It's our first lecture. And today we'll be discussing addressing administrative challenges with IRF admissions. I'm Lauren Shapiro. I'll be one of the speakers this evening, but I'm joined by Dr. Craig DiTomazzo, who is the Clinical Chief Officer from US Physiatry and serves as the Medical Director of PAM Rehabilitation Hospital, and Dr. David Steinberg, who is the Executive Medical Director at the Craig H. Nielsen Rehabilitation Hospital. And they'll both talk a little bit more about the settings they practice in and their roles there when they begin their talks. Next slide, please. So I'll be first. I'm Lauren Shapiro. I have been in inpatient rehab attending in a variety of inpatient rehab facilities or IRFs over the past 16 years or so. I very recently joined Brooks Rehabilitation as the Medical Director of their fantastic Stroke Rehabilitation Program, but I actually just finished my orientation there today. So I've yet to admit any patients. So any examples I provide today will be from a prior institution. And I'll be talking about why appropriateness matters and times it doesn't in some difficult situations you may encounter. So let's start with talking about why does the appropriateness of the admissions that we take really even matter? And I like to think of it as protecting the five P's. The first is patient. So first and foremost, we wanna make sure we're safely able to meet their care needs and that they have good medical and functional outcomes. Then comes our programs. They're judged by a number of metrics that we need to look good on for our programs to thrive. Our professional reputations, we wanna protect those, particularly with regards to our medical decision-making. We may wanna protect physiatrists more globally. We know that other types of physicians can serve as rehabilitation physicians in the IRF setting. And it's important that we demonstrate that we are best suited for this role in terms of determining who's going to do well in this type of setting and in making sure that we achieve the best possible outcomes. And last but not least, payment for this level of care. There have been proposals for site neutral payment for post-acute care settings. So it really behooves us as a field to ensure the patients that we're serving in our facilities and the outcomes we achieve are different from those that we see at less expensive levels of care. Next. The appropriateness of inpatient rehab is really, of our admissions is really under increased scrutiny. And a lot of this comes from the 2018 Office of the Inspector General report. They reported on a random sample of 220 inpatient rehab facility stays and concluded that 175 of them or 80% did not meet criteria for IRF. They concluded that the errors were occurring because many IRFs didn't have adequate internal controls to prevent inappropriate admissions. Next slide, please. And now we've seen the rollout of the Review Choice Demonstration or the RCD. And this has already been rolled out for IRFs in Alabama and more recently in Pennsylvania. Under this RCD program, IRFs must select either 100% pre-claim, basically prior authorization or post-payment review. If they demonstrate compliance with CMS regulations after about a six month review period, IRFs are then given additional choices including what is probably the best of the options available, the spot check pre-payment review. Next. Fortunately, CMS has made the checklist for the RCD to determine appropriateness of admissions publicly available on their website, which you can see at the bottom of the slide. And there are no surprises here. This is all stuff we've seen in CMS documentation in the past. They require that the documentation supports that the patient requires active and ongoing therapeutic interventions from multiple therapy disciplines, at least one of which must be PT or OT, an intensive rehabilitation program. The checklist says generally three hours per day, five days per week, but 15 hours over seven days remains appropriate when necessary. And they require documentation supports the need for medical supervision in the form of at least three face-to-face visits per week. They also require documentation to support that the patient can actively participate and benefit significantly from the rehab program. Next. As we know, sometimes admissions decisions aren't so clear cut, particularly when it comes to medical necessity. We know we have to demonstrate the need for a physician, and there has been a tendency in recent years for IRFs to take more and more medically complex and patients with greater acuity with time. Many IRFs have gone to great lengths and have added services like telemetry that they didn't have years ago. There is, however, some risk with that. We know it's generally a little easier to get prior authorization from other payer sources when we take more, you know, sick, complex patients, but there is some risk with CMS that they may be reviewed as taking patients that are too sick. And I've spent quite a bit of time in recent weeks looking at the websites of contractors who are involved in these IRF kind of reviews, have found that they do comment on this. So Noridian, for example, says, the IRF benefit is not to be used as a substitute to complete the full course of treatment in the referring hospital. A patient who hasn't completed that treatment is expected to remain in the referring hospital with appropriate rehab treatment provided there until the full course has been completed. And Novitas lists on their website a common IRF error of taking beneficiaries who were too sick to participate fully in an intensive rehabilitation program. I found it interesting, the example they gave on their website was that of a patient with pneumonia and recurrent arrhythmia because I think as someone who sees a lot of stroke patients on the inpatient rehab unit, we are very commonly caring for patients with like some aspiration pneumonia and paroxysmal AFib, and they're usually able to benefit greatly from their rehab setting and participate. So in these kinds of scenarios, if you're taking a very sick patient, I think it's a good idea to just spend a little bit more time on the documentation. Next slide, please. We also have some difficulties sometimes in cases where the functional status is either too high or too low. So if someone's activity tolerance is poor or if their arousal is really poor, we may think that there are interventions we can do in IRF to get them better so that they can fully benefit and participate from the program. And then there are also those cases where patients are really high level, particularly with PT and OT, and maybe with really extensive needs for speech therapy and or neuropsychology. I think we as physiatrists kind of know who best is gonna do well in our settings, and we may still take these cases where maybe things aren't so clear cut, but again, it really behooves us in these kinds of cases to spend a lot of time on our documentation, making sure our thought process is really clearly laid out. Fortunately, the RCD checklist does not include the likelihood of a community discharge as one of the criteria, which is fantastic, because we've seen that written other places in the past. But we do often take cases where the disposition may not be entirely clear, particularly if the necessary supervision assistance or home accessibility features are not clearly identified. Next slide. In looking back at my own practice in reviewing potential admissions, I certainly sign off on far more than like 90% of those cases that are presented to me. And then in the majority of the cases I deny, it's less of a no and more of a not yet, in that they're not yet ready for the IRF level of care, but are likely to be in the near future. Often it's a matter of IV medications we can't use in the IRF setting. You're getting IV pushes of hydralazine or libidol to manage their blood pressure, or there's something unstable in their labs or vitals, or maybe their workup isn't really complete and that may drastically change management. These are reasons to maybe delay bringing someone in. Also, occasionally I'm presented a case where they're scheduled for a procedure that's fairly minor, but will eat up much of the next day. And that's a problem because we have to kind of get those therapy evaluations done within those 36 hours. It's also really difficult in cases where there is history of refusals to participate in rehabilitation. We know that adjustment disorder is really common in the patients we serve, and there may be interventions to get them to participate, but it's really hard to justify when the chart says refusal, refusal, refusal. And then in a very small number of cases, there may be a lack of need for intensive multidisciplinary rehabilitation. I find generally admission liaisons are really good at identifying these, and they seldom come to my level, but every once in a while I'll get a PAS and the patient's just clearly too high level. Sometimes there's a real inability to carry over new strategies due to a premorbid condition, like really advanced dementia, or perhaps they have a diagnosis that's really incompatible with or not requiring rehabilitation. You know, like once a year, someone will show me a case of Todd's paralysis, and functionally they may look really bad, but if they rest a little bit in acute care, they're usually fine to go home without intensive rehabilitation. Next. So we're gonna throw a poll out to the audience if everyone can kind of chime in. How often are you asked to admit a case to IRF that clearly does not meet criteria? Often, sometimes, rarely, or never. All right, so I think we'll just end the poll so we can get to everything. But yeah, sometimes, you know, is the overwhelmingly favored answer. And I think that's true for me too. You know, every once in a while, certainly look at, oh, I'm going to share the results here. There we go. You know, we get these cases that just don't meet criteria. I think that's fairly normal, and that's why there are physicians who are reviewing the cases. Next, please. Now, there are some times when it's totally appropriate to take otherwise inappropriate patients. And that's when there are waivers in place from CMS. So when there's a national public health emergency, there's often flexibilities in place. Some of you will remember the COVID-19 public health emergency that ended in May of 2023. And during that, there were flexibilities in place for IRFs regarding the three-hour and 60% rule. When there are more regional disasters, like hurricanes and wildfires, there will often be flexibilities in the 60% rule compliance for affected counties, and CMS will put that on their website. But if you are admitting a patient to IRF solely to respond to an emergency, it's really important that that be very clearly documented in the electronic medical record. So it's as simple as, I am admitting this patient in the aftermath of Hurricane Irma, for example, because of a lack of available acute care beds and the presence of a CMS waiver. Next slide, please. All right. There are other times that are not really waiver situations, but where it's somewhat understandable that you may experience a little bit more pressure to take maybe the not most appropriate patient. It doesn't mean that we do it if they're inappropriate. It just means that it warrants some greater consideration. So certainly, if an acute care hospital to which you are affiliated is really overwhelmed and they have no available beds and they need to get people in from the ER, expect some pressure. Low IRF census, you may have a, oh, our slides are moving forward. There we go. You may have a close colleague who reaches out because they're genuinely worried about a patient and want more eyes on them. You may be confronted with a case of a so-called VIP or a case in which risk management is involved for some reason. And in these cases, it's understandable why they may want to bring the patient to the IRF setting. And it probably is a good idea to spend a little bit more time reviewing those cases and really think through, can I make a reasonable case to justify IRF for this patient? Often you can. There are a lot of like cases that are not black or white. Every once in a while, there's one you're going to have to say no to. And that can be difficult. I always give the example of a case I was presented with, of a woman with a humerus fracture. She had been visiting her friend in the acute care hospital to which our rehab facility was attached and had a slip and fall. She had no chronic medical condition. She didn't have a history of falls or neuropathy or arthritis. Her pain was controlled with Tylenol. And she was basically at a modified independent or independent level with all level, all of her functional domains, except for upper body dressing with traditional Medicare. So this is a case where I really could not say that inpatient rehab was medically necessary according to CMS criteria and had to deny the case. Next slide, please. There are other times you may experience some pressure. Certainly if you have an inexperienced admission liaison or administrator, but that's a situation you can fix. If they're amenable to education, just offer to teach them. Often they're not onboarded with a great amount of education. So just sit them down. And I've certainly given many, many in-services to admission liaisons over the years and have found it really benefits the program. Unfortunately, we know that some people will encounter weak and or unethical leaders. And in just a few minutes, I'm going to turn things over to the other panelists who are going to share some really great recommendations on how to partner with administration to really create harmony and make the best optimal rehab admission situation. I think their advice is going to be really, really valuable, but it will not necessarily be beneficial in the case of a very unethical leader. And unfortunately, we have heard from some members over time who are encountering these, though it is rare. It's important to think about what pressures they themselves may be under. They may be dealing with unrealistic expectations that are imposed upon them, but such leaders can sometimes really endanger the programs in the long-term. And sometimes, again, extraordinarily rarely, but we have heard from physiatrists who have been kind of encouraged to document things that they knew were incorrect that could potentially jeopardize their long-term career, which, you know, we don't like to hear about. Next slide. So where is the, oh, sorry, poll question number two. Have you ever experienced some form of pushback for not signing off on an inappropriate admission? If everyone could just kind of respond. So, so this is really helpful information, actually, because we weren't quite sure how prevalent this was. But the vast majority of people are saying yes. All right, so I'm going to move on to the next slide. Okay. So, in the remaining slides I have, I just wanted to talk a little bit about where's that line when pushback becomes inappropriate, because it can be sometimes difficult to discern. Some degree of questioning, I think, is appropriate and healthy dialogue. So just as I should be professional if I'm questioning someone else's decision, they should grant me the same respect. Questions like, can you walk me through how you came to that decision? Is there additional information I can provide that might change your mind? Is there anything that might change that would make this patient appropriate for admission? I think all of those questions are 100% appropriate and can really foster a really good dialogue. There have been times when people have come to me in this way and we review the case together and we realize, like, information flowed to the PAS that was really outdated. So I was making decisions based on really old data, and we were actually able to take the patient. So, so these conversations presented this way are great. Next slide, please. But we know that some people are experiencing other things. So what are some inappropriate responses? Condescension is not really appropriate. I will say when I denied the case of the humerus fracture, someone knocked on my door and said, who do you think you are? That's not cool. Deception is never appropriate. I once had a situation where a physician advisor of a neighboring hospital was just making up information to get me to take a septic patient, like an acutely septic patient, lying to me about vital signs. And fortunately, I could tell something was up and I looked at the chart and was able to identify it. Deception is not cool, especially because it can reach, harm can reach the patient. So in any case where someone is intentionally trying to mislead you, I think an incident report or complaint is very much warranted. And of course, harassment and retaliatory behavior is never okay. Now, some physicians may be at higher risk than others. Next slide, please. For experiencing some mistreatment when they don't agree with administration. I don't have rehab specific data, but there is research showing that physicians who are women, those who are early career or young, those from minority racial and ethnic backgrounds and those who are international medical graduates are at higher risk for mistreatment by hospital administration. Next slide. So if it happens to you, and I very much hope it doesn't, it's really normal to be upset. It's important to think through, is this an isolated event or a recurrent problem? Because anyone could have a bad day and come off as a little condescending. If it's a one-time thing, I think you give someone some grace. But if it's going on a lot, I think it's important to vent to someone you trust, but quietly if possible. Because when there's wrongdoing going on, they're going to look to blame your response rather than the wrongdoing that caused your response. So don't give them that opportunity. If you are reporting wrongdoing, there's some safety in numbers. So it's helpful if you work with other physicians or other people who are noticing problems to talk quietly amongst yourselves about it and consider reporting together. If there's potential legal issues involved, things like massive fraud or noncompliance, I would recommend discussing with an attorney just so that you can protect yourself as retaliation in those scenarios can occur. And if you're having recurrent issues after you've tried to fix a problem and report a problem, for your own safety and for the longevity of your career, I really would recommend planning a safe exit from the organization. There are a lot of wonderful rehabs out there who would love to have a physiatrist working alongside with them and who will value your expertise and treat you professionally. So with that, I'm just going to share my contact information. If I can help you in any way, please feel free to reach out. Thank you. All right, thank you so much, Lauren. That was a really excellent presentation. My name's Craig D. Tomasso, and I'll be talking, taking you through the next section. And that's understanding and managing the admission conflicts. Just a little bit about me. I am a physiatrist. My area of expertise is disorders of consciousness after severe traumatic rehab. I've been in private practice since 2019. And the thing I'd like to highlight is that I've been the chief clinical officer for U.S. physiatry for about three, four years now. And so I've really worked with young physicians and early career physicians across the country, and many of which are dealing with these administration conflicts. So I'll try and give you not just my experience, but what I've seen across the country. My mother recently visited from Pittsburgh, Pennsylvania, where she lives, and she is a English professor, and we got on a little Shakespeare rant. So I will impose a little bit of Shakespeare on you throughout this. And the first thing I'd like to start with is that a few words from the Bard about fate, because really one thing I always try and impress upon young physicians is there's a game being played way over our head, and there are forces moving that we do not fully understand as physiatrists nor have access to. And some of those forces will have strong decisions in these things, and we need to understand that that is part of the milieu. So when I'm talking to physicians about conflicts, they usually come in either one of two flavors. Either there are patients that you want to admit, but administration doesn't want you to, or there's patients that administration wants you to admit, but you don't want to admit. And that's by far the more common and what Dr. Shapiro spent most of her time talking about. There's lots of different reasons that we have differences of views, and I listed just a few examples, but this is typically where we see these conflicts arise. And the conflict should not be trivialized, right? I think it's easy to kind of sweep things under the rug sometimes, but eventually it will lead to moral distress and moral injury. Again, uneasy lies the head that wears the crown, right? You have to deal with these because you are probably the physician or maybe the medical director dealing with it. So the moral distress, you know, causes real psychological issues and the burnout being very high in medicine, especially physiatry, that's not something to laugh at. And that moral distress can turn into moral injury when it's there psychologically causing harm for long periods of time. And Dr. Jen Substeg of University of Washington has presented this much better than I ever could and if you ever need to talk to someone more about it, she really is an expert in the field. Oh, went too far. So the way I'm going to break this down to you tonight in a time that I have less is that one, understand a little bit about those forces at play. We don't want to have time to go into all of them tonight, but having some idea I think is important. Number two, these admissions seem to be viewed from multiple perspectives. You've probably gotten very comfortable in one or two of those perspectives, but there's a whole lot more. And then finally, I'm going to implore you when possible to create a no-lose situation so that you can minimize those conflicts where they may arise. Some rise by sin and some by virtue fall. So think about yourself the physiatrist and then compare that to the hospital administrator across from you. You're primarily concerned in the patient care that you provide and the rehabilitation that you're able to engineer as a clinician. But that hospital administrator, they're essentially a business manager, right? Their job is to grow a business and to be financially successful. And so they're never going to have the same perspectives as you do. They're never going to feel the same pressures that you do. And this is where a lot of that conflict comes from. You have to meet those expectations. You have to provide for those patients in a way that allows the business to grow or they'll simply turn off the lights, right? Just to give an idea of who's running this show, at least one of the perspectives, a lot of our rehabilitation providers work for HCA. HCA made $46 billion in 2023. Select Medical is another popular rehab provider, 6.6 billion. Encompass 4.8 billion. And UPMC, although they technically don't post a profit because they are not for profit, brought in more than $27 billion. Now, I mean, all of this pales to the overlords at United Healthcare, right? And their little fingers dictating it. But these are some of the powers, to give you an idea of the size and the scope of who's really calling the shots and what we're stuck under and between and where the pressure is coming from. Because these healthcare corporations, right? They're really businesses. We think of hospitals and taking care of patients as some kind of calling, but they don't, right? To them, it's just numbers on a spreadsheet. And so they're gonna make the decisions that make the most for their business. And anybody who gets in the way of those businesses making money is just a cog in the machine. So whether that's you, whether that's the administrator, whoever it is, they need to make sure that they continue to make, if it was 6 billion last year, 7 billion next year, right? And so they're gonna apply the pressure as needed to make sure that those things occur. But you have to know yourself, right? We can lament the powers that be all day, but to thine own self be true. So you may wear the hat as a medical director. Upon accepting that responsibility, you've got to understand that you've got your foot in two worlds already. While you may not be totally in bed with the selects or the HCA's or whoever else you're working with, you are gonna have some responsibilities to them. And so I made a slide here with some credit to Dr. Charlotte Smith about just thinking about how those loyalties, those responsibilities, those things are different as a medical director than it's just a physiatrist, right? Not to say just a physiatrist, but when you're not wearing that hat. There are different challenges, but there are also different benefits. The point of this was not to scare anyone away from thinking about being a medical director, but just understand that there are pros and cons to all of that. And so you'll need to take some time and really figure out how that affects you and how you're gonna deal with these conflicts because managing those conflicts will very much determine whether or not you're going to be successful in that role. So when we talk more about that perspectives, and this is what I want to be the bread and butter of what we talk about tonight, remember that maybe there's nothing so much good or bad, but thinking makes it so. And so take a second and just think about some cases from some different perspectives. Your rehabilitation center where you work, again, from a business perspective, has a customer base, right? There are particular patients that you're expected to serve. Those patients are reflected by who's referring those patients to you, right? You could have an acute hospital attached to you, in which case that referral source is very direct, or you could be a standalone rehab, in which case you're probably catering to a lot of different referral sources. Insurance trends certainly dictate to some degree who your customer base is. I don't think that that's ethically appropriate. I think the physician should make the call, of course, but unfortunately the insurance companies will not take their noses out of our business. And then your rehabilitation center will of course have marketing efforts. They will attract patients who they think are most appropriate. So if you really look at CMS, if you read the original criteria, and I promise you I do this every so often just to keep myself grounded in what it is we're supposed to do, there are five real topics that come up over and over again. And those have already been mentioned to some degree by Dr. Shapiro, but these are them, right? They're not particularly specific. They're not particularly inclusive or exclusive any group. They're very generalized topics which have to be addressed. But if you fail to address them, then clearly that patient is not appropriate. But as physicians, I don't think we really think about that a lot, right? When physiatrists are thinking about who should I admit to my rehab, we're thinking more about the diagnosis and the prognosis, the goals and the support at home, because that's what we do. Again, we are clinicians. We're not business people and we're certainly not administrative people by training. Our goal is to have the best care for those patients possible. And that's what's in our mind. So, you know, even just thinking about CMS, we all went through residency, we all had the education, but those CMS criteria are pretty vague as we just saw. It's this kind of thought process about who can we help and how can we get them to their goals, I think, that dominates our perspective. And then lastly, I am not allowed to admit where I got this information from, but these are the top, I guess, what is that? Seven reasons why a particular company that has lots of inpatient rehab centers found as denials from our friends at the insurance companies who are always trying to help us out so much. And these are the types of things that they're citing, right? There's lack of medical complexity or there's an absent need for high intensity. Again, these are very vague things. They don't mean anything in the real world. And they're not the kind of things we're thinking about when we're trying to take care of our patients, but these are the perspectives or perhaps excuses that some of those insurance companies are using to deny the patients. And so again, there's lots of perspectives here. But getting back to the conflict at hand, you have an administrator in front of you who wants to admit a patient who you don't feel is appropriate. I'm willing to bet that there's a way to talk to them on their level to really kind of manage that. And let's break that down. I'd say three main categories, the payer, the referral source, and the rehab metrics. So number one, administrators are always worried about profits. They are, as I mentioned, running a business, right? That's what they do. And so if your administrator's primarily cost and profit driven, talk to them a little bit about how this patient may cost them more than they expect. Are they gonna be there too many days so that the cost per patient day is gonna be diluted? Are they gonna be there too short so they may not capitalize on the full payment? Are there medication costs involved that may make this patient undesirable or specialty equipment? Those are things that an administrator understands that may help to help your discussion of who is or isn't appropriate. Understanding that latent length of stay is a high level topic. And for those of you who've been medical directors for a while, you know what I'm talking about. Is the patient paid by their payer on a per diem or a CMG? And can you work within that per diem or CMG to make this patient stay successful? That's something that would be a reasonable talking point for most administrators and one that they may or may not help to sway them, may or may not have to sway them your way. Or what are the discharge options for this patient, right? If the patient is an excellent rehab patient but has no chance of being discharged anywhere, then you're going to certainly drag out the length of stay. You're gonna make that length of stay unmanageable and that will certainly affect the bottom line and they'll understand that. Another reason that's often brought up is some kind of relationship with a referral source, right? And so, I think as Dr. Shapiro already expertly mentioned, there are certain needs that acute care facilities will have at times that will emplace certain pressures upon a rehabilitation center. But that also, there has to be some symbiosis within that relationship, right? The acute care hospital can't be expected to dump all of their patients that they don't need on a rehab center. And the rehab center shouldn't be able to take that. Any relationship, whether it's your marriage, your relationship with your children, there's some ebbs and flows, but there has to be mutual respect for it to work. And I think a lot of administrators understand that because if they're constantly being taken advantage of, they're not gonna be able to make their finances either. And that's gonna have severe downstream effects on their profitability and their margins. Hospital metrics, I'd say this is a weaker argument. The administrators who we're talking about who we have lots of conflicts with are probably less concerned. But if that CMI gets too high or too low, it does affect the reimbursement. It also is a good predictor of acute care transfers, which affects profit in the end. And it can really undermine staff morale, which is very important for rehabilitation centers right now. Also, if the patient is too high or low level, you're not gonna get much movement on those GG scores. And that's gonna decrease the overall ranking of the rehabilitation center, which could eventually have long downstream effects on profitability. Also, again, if the patient's not able to be handled by your therapy staff, they could leave or be sent back to acute. They're unable to improve. They may have problems with length of stay again. So these are different ways that maybe you can frame the patient or give the administrator some different perspective to help find some common ground. All right, time is running short. So we're gonna move on to what I would encourage everyone here to think about, and that's creating a no-lose scenario. Of course, the only one who loses, again, is the insurance company because they only want to make profit. But we'll talk a little bit about what we can do here, at least internally. So PM&R physicians, we know that we're very good at program development. We can collaborate with administration to make new programs. And I think that this can really help to appease or to mitigate a lot of these conflicts if done right, because it allows a different perspective, again, to try and find the patients who maybe would slip through the cracks otherwise. My hope is that by implementing these programs, you would be able to find some way to decrease your own moral distress. So what am I talking about? I'm talking about building a team that within it, you'd have all the components of the multidisciplinary team, the intensive therapy, the ability to remove, improve, excuse me, medical management and interdisciplinary approach. This has to be really customized to your rehabilitation center, right? If it's done properly, it will allow you to accept more patients. It will be born of a local environment and create a natural flow for those referral sources. It will increase the capabilities and the function of your rehab hospital. And ultimately will drive marketing and recruitment of more appropriate patients to help steer the hospital in the right direction. Sorry, hard to talk about in the ether. Let's give some real world examples, right? Using our strength appropriately, not like a giant. All right, so vestibular program. This is a really good program, which I've had some experience with in the past. I don't currently have at my rehab at the moment, but a vestibular program I think is really important because really a wide range of patients are gonna have vestibular problems, right? You can bring them in and there is the sitting balance scale, the Berg balance scale, the Tenetti scale. So whether the patient is a high level patient or a low level patient, you can document a standardized scale, which has real world data and translates to functional independence in the community, or if not at home. And you can show improvement in these patients that the GG score may not be sensitive enough to show. Certainly once you build these vestibular programs, you're automatically documenting or building into the program, I should say, where the OTs and the PETs, or maybe the speech therapist, the respiratory therapist, whoever else is on your team, are working with the patients in a variety of settings. And so you'll have to justify that intensive therapy requirement. This is easy to market. Vestibular therapy programs are easy for people in the community to understand. So you can teach your marketers and clinical liaisons, physician advisors, whatever you call them, to go out and start to market it. And it will start to grow itself. Your therapists need further training and balance training. You can get equipment that helps with balance, involve your neurology colleagues, whoever else, family practice positions, and this begins to grow and grow. Similarly, one program that I've had success with at multiple levels, inpatient rehab, LTAC, SNF, you name it, our pulmonary programs. This has been a huge need since the COVID infections, especially here in Southeast Texas, where everybody drinks, everybody smokes, everybody works in a chemical plant, and hardly anybody got vaccinated. So nobody can breathe. We use our pulmonary programs to maximize the team members. RT has a huge role here. Pulmonary medicine has a huge role here. PTs and OTs working on the muscles of inspiration and things like that. We can treat a variety of pulmonary conditions, COPD, sarcoidosis, post-COVID. We have a great pulmonologist who's engaged. So it's really been a program that's been fun to grow and get bigger and bigger. It really does improve the health of the patient, right? We have lots of data now that this improves the morbidity and mortality of the patients. Will the insurers care about that? Probably not, but it's true. It's in the literature. And we'll decrease the supplemental oxygen use, which is a huge benefit for the patient. We build networks easily through this. Oftentimes the pulmonologist and family practitioners in the community have limited resources to really address these patients. And so you're giving them something really strong to work with here, which is very appreciated by the community in my experience. The other caveat, of course, is that you can extend those rehab hours from three hours a day, five days a week, to 15 hours over seven days for patients with frequent oxygen desaturation. So you just have to document it. So again, you think about these things that a particular rehab company gave me. It's their most common reasons for denials. And with my pulmonary and my vestibular program, I think I can answer each and every one of them. Would it be accepted? I don't know, but I would feel comfortable and morally appropriate answering them for these patients. So that's the end of my PowerPoint. I know we're running a little bit late. So I hope that you've seen how the forces at play are involved, some of the different perspectives on how to view these admissions, how to create some programs that may help you with the future, but will it really help your moral distress? I don't know, but I would say it certainly has helped mine. So I'll give you just a little bit of contact info, but I'm trying to move faster when Dr. Steinberg have lots of time because his slides are very powerful. All right, thanks everybody. Thank you. Well, thank you very much. I hope you can all hear me and thank you so much for joining us this evening from all over the country. It's pretty humbling to see how many of you are interested in this topic and a big shout out, thanks to Chris Stewart at the Academy and for my co-presenters, Dr. Shapiro and Dee Tomaso. Really appreciate their true masterminds and I'm humbled to join them. So I'm David Steinberg. I'm the chair at the University of Utah. I've been in academics for a little bit of time now. And my main byline, the reason I'm presenting here is I also serve as the executive medical director for the Craig H. Nielsen Rehabilitation Hospital. So let's see if I can advance my slides here. I have no conflicts to report. My experience is I lived most of my professional life in private practice, in a group practice in Ann Arbor, Michigan. One of seven physiatrists when I first came out of residency in the long past of 1995, when I first started. And I was in that practice for six years before I was thrust into the role as medical director for inpatient medical director. Happened to be in a private practice where four of us shared the duties on the inpatient unit. And I would say that even though the talk today is about navigating relationships with your administrators, one of the most tricky and challenging things over my career has been navigating the relationship with my partners. Because the conflict is not only with the administrators. Sometimes in the medical director role, you have to have some difficult conversation with your peers. And if those peers are more senior to you and have been around longer, perhaps the founding partner in a group, and they're exerting a lot of pressure because they want one of their VIP patients admitted, or you have to manage some other behaviors. It can be very challenging. The role of the medical director is not only navigating the relationship between the physician, representing for your patient and the administrators, but also with your colleagues and peers. So it can be very tricky. So after 23 years in private practice, I came to the dark side here in academics, serving as a department chair and now leading a large freestanding rehab hospital, the Craig H. Nielsen Rehab Hospital. I've got lots of background experience across the continuum of care, much like my colleagues, but my focus has been on inpatient rehab and helping with physician wellness and program development. So why is all this important? I think you guys all get this, but your job is to balance multiple factors. When you navigate a relationship, you're balancing all these stakeholders. And your job as the medical director is to make the best judgment for what's best for the patient and the institution. And as my colleagues represented, is also to have a long thriving career. So if you're burning bridges left and right because you get angry quickly and you respond to every affront, every denial as a personal attack on yourself, and you become defensive and you're not gonna last long as a medical director, you've got to maintain your cool. You must be collaborative with administration. Ultimately, that's gonna help you improve the outcomes, streamline operations as necessary for success in your job. The challenge, of course, is to maintain this balance as you're advocating for financial success and clinical outcomes. You have to learn to navigate these challenging relationships. And this is critical. I think the one thing I'd recommend to you as you think about your success going forward is to build strong relationships when you're in calm conditions. Because when you're in the midst of a heated battle or a disagreement, it's very easy to forget that you have to trust these and work with these people long-term. So when you fill the bank by making deposits in your relationship and develop a personal relationship over time, then you can call on those when difficult problems present to themselves. You must become a skilled negotiator to recognize what the needs are for the other partner in this. It's not an us versus them. It's really when you're looking for a win-win. And every negotiation is much stronger if you take time to listen to the other partner to understand what's important to them. Dr. DeTomaso described this, which is really putting yourself in their shoes. Talk their language, understand what's important to them so that you can find the win-win. It's critically important to hone those skills over time. A cooperative approach is always better. You catch more flies with honey than with vinegar. So really important to become skilled at that. This is how I spend most of my life, I think. This is one of my favorite slides. I've been doing pain management for a long time. This represents many of my patients who are dealing with chronic pain. But this often is how we feel, like our experiences as a medical director, that we're often overwhelmed and we're facing very big challenges. So I'm gonna first tell you how to do it right. The key steps are to have structured, respectful, evidence-based conversations, just like my partners were talking about. Understand the criteria, familiarize yourself with those specific criteria, speak the language, and clarify the decision when you're facing a pre-review or a denial. Ask them for specific reasons behind the denial. Understand whether it's due to clinical, financial, or policy reasons. And I'll just say that sometimes, especially with our Medicare Advantage programs, sometimes I think the outside reviewers are just told they need to deny a certain number of cases in order to keep their job. They have to deny 25% of the cases, even if they know they meet criteria. And we've recently had conversations with these reviewers who they nod, they listen to you, and they say, I'm still denying it, you're free to appeal. At the end of the day, you can't take it personally. They're making an unethical decision because they're just trying to appease their bosses. Gather good supporting evidence. Support medical necessity through your documentation. Get lots of recommendations from others in the medical record. Understand the patient history better than anyone else does because you need to go to bat for your patients. Craft your argument. Be careful before you understand where you're gonna have your leverage. Be concise and focused. Refer to data and guidelines. Highlight the risk factors that could come up if you accept the wrong patient or if you deny the wrong patient. And then always be prepared for appeal if you need to. There's lots of appeals are successful. Every time I've been in front of an administrative law judge, I've been able to be persuasive by explaining my perspective with lots of years of experience and doing what's best for the patient. Administrative law judges have overturned every denial that I've gotten in front of them with, if you need to get a patient advocate involved. And always, always, always maintain professionalism. When you combine a well-reasoned argument with supported evidence, you increase the likelihood of having the decision overturned and securing a good alternative. But that's not always the case, right? So we sometimes need, you know, we find ourselves pulling our hair out, and I'm not gonna refer to any of my colleagues on the call about, but Dr. DiTomaso indicated that he's had too many of these episodes. So what do you do when you have disagreements? These are the most common ones that I've run into, borderline cases, where you, you know, you're not really sure if they meet criteria. The administrative concerns that we've talked about. High acute care census, when they're trying to unload patients to you from the acute care hospital because they need to free up beds in the ICU. Or, you know, the administrators are feeling pressure because the census is low and they need to meet their margin goals and otherwise, or a close colleague refers a patient that they're worried about. Waiver situations, either as formal waiver situations or some of these borderline cases where you're requested to kind of make a judgment call about a patient that's sitting on the fence. Patients without full approval or maybe the VIP patient. Sometimes it's the VIP patient because they're a friend of the CEO. Sometimes it's a VIP patient because they're feeling entitled. It's a patient who's used to getting their way, or they feel like if they argue, scream loud enough that they're gonna get their way, and they're gonna try to appeal themselves to Medicare. And lots of administrators have legal and financial concerns. Risk management situations can also be big challenges. So here are a couple of examples. You know, the isolated humorous fracture, like Dr. Shapiro talked about the VIP patient. Complicated patients, either psychosocially or medical behavioral challenges. Deconditioning patients that are non-compliant or unfunded patients. Always maintain collaboration, just like I talked about. Have a mindset of collaboration rather than confrontation. Seek to understand. Have empathy and understanding about the administrator's situation that they're in. Always use that evidence-based justification and look to build the relationship over time. It's really critical. To navigate these cases, you would need to see yourself as an advocate for your institution, but also for the patient. And then look for compromise and solutions if you can. Sometimes it's because if I can explain to a medical director that I, you know, I also understand that the patient's borderline and I'm only looking for five days or seven days. In the long run, I know I'm gonna be on the call with that medical director many times in the future. Understand when and how to request a waiver. Understand when you need to look at the patient's benefit and manage the risk of the organization all the time. And then sometimes you could even walk through some of these scenarios with your administrator when it's a hypothetical. So you can set the table saying like, look, I know we're gonna have some disagreements in the future. Let's think about how we can, how we're gonna navigate these problems down the road. Let's frame the discussion in terms of what's best for the patient as well as what's best for the facility. Understand why the administrators are risk-averse. Liability and financial concerns. Strategies for managing that risk are also critically important. And then ultimately, if you need to, just like Dr. Shapiro talked about, you may need to speak to the legal team or the risk management team about making a judgment call when there's facilities at risk because there was a iatrogenic problem that occurred and you might need to take that patient to the rehab unit to solve those issues. Key takeaways, be proactive, frame your discussion, always be prepared with data solutions and compromise. Build that long-term relationship and always, always, always maintain your role as a patient advocate. Ultimately, that's what your medical degree is valuable. The administrators cannot put themselves in that position. And at the end of the day, the physicians should be making these kinds of judgment calls, not the administrators. And as Dr. Shapiro said, you gotta protect the five Ps, patients, programs, your professional reputation, our broad community of physiatrists, and then payment for this level of care. This is a picture of Dr. DeTomaso after one of his recent negotiations. So I'm not gonna tell you which one he is in this slide. But understanding how to manage conflict so you don't feel like you're in a battle where there's a winner and a loser. Build that strong relationship, know yourself, understand what triggers you, try to maintain your calm always, understand priorities, yours and theirs, recognize that sometimes there's not a win-win, it's a polarity, it's gonna be a win-lose, and you wanna understand those situations and how you can balance those stressors. If there's one thing I'd recommend to you, become very skilled at difficult conversations, practice it, go out and find courses like Crucial Conversations or other communication programs, become very good at negotiating if you can. Prepare yourself mentally, when you know you're going into a crucial conversation, assess the situation, take time to understand it, and maintain your emotional regulation. Calm your emotions before the conversation. Do some deep breathing, maybe a little yoga and meditation, it can help a lot. Choose the right time and place so you don't have to call someone right back if you know it's gonna be a conflict. Make sure you're in the right frame of mind, you're not rushed, you can have the time and have an open diplomatic conversation. Always maintain your cool. There's this concept of observing as if you're watching from a balcony. When you feel yourself becoming stressed, the hair is rising in the back of your neck, you wanna be able to calm yourself down and say, hey, maybe there's a different way to approach this, especially if you just ask questions. Seek understanding before judgment, it's really, really important. Be a good active listener, give your full attention, clarify, reflect back, use the language like Dr. Shapiro talked about, say to them, so if I understand correctly, you feel that this patient doesn't qualify because of X, Y, and Z, ask open-ended questions. Can you explain what happened from your point of view? Explain your situation so that they know that you're listening to them and you're understanding. Avoid blaming language, this idea of I statements can really trigger people. Say things like, I feel frustrated when I'm interrupted. Don't always say, you interrupt me, don't be pointing fingers at people. Focus on specific behaviors and not personal attacks. Always be professional, can you walk me through how you came to that decision? Is there anything that might change your mind? Stay professional, keep your emotions out of it, keep it focused on the facts, maintain respect, even if you disagree and avoid public confrontations at all costs because you need to maintain relationships with these people over time. Find a private place to have difficult conversations with someone else, I think that's critically important. Stay open and receptive and maintain eye contact. Acknowledge when you've made a mistake, at another time you might say, you know, I appreciate your help with that difficult case, you know, it turned out that, you know, you were right, I was wrong, you know, that builds a lot of respect over time if you're willing to accept responsibility and you don't come across like a know-it-all because no one's perfect all the time. Demonstrate accountability to your partners. Check in afterwards, you know, because we're friends with these people over time. Make sure that you're good with your relationship, even if you have a conflict, you know, tomorrow's another day. Monitor the situation and when you have resolutions, check back in with yourself, with your partner. At the same time, sometimes it doesn't go well, as Dr. Shapiro said, sometimes you're dealing with an administrator who's unethical or has difficult challenges with their personality. If the issue escalates, understand when you need to go to HR, when you need to find a trusted colleague to talk about and document it as carefully as you can. In conclusion, conflict is gonna happen, it comes with the job as a medical director. Understand that this is just part of the job, you're not alone. How you manage conflict, though, makes all the difference. Approach these difficult conversations with professionalism, empathy, and solution-oriented mindset. If you can become an effective conflict resolver, you'll be an excellent medical director over time. In the long run, healthy conflict actually is a healthy thing for an organization. It builds stronger, more cooperative relationships if you're able to get your ideas out in front of everyone else. So here's some of my contact information. I welcome, you know, if you'd like more information or if you're in Salt Lake City and you wanna come by and see the cool things we're doing here, I'm glad to meet up with any of you at any time. So thank you for your time, and maybe we have a couple of minutes for questions. If anyone would like to raise their hand and come on camera, that would be great, but we'll also check for any questions in the chat as well. I see some thank yous in the chat, which is great, and I appreciate all that. I have a question for you, Dr. Shapiro. Have you run into situations where you felt like, okay, this is like the end of my rope. I am like, I'm not sure I can resolve this over, you know, and yeah. Absolutely. Yeah. I feel like I'm very patient when I don't have clinic and it's not a weekend or a week when I'm on like day 12 of consecutive work, I think. But yeah, sometimes I've had to engage a colleague and say, hey, I'm going to run this case by you. Am I out of line in any way? Or what do you think? And I found that other colleagues have done that as well. When they faced a lot of resistance, sometimes it's helpful to talk through a case. And then there were times when two or three doctors went together to administration to say, hey, collectively we all have concerns about this case because sometimes they need to hear that as well, I feel like. But certainly there are times when I have to like hide in my office and I have a dammit doll in my office and I used to like hit it against my desk because they were driving me crazy. Any other questions from the audience? I do see a question in the chat from Stacey. The question is, does the panel have recommendations regarding advocating for the patient in the LOS issue? For example, anemia with hemoglobin less than seven and recommending that we wait until the hemoglobin is stable before admitting to rehab. So about the length of stay, I think. So I think like Dr. Shapiro, you talked about that issue about how you look at a case and what the triggers are for you to hold if you feel that a patient isn't ready to participate. But some of this is about completing the course of the acute care. So anemia alone is not necessarily a reason to deny a patient coming to the rehab unit. I don't have a hard cutoff for hemoglobin. I do for platelets only because most of the therapists I've worked with have cutoffs for therapy. But if the trend has been like a very significant drop in hemoglobin, I would want to see that stable because the last thing you want to do is bring someone to rehab and transfer them out the next morning for a colonoscopy. So I don't have a hard cutoff for hemoglobin. I do for platelets only because most of the you want to do is bring someone to rehab and transfer them out the next morning for a colonoscopy or AGD. But if it's stable and it's hovering around seven and they're not symptomatic, I would usually bring them so long as they've been tolerating therapy and in acute care. One thing that I found is that I was having a lot of arguments or disagreements with my director of therapies. She was the rehabilitation manager and she was getting pushback from the rehab therapists that they felt that we were taking patients that were medically unstable. And we had a lot of kind of arguments about when someone was like what the vital signs were, the appropriate range. So without having a real difficult case right in front of us, we actually put together a task force so that we can come to agreement and consensus about what would define medical stability, what parameters were important like platelet count or hemoglobin or vital sign problems so that we could make consistent decisions because our consult team was we had a different doctor each day of the week. We wanted to make sure that the doctors were using consistent criteria for when a patient was stable to come to the rehab unit. So we worked with our therapy colleagues to make sure that we looked at evidence to support what those factors were like for heart rate parameters as a good example. If someone was tachycardic at 150 or 160, maybe they're not coming to the rehab unit. But if they were 110, probably they could come. But we made those decisions collaboratively with our therapy colleagues. So someone had asked about our platelet cutoff. I could talk about my prior institution. It was usually 20,000, but if there was any blood on the brain or there were other bleeding events, we had a higher standard that was outlined usually by neurosurgery or GI. And then as far as medical stability, certainly I think that Dr. Steinberg's approach is great, but not all of us work in an academic setting where you really have the resources to do that. There was a study by the Johns Hopkins ICU mobility team a few years ago, where they created a stoplight scenario, a red light, a yellow light, green light for a host of medical conditions. And that can really serve as at least a starting place to have the conversations. They've kind of done a lot of the legwork for you about who can be mobilized and who can't. I understand that the ICU in Johns Hopkins is probably a much different place than your rehabilitation, but at least it's a place where if you're having similar issues, you can use that as a guide to start the discussion with your therapy or nursing team. And I see Paul has asked a question there. I don't know if you can all see it. How about a patient coming from home with a specialty procedure coming up in the next week or two? I don't know if any of you want to take that or I can jump in. I think it depends on the specialty procedure because the timing of the rehabilitation may be better if it's a procedure that might change precautions or like weight bearing status. So it's very hard to say. It also would depend on how long I think their length of stay will be. So if they only need about five days in rehab and they'll be home for that specialty procedure, it may warrant a short inpatient rehab stay. But I'll be honest, sometimes you may look at it also in terms of how your facility is doing in terms of returns to acute care. So if your numbers are not looking great because you had a bad run of really complicated sick patients you transferred back, you may not want to take as much risk. And I think that's often a consideration. Now the questions are all rolling in. We use a stoplight for referrals. I'm not sure. I'm not sure what that is. Well, I think it's like what Dr. DiTomaso was talking about is that you can all agree about what are the green light scenarios where this patient is clearly stable, you know, no fever, labs are stable, they're participating in therapy, check, check, check, check, check, green light, everybody's on the same page. And it's always clear with the red light scenarios. Patient who's a febrile, you know, hypotensive, you know, they're not able to get out of bed or participate in therapies, you know, people, they don't have the tolerance or the behavioral issues, what have you. But there's a lot of gray zone or the yellow light where it's not really clear, but it's enough to pause the admission so that you can get together with the administrator and kind of review the case to find out, like, dig, dig into the case, get more detail. I think that's what they're talking about. Or maybe delay the admission I think that's what they're talking about. Or maybe delay a day. Like you're saying, Lauren, sometimes the patient may not be ready today because you want them to, you know, probably be better if you waited a day or two and then bring them another time. And I'd like to jump on Dr. Willis's comment about taking patients from the ER. This is something that seems to get a lot of physiatrists very excited, and I certainly understand why, but I have to say, at least for the for-profit centers around the country, is more or less becoming the standard of care. Good or bad, I don't know, but I see an awful lot of it. I would say personally, I usually don't have any problems taking these patients. I like doing a little bit of medical workup, and I almost always find something undiagnosed in them, a peripheral neuropathy that's getting worse, history of a small stroke that's contributing to instability, something like that. And I really like doing that kind of work, and it justifies the admission to me in my heart, which is what I'm most concerned about. I think those patients almost always need us. It's just that the documentation in the pre-workup isn't always there to justify it. And so again, I like taking them and kind of creating that structure where it needs to be. But I think financially, they're very risky, because a lot of payers will deny them or say that their medical course was inappropriate. A lot of the insurance companies will try and prevent them from coming through your doors. And you do have the risk that you find something big that should have gone to acute, and now you've delayed their care, or you've at least slowed it down in some way. And so it's risky, for sure. I like doing it, but I think you have to really kind of know your clinical liaison or whoever's looking at these patients, your ER docs, if you can, and definitely have an extra level of scrutiny when considering a patient from the emergency room. I would also add, sometimes patients were hospitalized, and inpatient rehab was recommended, and they decided to go home despite that recommendation, and they bounce right back to the ER. Those are cases for which the documentation is usually pretty good, and those are pretty safe to bring in. So I see, what about a patient with prior limitations, now worse after a minor procedure? Example, prior stroke, now status post-carpal tunnel release or rib fracture. I mean, I would say, rib fracture is a little bit hard, but if there were significant functional impairments and activity limitations from the carpal tunnel release, such that they couldn't use their assisted device, you may be able to make a case for that. Generally, if someone has premorbid functional impairments due to a neurological condition that complicates their rehab picture, I would suggest that they go to the ER. I would also say, if someone has a pre-existing rehab picture, I would give it more consideration than I would someone else. I very commonly admit patients who have baseline hemiparesis or aphasia, and they're hospitalized for something relatively minor that usually would not require inpatient rehab, but the complexity of their picture is just so different because of their pre-existing impairments that I might consider the case. I would say, I do strongly agree with everything Dr. Shapiro said and add that. I think that recrudescence of stroke symptoms is more common than some of our colleagues may believe. When these stroke patients or severe brain injury patients have a UTI or a pneumonia or something, we do see that spasticity and that weakness getting worse. I don't know if I've ever seen it with a rib fracture that may push me just a little bit, but if you believe it's truly worse, I think it may be worth at least considering. We have a long question here. Working at a facility with in-house IRF, conversation around length of stay on the acute medical side is a constant issue. Any input in regard to conversation with administration in regards to benefit of waiting for insurance prior authorization for IRF versus pushing patient to SNF, as oftentimes prior authorization for SNF happens more quickly than IRF? I don't know if one of you wants to chime in. That's a big one in the private world. I'd say that it's a big challenge because more and more, especially Medicare Advantage programs are delaying their decision. Sometimes they'll take up to 72 hours or longer before they will get back to you. And you're right, they can get a SNF authorization much faster and the SNFs are often willing to accept patients very quickly. I don't know that there's a good resolution for this other than being sure that you're advocating for your patient about what's in their best interest for their, because the outcomes at SNFs, especially it's well-documented that stroke patients do better with intensive inpatient rehabilitation. So advocating for your patient, especially with your neurology colleagues and trying to have as efficient of a process as possible to have them get that prior authorization quickly. There are cases that we've had some agreements to take patients before we get the authorization, but you need to do so very carefully only when you know that either a straight Medicare case where you know that they're going to be approved, or you have agreements with a commercial carrier ahead of time that they want the patient to get there sooner, like on a Friday before a holiday weekend. Yeah, Medicare shouldn't require a prior auth, but absolutely. The other thing that I would say here is just it really pays twofold. One, if you are in private practice to have a foot in that SNF world, because oftentimes you can kind of reroute them once they get there, if they're really more appropriate for rehab. And then two, to find what the readmission rates and the complication rates are at your local SNFs, because those readmission rates hurt the acute care hospitals just like they hurt our rehabs. And if you can really scout out the local SNFs and then go to the administrator and say, hey, I mean, the local SNF near my rehab has a readmission rate of almost 50%. I mean, that's half of the patients, right? And ours is at like 10. I mean, that's real data that you can bring and say, look, 50% of their patients are going back to the acute care hospital. 10% of ours, you don't want to deal with that, neither do we. That's a huge cost savings for that hospital if they can get the rehab right the first time. So I see a question from Dr. Friedman. If a planned procedure occurs during the rehab stage, does the cost of the procedure come from the rehab compensation? I can say it sort of depends on how your facility set things up, but there is some risk of nonpayment. My prior facility, we had a list of procedures that would be done under the rehab FIN so that it would come from the IRF payment, but other procedures for which there were special arrangements. So for example, transplant patients that had frequent biopsies or bronchoscopies, they figured out other pathways. But if we had a place like a PICC line or an IVC filter, that would come from the IRF payment. Depends a lot on the payer, right? For Medicare, you're pretty much on the hook for almost any procedures that occur while they're admitted to the inpatient rehab unit. It's really hard to get anything else covered. If it's a private insurer, if you can document it properly, there's a chance that the private insurer would pick it up separate from your inpatient rehab stay. Yeah, Dr. Ryder's put in some information and I agree with what he's writing from what I can see. Okay, sorry, now they're coming in quick. I'm going to take Beth's question first because I think that's a relatively easy one. A patient that is low functional level can tolerate three hours and is medically complex, but you know will still need SNF after IRF as they will not be safe or functionally able to go home. The answer is almost always, I would advocate for that patient to come to the rehab unit. If you think that the inpatient rehab intervention is going to make a significant difference for that patient, then I'd always advocate for that. And it's not part of the criteria that they have to have a discharge to the community as Dr. Shapiro referred to. I would just say in terms of wording, like tolerance is different from potential to significantly benefit. So if it's just that they could tolerate the therapy, maybe not, but if they can substantially benefit in some way, then definitely. And I'll say that's specifically why I had that slide in my presentation about what the CMS criteria is, because this tolerate is an idea that UnitedHealthcare, someone came up to help with their denials. The Medicare criteria is to be able to benefit from and engage with three hours. And that's a much different, those are much different words. And so if you think that this patient's rehab appropriate, I wouldn't worry about anything else on. I don't know if someone wants to take Stacey's question is, and then maybe we can have one last question after that, and we can wrap things up. And then if anything else comes through, we can get a direct response to you offline. Yeah. Oh, I forgot to plug. Thank you for reminding me Dr. Steinberg. So I am the moderator and the chair of the inpatient rehab community on PhysForum. I took over from Dr. Shapiro, who did a much better job with it than I did, to be honest. If there are any other questions or issues that come up that you remember over the next few days, because if you're like me, you're going to lay in bed and feed off this over your head over and over again. Please type it in on PhysForum. You'll not just hear me blabber on about it, but you'll get the whole community to answer the question and you'll probably get some really great answers. Dr. Hoffman, I don't think I've seen great data. I think that's an area where great data would be very, very useful. So I would encourage anyone who is really interested in that kind of research to do it and publish and share with the rest of us. Great. Well, with prompting from our AAPM and our colleagues, I would just really thank everybody for participating. And we're probably at time unless someone has one last quick question, but otherwise, Dr. Shapiro, do you want to bring us home and wrap things up? Sure. So thank you everyone for attending and for participating. If we can help answer any questions, please feel free to reach out. We've shared our contact information. We'll also be checking the PhysForum like Dr. DiTomaso said. So thanks again. If there are any other topics you think would be helpful, please share that with us or the Academy staff. Have a good night.

Inpatient Rehabilitation Facility

IRF admissions

Lauren Shapiro

Craig DiTomasso

David Steinberg

Review Choice Demonstration

CMS documentation requirements

interdisciplinary therapy

insurance trends

program development

PhysForum