Hello, everyone. Thank you for joining us tonight for an AA PM&R webinar on challenging Medicare Advantage denials of PM&R physician services. If I let it go just a couple minutes here just to get some stragglers on board so we can get as many people in here. So to kick it off, I will be doing some quick housekeeping notes. So this webinar is being recorded. It will be available on the Academy's online learning portal within, I believe, a week of us closing this out tonight. For the best attendee experience during this webinar, make sure that all of your microphones have been muted. I believe that that option is turned on for everybody right now, but just in case, make sure that those microphones are muted. So during the Q&A session, I'll be able to unmute you. You'll be able to put your questions into the chat as well. We'll go into how to ask questions. So basically, you can raise your hand, you can put it into the chat, or you can go into the Q&A. You have multiple options there to ask any questions, and there will also be the opportunity for emailing us after the fact as well if you have something that comes to mind afterwards. So for a quick rundown of the agenda for tonight's webinar, we'll be doing introductions. We'll be going over the purpose of this webinar. We will have a PM&R physician perspective on Medicare Advantage and prior authorization denials. We'll also set the stage on Medicare Advantage and prior authorization in terms of how the legislative and regulatory environment is looking in this space. And then we will have an expert providing background and tools for you all to use in terms of new rules for providers and patients on challenging Medicare Advantage denials. After that, we'll have a questions and answers session and then brief parting comments. So quick introduction. We have Dr. Carrie Gill DeLuca. She'll give you a little bit more information about her background, but she is a member of the Health Policy and Legislation Committee at the AAPM&R here. We have Peter Thomas. He is a managing partner at the Powers Law Firm. He has decades of experience in this space, and he works very closely with AAPM&R advocating for these issues. And then finally, my name is Chris Stewart. I am the Director of Advocacy and Government Affairs at AAPM&R. With that, I will go over the purpose of this webinar. CMS has issued new formal rules to rein in overuse and abuse by Medicare Advantage, MA, plans of prior authorization, PA, in order to deny claims. So what this means is that there are new rules out there offering AAPM&R physicians, all providers, and patients a new toolbox in order to challenge denials of AAPM&R care. So these are tools that were not available before earlier this year. These are things that will help you do your job and will help you improve access to care for your patients. So many of the AAPM&R denials, as I'm sure you all know, they occur at the prior authorization stage, and these rules address that area in depth. So this webinar is designed to give you all, physicians and your patients, tangible, usable arguments backed by citations for the new regulations in order to secure coverage and payment for your patient services. And with that, I will hand it over to Dr. DeLuca for her to give a little bit about her background and some concrete examples of how MA denials, MA, PA denials have impacted her practice and her patients. Dr. DeLuca. Yes. Hi, thanks, Chris. Thanks for inviting me to speak. Sort of one of my favorite topics, just a little bit of background. So I've been the director. I am currently the director of the AAPM&R consult service at UPMC Presbyterian Hospital. So I work in a large urban teaching hospital. I am also the medical director of the Rehab Network. So we have over 200 rehab beds spread from Central to Western Pennsylvania and into Western Maryland. And I've been doing this job of inpatient PM&R consults here at UPMC since 2005. So like many of you, I'm sure on the call, my job involves evaluating patients while they're in the hospital to make sure that their rehabilitation needs are being met. My job also involves evaluating what level of post-acute rehab is appropriate for these patients. Often I do peer to peer discussions with insurance medical directors to advocate for my patients. And my job also involves teaching residents and fellows how to have these peer to peer discussions. So as part of my day to day job, I work with PG3 level residents. And during their time on the consult service, I feel that it's really important for them to learn how to think through these issues, frame the discussion, and be ready to have these conversations with the insurance company medical directors. So I'm sure you all know these criteria. So these are just the CMS criteria for inpatient rehab. So I don't need to read it, but patient needs to require multiple disciplines. One must be PT or OT. Patient needs to require intensive rehabilitation. The patient needs to be able to participate, and we need to think that they're going to make measurable improvement in a reasonable amount of time. The patient has to require supervision from a rehabilitation physician and needs that intensive and coordinated interdisciplinary approach. Next slide. So my own personal experience with peer to peers, I have to say, is often frustrating. Sometimes I will get the call from an insurance medical director. Basically, it's framed as an intent to deny call. I'll get the call and they will say to me, I have every intention of denying this and I'm just letting you know, which I don't feel is very fair. With some medical directors, however, I even had a call today with Nava Health and the medical director said, you know, I just need more information. I have a concern about this patient's blood pressure. I just want to speak with you about this patient. And that medical director ended up approving IPR for my patient or inpatient rehab admission for my patient, which was actually pretty gratifying. But I will say overall, on the whole, I think the experience is really pretty frustrating. As you know, Medicare Advantage plans don't always use Medicare criteria. So we're all well versed in what Medicare criteria are. However, we will have conversations with medical directors from insurance companies, and they will clearly be using a different set of criteria. So we know that there is a differential in access to care for Medicare fee-for-service patients versus managed Medicare patients. So the statistic I've heard is basically one third, it's one third the access for Medicare Advantage patients compared to fee-for-service Medicare patients. So we know that these patients clearly meet CMS criteria, but they're denied access to inpatient rehab. Next slide. So in terms of peer-to-peers for managed Medicare patients, you know, you may have the discussion and they may result in an outright denial of inpatient rehab level of care, despite you as the physician clearly outlining how the patient's appropriate for inpatient rehab. The review process also causes significant delays in getting to an inpatient rehab level of care. So first you wait a number of days to even have a determination. Then in the middle of your busy day, you're notified that you have to have this peer-to-peer discussion. You're given a timeline. There's additional time spent preparing and having that discussion. Then if you're denied at that peer-to-peer discussion, then there are delays while the appeal is processed. So as you all know, on the wards, there's a real emphasis on decreasing length of stay. And many times primary teams or care managers really don't want to wait for that appeal. So that becomes another stressor in trying to get your patients to the correct level of care. I have had situations in my career where the primary team just decides they're not going to keep the patient in the hospital and pursue that appeal. They are going to send the patient to a skilled level of care, even though I recommended something else. And in terms of physician burden, you all know the time that you spend preparing for these reviews, conducting the reviews in the middle of your busy day when you're doing lots of other jobs, it becomes onerous and it really is a significant burden on physicians. And as I mentioned, these calls occur randomly, often with tight deadlines. And we've had some rare occasions where we were notified about a deadline even after it's passed. So it's just an all-around frustrating situation for many of us. I did have one example. Chris, is that my last slide, I think? I think it is. Oh, no. One more. Good. So actually, the next slide would be great. Sorry. So having more tools in our toolbox will be helpful. So I'm really actually looking forward to this discussion because I think it's important for all of us to really have a lot of strategies and a lot of tools when we're trying to challenge insurance companies during these discussions. I will give one timely example. So this past Saturday, I was called by our UPMC health plan. So I work in a system that has integrated health care delivery and finance. So I was called by a medical director from our health plan, basically telling me that he planned to deny the inpatient rehab request because my patient didn't need moderate assistance with OT. So I just happen to have my laptop open. I happen to be able to pull up the chart. And I found out, well, actually, the patient had been seen by therapy the day before, did have demonstrated modest needs, so actually met criteria, and we were able to have that discussion. However, in the course of that discussion, I said, well, why are you asking me about moderate assist specifically? And the medical director said, well, that's a Medicare criteria for inpatient rehab, to which I said, no, no, it's not. I know the Medicare criteria. That's not a criterion. Then the medical director came back and said, oh, well, then it's an interqual. It's part of the interqual criteria. I said, no, it's not, to my knowledge. And I've been able to review interqual criteria as part of being part of this IDFS. The interqual criteria, to my knowledge, required meniscus level needs, not modestness. So I pushed back again, but I know I've had conversations in the past. I can recall one with the medical director from UnitedHealthcare, where at first we were talking about the patient's needs, and the medical director said, well, that patient doesn't meet Medicare criteria. And I said, well, they actually do meet Medicare criteria, and here's how they meet Medicare criteria. Then the medical director said to me, oh, well, that patient then doesn't meet our insurance criteria. And I don't know UnitedHealthcare's criteria. So I feel like having more tools in our toolbox will be really, really important. I do, however, think that we're going to have continued difficulty when we do these reviews, because there are going to be some conversations about that whole issue of why the patient needs to have physician oversight, physician management. That's still not covered by, I don't think it's covered by anything we're going to discuss tonight, and I think that's still going to be an ongoing conversation. But I am really excited to hear everything that Peter has to say tonight, because I personally feel like I need to have as many tools as I can in my toolbox when I have these discussions. And that's all I have. Thank you, Dr. DeLuca, and thank you for setting up, Peter. Unfortunately, you're going to have to listen to me talk for a little bit before we get to Peter's substantive covering of these new toolbox items. So I'm going to give you a little bit of background right now on Medicare Advantage prior authorization reform efforts, basically some of the work that the Academy has done along with other allied stakeholder organizations and coalitions that the AAPMNR takes part in. So to start, Medicare Advantage, as I'm sure many of you know, it now covers over half of Medicare beneficiaries, and the number is growing daily. So with that growing number of beneficiaries, the HHS Office of Inspector General has looked into the access to care that these beneficiaries actually have under Medicare Advantage plan. So in 2018, there was an OIG, acronym for Office of Inspector General, report that determined that many Medicare Advantage plans have been misusing and abusing prior authorization as a method in order to limit their payments to providers and basically deny access to care for their patients in order to cut costs. So the OIG recommended reforms. That recommendation did not really go anywhere that we wanted it to. In 2022, OIG issued a very similar report, finding that there was still widespread misuse and abuse of prior authorization in MA plans in order to cut costs and deny access to care. So this has clearly been an ongoing issue and obviously you are all practicing in this space, you are well aware of that. So at the congressional level, because the hands of CMS are a bit tied in terms of what kind of reforms they can actually do through rules and regulations. At the congressional level, we have had legislation introduced in previous Congresses called the Improving Seniors Timely Access to Care Act. So in the past Congress, that was H.R. 3173 and S.3018. That legislation was wildly bipartisan, incredibly popular, had 362 co-sponsors in the House and 52 in the Senate. And I'm not sure how many of you all are familiar with co-sponsorship numbers for legislation in the U.S. Congress, but those numbers are practically unheard of. It's widely popular with Republicans and Democrats. So there's widespread acceptance for your federal elected representatives that there are reforms that need to take place in this space. That legislation passed the House in the fall of 2022, but unfortunately, it did not cross the finish line. It was not taken up by the Senate and passed and then signed into law. Basically, the Congressional Budget Office estimated that the cost of implementing that legislation with current rules and regulations, current law, they estimated that that cost would be about $16 billion, which is a huge price tag. We have, well, we definitely disagree with that estimate, and we have done outreach with CBO and Congress in terms of how they got to that number and how can we get that number lower? So that will lead us into the next slide here in terms of where we are at now. So that legislation has not yet been reintroduced in the 118th Congress, but sponsors are working in order to decrease the cost of that bill. They're working on the language. They're also working with CMS in terms of some of the rules and regulations that CMS is considering that could potentially lower the cost of taking legislative action in this space. So you have multiple congressional committees that are currently considering portions of that legislation that we support in other legislative vehicles. So you have the Senate HELP Committee, you have the House Ways and Means Committee, and you have the House Energy and Commerce Committee already taking actions to advance portions of that overall legislation. So not the entire panel of reforms for the Medicare Advantage Program that we would be supporting, but basically pieces of that that would be great to move forward. We also have pending at CMS, a rule that would reform prior authorization for Medicare Advantage, Medicaid Managed Care, ACA plans, and other payers. And that would include time limits for PA decisions and other reforms that would be incredibly helpful in the prior authorization space for y'all and your patients. So AA, PM&R, along with its partners, including the Regulatory Relief Coalition, the AMA and other physician groups have all submitted comments in favor of that proposed rule. It's something that we have been pushing for on behalf of physiatrists and your patients for quite some time now. Congress also jumped in here as well to urge CMS to publish that final rule, which has been pending for a while. We're hoping that that rule will be released in December of this year. So we have our eye out for that right now. And as part of that push for Congress to push Congress to push CMS to release that rule, we had a grassroots letter writing campaign that we had a significant number of physiatrists, AA, PM&R members take part in. So asking their members of Congress to support this initiative. So that clearly had an effect because the letter that went out from Congress on this issue had an overwhelmingly large bipartisan number of signers. All right, and this is me setting up the table for Peter here. So we have new rules for providers, patients and challenging Medicare Advantage prior authorization denials. So CMS issued a final rule on April 12th of this year in order to reform prior authorization and other utilization management techniques that are used by Medicare Advantage plans to control costs. So that rule went into effect June 5th of this year. It's effective. It goes fully into effect on January 1st of next year. So excuse the typo there. Basically when the Medicare Advantage plan documents are updated and issued to enrollees for the new plan year. So that final rule, this final rule only applies to Medicare Advantage plans, but it's a very significant one. It makes significant regulatory changes. It's gonna help level the playing field when coverage disputes arise and help provide better access to care for your patients. And hopefully reduce burden on y'all in terms of getting some of these prior authorization requirements off your backs. So these new regulations are definitely seen by the MA industry, the Medicare Advantage industry as a blow. And it's definitely a watershed moment in terms of how Congress and CMS are looking at Medicare Advantage. So this last one, I'll set up and hand over to Peter after this. So you have new tools to challenge prior authorization denials. Basically requiring Medicare Advantage plans to abide by traditional Medicare coverage rules. Limiting the use of internal Medicare Advantage or proprietary coverage guidelines. Limiting prior authorization to certain situations. Strengthening medical necessity determinations. Establishing guardrails around utilization management tools and marketing. And strengthening the qualifications of claims reviewers. And with that, I'll hand it over to Peter. He can give you a little bit of a background on his experience in this space and walk you through the logistics of these tools. Take it away, Peter. Thank you, Chris. Thank you, Dr. DeLuca. It's a pleasure to be here. Good evening, everyone. We have about a little less than a half hour to go through about a dozen slides that really detail the substantive aspects of this new regulation. Again, went into effect June 5th of this year and will fully go into effect on January 1 of 2024. So just a couple of months from now. The reason I say fully go into effect is because the health plans, all the MA plans have to publish guidance that's consistent with this rule in their plan documents. And so it'll be much more known to people once that occurs. But you can use these slides and citations to the regulations right now in everyday conversations with other physicians at MA plans when you're haggling over whether they will admit and pay for rather an IRF patient. We put the regulations in these slides on purpose. Usually you don't see that kind of legal citation. We're hopeful that you'll take these slides, print them off, use them as a guide, review them before you start talking with the physicians. Even cite them. If you're talking with a physician and you say, well, actually, maybe one physician says something that Dr. DeLuca heard, say, actually, that's not true. According to 42 CFR, section 422.101, that's not actually correct. That's gonna get their attention when you start citing chapter and verse of the regulation. And they can actually go and fact check that. Of course, if you insert 42 CFR 422 into Google, it will pull up that citation and all the regulatory language immediately. So never hesitate to do that. It's a very easy way to pull up those regulations. So here's a few things that the new rule does in detail. MA plans must make medical necessity determinations based on traditional Medicare coverage and benefit criteria, such as the Medicare statute, the regulations, national coverage determinations and local coverage determinations. Now we know from IRF care that the statute is fairly nondescript. There's not a whole lot in there. There's a few things around IRF coverage, but the regulations detail in depth. In 2010, CMS issued very in-depth regulations around medical necessity criteria and documentation for an IRF stay. There are very few, if any, NCDs for IRF care, and I don't think there's any LCDs. I would say in PM&R practice, outpatient practice, there are certainly NCDs and LCDs to consult if you're being denied on those claims as well. Now, MA plans can no longer deny coverage on the basis of internal, proprietary or external clinical criteria that are not found in the traditional Medicare coverage policies. That's directly out of the final rule. Basically that establishes that if they say to you, well, this is interqual, our interqual guidelines that we use don't permit a person who has this mod assist for OT, that fails to meet our interqual guideline. Well, doctor, the interqual guidelines cannot be relied upon by an MA plan to deny an IRF admission. You need to follow the Medicare coverage criteria. So that's the kind of dialogue we're hoping, the reasons we called this a toolbox, the reason these are new tools is because they obviously give you some additional arguments to make when you're haggling over whether to admit a patient or not. Finally, Medicare Advantage plans may not use and specifically state in the Federal Register interqual, Milliman coverage guidelines criteria or similar products to change or coverage or payment criteria already established under traditional Medicare laws. So yes, it's true that the general rule with Medicare Advantage has always been that it's supposed to cover what the fee for service traditional Medicare plan covers. But plans certainly have not met and adhered to that requirement. This regulation makes the rules that much more specific and thereby, we hope, more enforceable. Next slide. So MA plans, they aren't prohibited from utilizing internal coverage criteria, but they have to go through a process and they can only be used when the traditional Medicare coverage criteria are not fully established. That's the standard. So that means in the statute, the regulation, NCDs, LCDs, if coverage is not fully established, health plans, MA plans can go forward and create new internal coverage criteria to assess various types of patients. And this is where the plans are gonna do their best to get around these regulations. They're going to say, well, this is a brain injury patient with X, Y, and Z. There is no NCD on brain injury patients with X, Y, and Z. You know that the Medicare coverage criteria for IRF care in particular are more process oriented than they are very specific to individual conditions. I would suggest the same applies in the outpatient setting, pain management setting. Perhaps they're a little bit more specific in that setting. But the fact is that there will be areas that the plans will claim do not have a fully established coverage criteria. And therefore they're going to feel empowered to create internal coverage criteria. But they can't just wave a wand and do that and claim that they've done that. What is fully not, and we'll get into that in a moment. What does not fully established mean? Well, it's essentially means that there is an absence of any applicable statutes, regulations, NCDs, or LCDs. NCDs and LCDs include flexibility that explicitly allows for coverage in certain circumstances whether or not those specific indications are included in the NCD or LCD. And that's an argument that PM&R physicians will make and other physicians. This applies to all MA plans. This applies to all services covered by Medicare Advantage plans, not just IRFs, not just PM&R physician services. But so certainly you can make the argument, well, you need some flexibility. You can't have regulations and NCDs and LCDs that cover every single condition that are treated by PM&R physicians. That's an extraordinarily broad scope of conditions. And finally, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. That's what the MA plans will say. They need to supplement that unspecified criteria through internal guidelines and to show that the criteria provide clinical benefits that are highly likely to outweigh any clinical harms. That's kind of a standard. And that citation there, CFR 422.101, please cite that if you feel as though you're starting to make some headway with the MA physicians. Next slide. So in developing internal procedures, there are very, very well-established criteria and processes that are put in place by this regulation. The final rule mandates that MA plans have to follow certain procedures when they develop internal coverage policies. The internal policies have to be based on current evidence in widely used treatment guidelines or clinical literature. And this is a language that often appears with respect to the quality of evidence. We're talking about acceptable clinical literature, large randomized controlled trials, prospective cohort studies with clear results, peer-reviewed journal articles, all the way down to even, I suppose, you could include a physician kind of anecdotal evidence. Meta-analysis certainly is much better and a higher quality than that. But those kinds of meta-analysis that summarize the literature can be extremely persuasive. Those are the kinds of studies that the MA plans are going to have to rely upon to develop internal MA coverage criteria. And frankly, in rehabilitation, there is not a plethora of these kinds of studies. There are some, but there are many that will be used or they'll try to use that may not necessarily stand for the conclusion that they're asserting a particular study stands for. And that's why the next slide is so important, but let me just finish. Unpublished evidence, evidence in kind of case series or reports, evidence that is derived solely from internal analysis that MA plans would perform does not meet this standard. So they can't simply say, well, according to our internal analysis, these patients aren't medically necessary in IRF care or it's not medically necessary to provide them with this injection or procedure, what have you. Next slide. So as part of the development of internal procedures, the MA plan has to provide in a publicly accessible manner, both the internal MA coverage criteria and a summary of evidence that was considered during the development of the internal criteria. That's a pretty high standard. So now you don't just have a requirement that a tangible physical document is created for the specific situation you're talking about that may not be fully elaborated upon by the existing fee for service coverage criteria, but you've got a requirement that those internal criteria be based on solid evidence and that it be issued and developed in a publicly accessible manner. So there has to be a list of sources of such evidence that would be available to the public. The MA plan has to publish an explanation of the rationale that supports the adoption of the criteria. And when the coverage criteria are not fully established, the MA plan is required to identify the general provisions that are being supplemented to explain how the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms. Again, that language used in the regulation repeatedly. So this is a pretty high standard. This is a much better position that PM&R physicians will find themselves in than has been the case in the past. Next slide. In terms of medical necessity decisions, the MA plans must make these determinations based on all of the following factors. Now, this isn't rocket science, but the fact is that they included this in the regulation, just to make it clear, whether or not the provision of items or services is reasonable and necessary. Reasonable and necessary is the standard for coverage for the Medicare program overall. They must take into account the patient's medical history, including diagnoses, conditions, comorbidities, functional status, physician's recommendations, clinical notes. They must look at, and not just look at, they must adhere to the coverage and benefit criteria, and where appropriate, they have to have the involvement of an MA medical director. MA plans, they have to ensure that they are making medical necessity determinations based on the circumstances of the specific individual. That's not new for Medicare law, but in many instances, the fact that MA plans would use interqual or Milliman guidelines or some kind of internal guideline to a group of patients. Oh, if you have X condition, you go to a SNF, which is not very far from what they do. They cannot do that. They have to assess each individual patient. They cannot use algorithms or software that doesn't account for individual circumstances. So NaviHealth and some of those other companies have been wringing their hands for the last several months, trying to figure out ways to get around this regulation. Frankly, maybe that's a little bit cynical, but I have no doubt that that's what's been happening in back rooms in many of these health plans for some time. And I expect that to continue. So I don't view these new regulations as a solution to this problem. I view it as a very positive step forward and a platform on which we can build going forward. Next slide. So prior authorization is the primary way that MA plans use to deny care or to review the payment of care before the decision is made to admit or to proceed with a particular service. The final rule establishes safeguards regarding prior authorization. These are meant to avoid disruptions in care, limit the plan's ability to partially approve care, which is something that I'm sure many of the participants in this webinar have routinely seen. Well, we'll approve three days. We'll approve seven visits. We'll, whatever it might be, two injections. But you've got to come back and you've got to demonstrate improvement or something along those lines. And to minimize repetitive prior authorizations. This goes to the definition of what they call the course of treatment. Approval of a prior authorization request for a course of treatment must be valid for as long as it is medically necessary. And this is to avoid these types of care disruptions that I just mentioned. When a patient switches from a new MA plan to another MA plan or from traditional Medicare to a Medicare Advantage plan, the MA coordinated care plan cannot disrupt or require reauthorization for an active course of treatment. And that's typically defined as at least a 90-day course of treatment. So I think that's very important when you've got changes between plans or changes of enrollees joining MA in mid course of treatment. The requirement applies even if the service is furnished by an out-of-network provider. So this is a pretty solid improvement to beneficiaries who receive disruptions in their health plan without disrupting their health care. And it's an important component of this new regulation. Next slide. Prior authorization, the processes for MA plans may only be used for certain reasons, to confirm the presence of a diagnosis or a medical criteria that are the basis for coverage, to ensure that an item of service is medically necessary, and that's for basic benefits. For supplemental benefits under a supplemental Medicare plan, under a supplemental Medicare plan to ensure that the provision of a service or benefit is clinically appropriate. So these are the reasons for prior authorization. It's not intended to delay care. It's not intended to serve the financial needs or interests of the MA plan. It's simply to confirm that the care should be paid for and is covered by the plan. If an MA plan approved the provision of a covered service through a prior authorization, it's barred from denying coverage later on the basis of a lack of medical necessity. That is a huge improvement. That will ensure that once you get the approval based on medical necessity to move forward with a treatment plan, they cannot subsequently challenge the medical necessity of that care. Now, what they can do, let's take the IRF example. If the physician's notes are not signed off, if the plan, if the team conferences are not appropriately and timely completed, if there are other kinds of flaws in the documentation requirements, CMS can indeed, MA plans can indeed go back and review that claim and can even deny the claim for reasons other than medical necessity. But based on medical necessity, if you get a PA decision in the affirmative, they are barred from later, you know, absolving themselves of that claim and rejecting it and having you fight through the appeals process. So these new requirements really should reduce the incidence of disruptions and delays and denials of care as a result of misuse and abuse, literal abuse of prior authorization by MA plans. And those are the citations in the regulation to cite. Next. All right, utilization management. There have been some changes to the utilization management criteria, although I must admit that these are not necessarily groundbreaking. Every MA plan is supposed to have a utilization management committee and very few do not. I might even say none, no MA, no serious MA plan would not have a utilization management committee at this point. But CMS has modified the regulations to align them with the agency's requirements for this rule, in particular, with respect to the creation of internal coverage criteria. So MA plans must establish a UM committee that is led by the plan's medical director and that utilizes UM policies and procedures, nothing new there, kind of a repeat of existing law. An MA plan is prohibited from using any UM policies and procedures, including prior authorization policies after January 1 of 2024, unless that UM committee has reviewed and approved those policies and procedures. So they can't just kind of say, oh, well, we already decided this back in 2012 and that's our position. The UM committee needs to review those policies and essentially give them the current imprimatur, the stamp of approval before moving forward and indeed using them to deny claims. And then at least annually, the utilization management committee has to review the policies and procedures of all UM used by the MA plan. So a much stronger role for utilization management review committees. And again, if they say, well, our internal policy was developed because the Medicare criteria weren't sufficiently clear, you've got all these reasons to challenge them on that. Did you go through the proper public process? Are they publicly available? Show me the policy. What is the evidence base? And even if all that fails, you can say, did the UM committee review this this year and approve this prior to you using it to deny a claim? Next slide. One of the key things that the Academy has been requesting for years now has been to increase the qualifications of reviewers of claims that routinely deny IRF or other PM&R claims really by unqualified reviewers, nurses or others, nothing against nurses, nothing against therapists, nothing against any other type of physician. But when it comes to very specialized rehabilitation care, there is a requirement that the Medicare program has. If you're going to request permission or request admission, I should say, of a patient to an IRF, the Medicare regulations requires that a rehabilitation physician with training and experience in rehab is the one that makes that decision. We've always felt as though that should be the same requirement for CMS contractors when they review and deny claims. So there are some very important new improvements to the reviewers that will be reviewing claims under MA plans. The determination of a claim, a denial in many instances, because an approval is not going to be challenged, but a denial would, must be made by a physician or other appropriate healthcare professional with expertise in the field of medicine or healthcare that is appropriate for the services at issue, including knowledge of Medicare coverage criteria. And there's a citation for you to use. You can't have someone that is not an appropriate healthcare professional with expertise in the field of medicine and healthcare, i.e. rehabilitation, denying these claims. And you can challenge that when these denials come in. What are your credentials? It's a challenging question of a physician. It might irk them. Try to do it as politely as you can. But the fact is, is that this is a requirement to the regs and they have to adhere to it. CMS states in the reg that the physician or other appropriate healthcare professional has specialized training, certification, or clinical expertise in the applicable field of medicine. That's tremendous language for us. And you should cite that routinely. The physician or other healthcare professional is required to have a current and unrestricted license to practice within the scope of his or her profession. So that's on the MA plan. Of course, that's on PM&R physicians as well. If the MA plan reviewer engages in peer-to-peer consultations with the treating physician during adjudication of a determination, this policy would apply. So you've got to have a professional who is current and has an unrestricted license to practice in the scope of his or her profession. Next slide. And I'm wrapping up here. There are a couple of things that are worth noting about this. The reviewers, it's not a slam dunk for PM&R physicians. We had some pretty strong advocacy on this point. First off, the reg makes sure and clarifies that all MA plans have to determine these decisions on a case-by-case basis in terms of what constitutes appropriate expertise and based on the services being requested and relevant aspects of the enrollee's health condition. So the plan is really responsible for making sure that their professionals who are reviewing these claims are appropriate professionals to do so. We did not like that. We would prefer to see that that be changed, but right now that's what's in the reg. Next, the final rule does not require that the reviewing physician or the healthcare professional be of the same specialty or subspecialty as the treating physician or other healthcare provider of the item or service. So that's the Academy's position. We believe that anyone that denies a claim in a health plan, MA or otherwise, ought to be in the same specialty or subspecialty as the treating physician. CMS did not go that far. And finally, CMS did not adopt a policy requiring the reviewer to have some kind of minimum number of years of specialized training in the particular field at issue. They want the MA plans to have some degree of flexibility to hire people and have them review claims, deny appropriate claims without having to hire every single medical specialty to review the claims that come across their desk. Next slide. So as you look at what this rule really means and the impact that this can have, this is a major advance for PM&R practices contending with routine delays and denials prescribed, for prescribed PM&R care for MA beneficiaries. The MA program now is at 50% of the Medicare population, traditional Medicare 50%, MA program 50% and growing. And it's right now open enrollment for Medicare Advantage. For these standards are critical to maintaining access to care in the future. In publishing the final rule, CMS did not wither under the pressure of the MA plans or the insurance lobby. They really strongly objected to this rule, but to their credit, CMS held tight and published this regulation that really I think is an incredible platform on which to build over time. But there are very needy tools that you can use tomorrow, today and certainly after the new year to ensure that your patients and that you get appropriately treated when it comes to MA healthcare. And finally, MA plans will continue to do end runs around this. They will continue to push back and there will be requirements in the future to try to tweak and enhance these regulations. But I must tell you that this is a major step forward on which we can build. Next slide. And that's it for me. Back to you, Chris. All right. Well, thank you all for sitting through this presentation. Peter had a lot of great information to share with y'all and Dr. DeLuca had a wealth of experience that I'm sure was probably familiar for most of you. So if you have any questions after that, we have another nine minutes here before we were planning to wrap this up. So please submit them in the Q&A session or you can put them in the chat function as well. So we have one in the Q&A from Dr. Littell. When the MA has a physician with appropriate expertise, can they use some type of internal training to make them experts? Well, it is in, do you mind if I take this Dr. DeLuca? No, go right ahead. I mean, there are current pathways that kind of dictate what a physician's level of expertise is in a particular area, board certification being the most obvious, but other types of certifications that may in fact be provided or other kinds of courses that can be taken. And that may be acceptable if you've got a physician that has a general background that's applicable to rehabilitation, say neurology or rheumatology or other types of physician subspecialties that may have a good platform on which to build. And in fact, the plan is in charge of determining whether that physician is appropriately certified, appropriately trained in order to deny claims around the kinds of, on the subject matter on which that's at issue. So I do think they will try to do those kinds of things, but it's not easy to create those from whole cloth. They can't just say, oh, well, we had an internal brain injury session, you know, a nice solid half hour webinar we listened to and now we're set. I just, that's not gonna cut it. And that can, you can push back on that for sure. I mean, part of the question of this whole regulation and one of the questions I just saw pop up in the chat as well is, what about the plans that just don't pay attention to this? You make your best argument, then they ignore it and they still deny it. Well, the first thing I'd say is that you've got a much better chance of getting those appeals overturned in your favor. Still gotta go through the appeals process, but you still, you have a much stronger set of tools to use to get those denials overturned in your favor. And next, I think it would probably be to start reporting plan behavior, certainly to AAPMNR so we can start compiling those and bringing those to CMS, Centers for Medicare and Medicaid Services. But also, you know, perhaps having the patient call 1-800-MEDICARE and simply complaining that the MA plan is denying the care, despite the fact that it's clearly in the regulations that they can't do what they're doing. And, you know, we wanna monitor those calls. We wanna make sure that CMS is flooded with calls for MA plans that don't pay attention to that. All right. We have another question from Dr. Zumsteg. Since we know insurance type when we're recommending IRF next site of care, do you think it's worth considering citing regulations in the assessment plan, i.e. great use of autotext to preempt predetermination calls slash denials? I like it. I like it because it will directly, you know, will direct them to exactly what it is that you're talking about and saying. Make sure you cite it correctly. If you're gonna put down a citation in a document like that, make sure to Google that citation and make sure that the site matches what you're trying to say. But I don't see any reason why you wouldn't wanna do that. It may be a little overkill, but in the beginning, it'll certainly get their attention. You wanna be careful about the use of auto kind of dropping in similar or same sentences into these kinds of documents. The health plans view that as a red flag. And sometimes people tend to start relying on that a bit too much. It's gotta be an individual assessment. And sometimes those auto features make it seem as though, and sometimes if you don't look at it closely enough and correct it, you could wind up putting in something that's not actually accurate. So be careful about the use of that. Thanks for the question, Jennifer. All right. We have another question in the Q&A box. Would these rules have any impact on MA plans currently only covering either IRF or SNF, but not both? And that's from Dr. Herman. Again, Dr. DeLuca, I'm happy to answer that. Yes, please do. By all means, by all means. These rules apply to any Medicare Advantage plan, Medicare Advantage plan, any service or item that is prescribed by a physician and any setting. So there are some MA plans that routinely out of, almost out of reflex, do not send a person to an IRF and send them directly to a SNF. They're gonna have to justify that. They're gonna have to now say, and you can hold their feet to the fire. Where is your policy that says that this patient goes to a SNF? The Medicare coverage criteria, the way I read it, completely lends itself to admitting this patient to an IRF. Please show me what evidence you're relying on, what policy you're relying on, internal or otherwise, to demonstrate that this person is really appropriate for a SNF rather than an IRF, or for SNF care rather than home healthcare, or whatever the case may be. So absolutely, this is applicable to those situations and should be used in every situation you think you can, that you think that it can be beneficial. All right, I think we have time for one more question here. So I'm gonna go with Dr. Shaw, who submitted first, and then anything else that ends up in the chat or the Q&A, we will answer, we'll circle back with you afterwards. So let's see here. Lately, I have a couple of patients where MA plans have taken over a week to week and a half to reply for patient appeals. Any suggestions when plans are not timely on appeals process as this leads to increased length of stays? Yeah, it also leads to acute care hospitals getting frustrated, needing to clear their bed so they can admit additional patients, and sending those people to basically whoever will take them. And that's a really unfortunate situation. The MA plans routinely play out the clock. You know better than I, the likelihood of getting an MA patient into an IRF if it's anywhere near a Friday. So I'm well aware of those shenanigans, to use an old fashioned word, that the plans typically employ to just kind of play out the clock. That's an example of something that I'm not so sure these regs firmly address. There's another regulation, the prior authorization regulation that would also apply to MA plans, as well as other plans like Medicaid managed care plans, ACA managed care plans, other managed care plans across the healthcare system that do establish certain timeframes and timelines for making PA decisions. But that's not included in this set of regulations. I'm afraid we're gonna have to continue working on that one. There's one last thing I wanna mention before we break. I know we've got only one minute left. In the preamble language to the regulation, that's non-binding language. When they talked about reviewers, what the qualifications of reviewers would be, in one instance, they actually discussed IRF care. And they said that defining what this meant, that you had a physician that was sufficiently trained and had enough experience in the area in which the care was being requested. They said that PM&R physicians, as well as neurosurgeons, PTs and rehab nurses would be appropriate reviewers for those claims. Just that's non-binding language. The good news is that they referred to PM&R docs, but they also referred to neurosurgeons because we think that's a mistake. We think that they might've meant neurologists. And then they're also now saying rehab nurses and PTs can recommend a denial, which supersedes the medical judgment of a PM&R physician. We're opposing that. We have a letter that's just about to go to CMS from the Academy on that very issue to try to clarify that in future regulations. Chris, back to you. Thank you, Peter. Thank you everyone for joining us tonight. If we did not get to your question, we will be circling back with you. We have it here saved in the chat. And if you think of any questions after the fact, please feel free to reach out to us at the Academy at healthpolicyataapmr.org. And slide. If you are interested in learning more about some of the advocacy work that the Academy is doing, and you're gonna be at annual assembly, we have some great sessions that we would love to see you're all at in person, or virtually if that's how you'll be attending this year. So we have Advocacy 101, getting involved at the local, state and national levels as PM&R physicians on Friday. We have inpatient evaluation and management documentation and coding for 2023 and beyond on Saturday. And also on Saturday, AAPM&R advocacy priorities, advancing PM&R on Capitol Hill and beyond. So if you attend Advocacy 101 or AAPM&R Advocacy Priorities, you'll be able to hear from Peter Thomas or Dr. DeLuca again. So anyway, thank you all for joining us tonight. Thank you for your time and let us know if you have any questions and have a great night. Thank you, everyone. Thank you.

webinar

regulations

CMS

prior authorization

Medicare Advantage plans

medical necessity determinations

coverage criteria

utilization management committees

claims reviewers