point, I want to make clear that people understand the IMPACT Act did not sunset. The IMPACT Act is still in effect. It said, create a series of metric spades, they called them, across, you know, metrics across these different four settings of post-acute care so that you could compare and contrast apples to apples and not have four different payment systems and four different quality metrics and all this. So that's all in place. What happens now? Do we just say, well, we beat back site-neutral payment. We beat back unified payment. Let's just go back to the way things were. There'll be an attraction to that because it's a lot simpler. And that does preserve the, not the independence, the value of inpatient rehab hospital care as a distinct entity and a distinct thing. But there was a proposal that the AMRPA put forward a few years back called the continuing care hospital approach, which aimed to kind of rewrite some of what we do in post-acute care. It didn't take off and has kind of been mothballed. But there might be potential interest in trying to figure out better ways to improve post-acute care. At this point, I think most people are just enjoying the victory. I'm not sure if people have thought through the next step at this point. Thanks to all of you in the Academy for a great presentation and for, I think, really putting the specialty and the patients we serve at the center of our advocacy, regardless of administration and always looking for opportunities and challenges. So thanks for that. I had a question about what I guess I'm thinking of as MedAdvantage plan prior off technical denials, which seems to be evolving. I do acute care consults and do not have an affiliated rehab unit at my current hospital. And so everyone is going outside. And a couple of weeks ago, we had a acute care to SNF MedAdvantage plan denial because the delegation of authority for the appeal was printed instead of signed in cursive. Wow. As a documented reason for denial. Wow. Which seems, so part of my question is just, are we seeing, it reminds me of the timestamp for IRF stuff and this kind of technical denial. This case was clinically very straightforward to be indicated for SNF. So wondering what we're seeing there. And that's challenging for me to refute that in order to proceed with an appeal on behalf of a patient who really needs those services. Yeah, that's illustrative of many of the types of denials that we see. I'm not talking about SNFs, I'm talking about IRFs. There's, I mentioned earlier the OIG has a medical review instrument they're using to assess these claims. There's 37 questions on the medical review instrument. If you have 36 yes checks and one no check, that's an error, that's not a payable claim. They've reduced treating IRF patients to a checklist. And that's one of the key talking points we plan on talking about with them is trying to figure out a way that we can modify that and have either some kind of either de minimis standard or some technical denial kind of allowance. Printed versus signed is just one of those examples. I would fight that, I would challenge that. But we see those all the time. And a hundred different things that I can mention. I think some of the legislation we've been advocating for is more transparency and also making sure that, for example, prior authorization, the other person that's reviewing what you're asking for is actually someone who's a specialist in the particular area that we're in. And so rather than an OB-GYN, for example, reviewing your ask for a prescription or something like that. That's also been something we've been advocating for strongly for the last couple of years. Yeah, this patient had apraxia and couldn't sign. So I put that all over our appeal. And I think there are elements of this that become discriminatory. And I work at a place that was willing to hold that patient, but it added nine days to their acute care stay. So thank you for continuing to work. Thank you. It wouldn't be high for any payer. So it would be high for any payer. It's an astoundingly high number. It's so astoundingly high that it's not really credible. And I think that's one of the reasons the OIG is actually, they never meet with, they never have providers work with them on audits. They audit a field and they audit it. They do their own thing and they come out with a report and you learn about it when they publish the report. The fact that they've invited us into the tent to give them direction and to give them our best thinking, there's no guarantees they accept what we say. But the fact that they're doing that I think is an indication that they kind of realize that something's wrong. In the same year, 2013, where the claims were pulled for that 2018 report, the CERT, which is the Comprehensive Error Rate Testing Service that CMS has to assess how the contractors are doing, said that the overall IRF error rate was 19%. And the OIG's audit revealed 84%. So that alone tells you that there's a disconnect. There's something off. People...I don't know if it's the level of subjectivity or whether it's just a lack of knowledge of rehab or whether it's that the documentation requirements are just too burdensome in the context of a busy rehab hospital. I'm not sure what it is, but that's the whole purpose of this OIG initiative is to try to get to the bottom of it and improve the situation. Thank you. Hi. Good morning. Morning. Question about reauthorizations for... and specifically for procedures with CPT codes. You know, I think the big reason why we have... less than the average number of these procedures, right? So has anyone looked at, or would it be helpful to look at, in this, the mention about the gold card got me thinking on this, scoring doctors, and if you're in the lowest X percentile, you don't have to do prior authorizations, whereas if you're in the 99th percentile, maybe all of them you should have to do. Like, has anyone ever looked at that? That's a great question. Matthew, do you have any comments on that? Yeah. I mean, I think that's essentially what the gold card program is, is each insurance company is kind of grading the physicians on its panel, but I don't think there's necessarily something uniform across all of them. Was the gold card, I may have misheard it, but was the gold card just, if you're successful once, you don't have to do it for another year? Well, that, I mean, there's so many iterations of gold cards in each of the states, and Texas had a big one as well, but that particular program that he was referencing was just for one year at a time. Yeah. Just tell you my opinion on that? Yeah. It's kind of nonsense, because anybody can get, anybody can get approval for, you know, you write the right thing in your note, you can do it, but, you know, where the money is, if you're doing, you know, if you're in the 99th percentile of something and you have a really good, you know, way of documenting, you're gonna get through it, but if you're doing that many of them, like, maybe you should have to do it, and that'll probably lower your numbers, and, you know, those of us who are not doing that, then maybe we are doing it more appropriately, and we wouldn't, and we shouldn't have to. Yeah, I don't think, to your point, I don't think there's any data that I know of in that particular realm, and maybe it's something we could look at, actually, and maybe even longitudinally follow, or retrospectively see how our membership or individuals are doing in that particular area, as well. Because that data's out there, right? We get emails that say, you, you know, build X number, you're in the whatever percentile, so that data's out there. Right, right. No, I don't think that's something that we've looked at. That's a great point, though. All right, thanks. And we have some of our Academy staff who'll definitely look into that, as well, on that, so thank you. Any other questions from anyone? I have one last question for you, Peter, on, just, I mean, I was wanting to talk to you, I might as well ask in front of everyone, because I was gonna talk to you about it offline, but I think it impacts us, because when we talk about our priorities, we've done a lot of advocacy work in, like, long COVID, other areas which I would anticipate the new administration may not be as, how, what are you seeing in terms of transitioning out of advocating for those specific areas, or do you see that those are areas that it's not worth any more working on? Yeah, it's early, it's, you know, I don't think I've really fully thought through every issue area, but I will say that this is not the first time that we're dealing with this. We had four years of President Trump. Demetrius Kouzoukis was a very important ally, I'll call him, in the administration at CMS. He was quite open to many of our arguments on key issues. It wasn't the watershed kind of change that some people might have assumed. I don't think long COVID is gonna be a big, you know, priority of this administration, but there'll be plenty of things that transcend the, you know, the party affiliation. I do think he will return back to, he meaning the president, will return back to his deregulatory agenda. So if you're trying to get regulations in place, if you're trying to tighten up on what healthcare providers can and can't do, I don't think that's gonna be a very fruitful area to pursue. So I do think there's probably less chance of really tightening and battening down the hatches on managed care. They're much more in the camp of private, you know, companies running a lot of, as much of healthcare as possible, and as least government as possible. So there'll be some macro changes, but on many of the issues that we work with, particularly all those technology issues I mentioned, access to therapy, I don't really think that those are gonna be all that impacted. I'll give that additional thought. It still is pretty early, and we'll probably do some additional thinking about that as a committee. You know, Melanie is here. I think you guys know Melanie Dolak and Chris Stewart, as I saw in the back, and there's a committee that we work with, and obviously you know, because you're here. Sounds good. No, that's great insight. No other questions. I think we'll end it right there. Just in closing, please, this email, if you have any questions, or something that's an issue that's impacting you, many of you mentioned some of those, please reach out to us through here, and also highly encourage you again, don't, well, you can ignore my emails if you want, but the voter voice campaigns, please look at those as well. They are really helpful for us to know what's impacting you as membership as well, but thank you so much for coming today. Thank you.

AAP Menard Advocacy

Physiatry

Capitol Hill

Dr. Prakash Jayabalam

Dr. Matthew Grierson

Medicare payment reductions

Telemedicine

Health Policy

Medicare reimbursement

Inpatient rehabilitation

Peter Thomas

Legislative advocacy