Hey everybody, thanks so much for joining us tonight. My name is Craig DiTomasso and I'm going to be the moderator. We're going to discuss some case files and hopefully highlight the subjectiveness of inpatient rehab. We're going to use some true experts in the field to kind of navigate the minefield and see if we can come away with a little bit of a sense of maybe who does go to rehab, who doesn't, and why maybe someone should or shouldn't. Of course, I think it goes without saying that everybody on this call is giving their own opinion. It should not be interpreted to be the opinion of any private or public entity or any organization or educational institution. We're all just giving our opinions and doing the best we can to navigate this. Without further ado, we'll get going. Oh, sorry. My experience. Thank you for allowing me to moderate this. My name is Craig DiTomasso. I am a private practice physician. I work with US Physiatry and I focus mostly on disorders of consciousness and the most severe traumatic brain injuries. I also have some various industry positions as listed here. So who goes to rehab? Well, there is a criteria, of course, but that criteria is rather vague and certainly open to interpretation. If you look at CMS, at least from my perspective, it kind of talks about five vague categories. One, the patient needing a multidisciplinary team. Two, the patient needing some level of medical management and support. Obviously, the need for intensive therapy. The patient has to have an ability to benefit and then ultimately requiring interdisciplinary approach. If you look at a traditional interpretation, and I'll use the AAPMNR physician statements, this is, of course, an AAPMNR event, and I'm a big fan of the AAPMNR, they list six or seven major issues, and I've listed them all here, and I think this is more consistent with what most people talk about when they talk about inpatient rehab. Even with this further delineation, though, I think there tends to be quite a bit of subjective interpretation, and I don't think any two people always see things the same exact way. And so we're going to have our AAPMNR moderators put in the chat a link to the AAPMNR inpatient rehab physician statement, and if you want to refer to it before, well, I guess not before at this point, but during or after the presentation, please go look at it there, just so you know this physician statement will probably change very soon, but it is what we're working with at the moment. So let's start with case one, all right? So in our first case, Ms. Leniko Kosik is an 83-year-old lady who was referred to Inpatient Rehabilitation Center from the local assisted livings facility. Three weeks prior to this referral, she was sent to the local emergency room for evaluation of unexplained weakness and increasing shortness of breath. Ms. Kosik was found to have a urinary tract infection. Her plasma white blood cells were 25. Her urine demonstrated clumps of white blood cells. There was a strong odor to her urine, and there was a high amount of sediment, as well as a reasonably high colony count. It is worth noting, I think, especially for my infectious disease friends, that she did not report dysuria at the time. She was found to have kidney insufficiency. Ms. Kosik spent the night in the hospital, was placed on broad spectrum IV antibiotics and IV fluids. The next day, her white blood cells improved tremendously, and her creatinine was nearly back to normal. She was considered stable and was discharged back to her assisted living facility and instructed to continue oral antibiotics. However, upon returning to her assisted living facility, she spent most of that time in her bed. She became profoundly weaker. She had severe fatigue and at times required a little bit more oxygen and was incontinent of urine. She was evaluated by the facility geriatrician who found those things that I just mentioned. And the three liters, of course, I should mention is an increase from her baseline of two liters. She was evaluated by the assisted living associated physical therapist. Evaluation found profound weakness in all four extremities. She's weaker more proximally than distally. She had difficulty standing from a sitting position. Her balance was severely impaired. She consistently fell backwards. Formal testing, the physical therapist graded her as a mod A for bed mobility, max A for transfers and unable to ambulate. Of note, her past medical history as listed here and past surgical history as listed. And again, as mentioned earlier, she was typically on two liters due to interstitial lung disease, but now on three. Socially, Ms. Kojic has lived in the assisted living facility for quite some time. She is a retired professional ballet dancer. She is widowed, has no children. She was not a heavy drinker, but typically drank one to two glasses of wine a day, but has abstained for the last 10 years. Of note, she does have a significant family history, both with Sjogren's syndrome and Alzheimer's disease, but does not at this time carry either of those diagnoses. And prior to her hospitalization, of course, she was in the facility only with a rolling walker and without assistance, which I would call modified independent or mod I. She was performing almost all of her own ADLs, but she did require assistance for showering at times, mostly contact guard assist related to balance deficits. She was contact guard assist, again, for transferring in and out of certain vehicles. She could get in and out of typical vehicles on her own, but high or low vehicles she requested assistance, again, due to balance. Cognitively, she was described as rather intact, but she was noted at times to be forgetful of medicines and times and dates. And I think that paints the picture of Ms. Kosick, who I'm going to leave you with. I'm going to mute myself and turn the discussion over to Dr. Vish Raj, a gentleman who needs no introduction, the Interim Chair of Carolina and Medical Director. All right, thank you. So my stance is going to be one that suggests that the patient does not need inpatient rehabilitation. And the opinions I'm going to share are not necessarily my personal opinions, but more for the purpose of discussion. But one important thing is that much of what I'm going to say is going to be rooted in my experiences in peer-to-peer and ALJ cases where patients have been denied for what I thought were obvious reasons to admit, but others did not agree. So when we're reviewing this case, the first issue here is that this is a patient who was admitted to the hospital with a UTI, a UTI that was actually treated in acute care. And although she seems to be doing a little worse from her functional status, the truth is her white count is better, her keratinin is improved, she's on appropriate antibiotic treatment. And there is a question about what the medical management is or what the medical necessity would be for a patient with a UTI requiring a more intensive level of rehabilitation care where they would need the three hours of therapy a day and also interdisciplinary care. I think one of the concerns here is that she went back to a home setting and maybe she hasn't gotten out of bed that much. So I can understand that she's not mobilizing, but given her age and given her medical condition, I would worry that she simply couldn't tolerate three hours of therapy a day. If anything, I think she needs a lower level of care with a less intense program of therapy because of her age and her medical comorbidities. At the same time, I think there's an honest question about what here necessitates the rehab physician, rehab nursing supervision, that 24-hour supervision that specifically has to be provided with rehab goals. In this case, this is a patient who had functional decline. She is not mobilizing, so the question is what is it specifically that a rehab doctor is needed for to address this patient's issues? When we look a little bit more carefully at some of the medical issues, she has been on oxygen chronically. Granted, she's on a little bit more oxygen, but that might just be because she's deconditioned. And ultimately her other comorbidities, the hypertension, the atrial fibrillation, even the anemia, these are chronic issues that we can work around at a lower level of care like a skilled nursing facility, or maybe even if we had a more intensive home health program with some supervision in the assisted living facility. So all the way around, I would have concerns about putting this patient in a higher level of care. Just to make an argument, when you look at the 60% rule, there's compliant diagnoses and there's non-compliant diagnoses. One would argue if they're non-compliant, they probably shouldn't be coming to rehab. That's why it's called non-compliant. So all the way around, I think there's probably not a strong case for this patient to go to this more intensive rehabilitation level of care. And I think her needs could be met at a much lower level of care. And for the retort, we'll now turn to Dr. Kuro Alexeya, the Senior Medical Director for PAM Rehab nationally for the company, as well as the Medical Director in the Dover, Delaware Hospital. Thank you. Thank you, Craig. Dr. Raj, I give you a lot of credit. You represented CMS very well. Thank you. So from a standpoint of, I guess, the good guy. So we have this 83-year-old female, and what I like to do is I like to dissect the cases. And again, a lot of the criteria is very gray areas, and you have to make a determination really case-by-case basis. So the way I look at it is, this is a patient that's been living in assisted living for the past eight years successfully. Now, as mentioned before, she doesn't have any family, and assisted living is her home. So there's really no other alternatives for her to go anywhere else. She doesn't have another home. This is her home. So considering that this patient was pretty much independent, modified independent with a rolling walker, ADL is independent, just required a little bit of contact guard with showering and getting out of vehicles, I mean, she's doing pretty well, we could say, prior to this little incident. And then she went back, and she keeps declining. So a couple of things I want to look at. First of all, where are we at now? So now she's back in assisted living. She now requires three to four liters of oxygen, DNA is a canyon, which is almost double what she had before, right? She was in two liters before. And why is that? She had an interstitial lung disease. Can we tie in the interstitial lung disease possibly with the family history of Sjogren's disease? Absolutely, because one of the main frequent manifestations is respiratory, and it manifests with coughing. So we could maybe say that this is possibly related to the family, undiagnosed Sjogren's in this family, that's a possibility in this patient. So the other thing that we're looking at is incontinence to urine. So this is a patient that was fairly independent. So now why is she also on incontinence to urine? We have to really kind of dive into that. So when she was evaluated by physical therapy, physical therapists and geriatricians found that the physical therapist showed proximal muscle weakness. She was unable to go from sit to stand. She had severe balance impairment, and she was falling backwards constantly. She's now moderate assistance with bed mobility, maximum assistance with transfers, and unable to ambulate. So we can't really call that a mild change. This is a really major change for this patient that's been successful living for eight years in assisted living. Geriatrician, the physician, and the physical therapist at this time both agreed that the recommendation is acute inpatient rehabilitation. That's the recommendation, that's the referral. So when I look at the criteria, I try to break it down into three different aspects. I look at the medical complexity, I look at the functional decline, and then I look at does the patient really need two out of the three therapies, occupational therapy, physical therapy, and speech therapy? Which two out of the three does she need? Does she qualify for those, at least two? So when we look at the medical complexity, again, she has increased demand in oxygen, could be possibly undiagnosed shortness, could be possible pneumonia because she's been debilitated, maybe some fluid collection. And this could be because of lack of mobility, could be CHF exacerbation. She went to the hospital, she got some fluids, and then now she's a little bit fluid overloaded. And then we look at the urine incontinence. Did the UTI really resolve? Was the course of antibiotics appropriate? Were the antibiotics maybe resistant? Now does she have more memory loss? Remember, family history of Alzheimer's, this 83-year-old female, maybe Alzheimer's kicking in, or maybe UTI exacerbated her Alzheimer's in this case, and then caused a little bit of confusion, right? So we're talking about the cog aspect as well here from medical necessity. And how does that affect her day-to-day? Because she already had trouble remembering to take her medications. Now UTI could really set somebody back significantly, especially of that age. And then we're also talking about chronic anemia as a part of past medical history. Did they get the hemoglobin? Maybe she needed a transfusion, maybe that caused the fatigue, and that's why maybe she's not moving around. So that's all the things that we kind of think on the back of our head for the medical complexity. But a functional decline, as I mentioned, somebody who's pretty much modified independent, with a rolling walker now, is mod assist for bed mobility, max assist for transfers, non-ambulatory, that's significant change, creates a really big fall risk. Now this is a patient who I look at is basically one instance away from ending up in acute care hospital, right? So we're talking about maybe another UTI exacerbation of fall, getting a subdural hematoma, or maybe just worsening of the medical condition. And then we look at the two out of three therapies, which I'll get to in a second. So when I look at my differential for rehab, first of all, the therapist is talking about proximal muscle weakness. So we're thinking about maybe disuse myopathy, compliant diagnosis, a 60% diagnosis, again, could be secondary to lack of mobility, but it's really no way of telling until you do a full physical exam, and find out for yourself and how weak is that patient really? What are the symptoms are there are present to be able to utilize this compliant diagnosis? Second thing we're looking at is shared a UTI, I mean, again, was that not fully treated with antibiotics? Is this a metabolic encephalopathy, a non-traumatic brain injury, another compliant diagnosis 60%. Then we look at things like worsening pulmonary function, even though pulmonary is not compliant, we look at again, the pneumonia, possible shorgans, CHF exacerbation, maybe weakness of the diaphragm, just lack of mobility. And then think about proximal muscle weakness, difficulty from going sit to stand, use your rehab skills, how am I algebra matica jumps out at me right away. So what do we need to do? We need to possibly test further ESR, CRP, things of that nature, and then really kind of, you know, get to the bottom of it. So my final thoughts, so patient, again, was previously modified independent. Now it needs to be very high functioning and assisted living in order to return back to assisted living, you really need to be fairly independent or modified independent in order to be there. Otherwise, for any reason, they'll just send you right out and it's not an appropriate place for you. Again, she doesn't have a home, she doesn't have family. So this creates a problem for her. So you know, why do you need the physician? Why do you need the nursing? Why do you need that care, the multidisciplinary approach? So, you know, we're talking about, you know, maybe managing pneumonia, utilization of antibiotics, maybe she needs the Lasix for CHF, testing for the shorgans to see maybe that was misundiagnosed, treatment with steroids, immunosuppressants, talking about monitoring for recurrence of the UTI, you know, maybe testing again, test of sensitivity, maybe she's resistant, drug resistant to the ZTI and antibiotics. And then the chronic anemia, testing the hemoglobin, does she need another transfusion? What else can we do with this? So this, again, is a patient that is one move away from possibly ending up acute, we could save that from happening just by bringing her in for a short term stay in acute rehabilitation, getting her tuned up, getting her better, and getting her back to assisted living where she would actually function appropriately and continue living eight more years or more, you know, in assisted living, function just as well as she was functioning before. Remember, assisted living have programs, dining, events that they all need to get to. That's why they need to be fairly, fairly independent in this case. And then it brings up to the third part that I've mentioned before, the requiring therapy. So speech, occupational PT. In this case, I really think she benefits from all three of them. I mean, speech for memory and tasks, right? Do we know this is advancing Alzheimer's, UTI on top of that? OT for ADL retraining, PT for transfers and ablation. All three, I think are very, very appropriate for this case for this patient. My last three points I want to make real quick here is when we're talking about subacute nursing facility, keep in mind, subacute nursing facility needs a three-day stay in acute care hospital. We cannot just transfer somebody from assisted living directly to a skilled nursing facility, except for some rare instances. Okay, so from that standpoint, you need a three-day stay. So SNFs are out of the picture altogether right now. Home is out of the picture. She's too low functioning for outpatient. So what are her options, acute rehabilitation or home care? And home care clearly is not doing their job. So when we're also talking about the ALF, I mentioned very high functioning patients need to be independently living there. It's their home. It's not a lot of assistance provided besides some home care and occasionally outpatient. And then the last thing I want to point out, on February 6th, finally, thank God, CMS gave some clarifications to when do we send somebody to acute and subacute and so on and so forth. So they stated the clarification document came in February 6th, 2024, saying for Medicare and managed Medicare plans that if a physician determines that the patient meets the criteria for an admission to a post-acute care facility, such as acute rehab, LTAC, SNF, Medicare cannot deny the submission to the particular setting and or readmit to a care to a different setting, meaning a lower level of care. So clearly from the standpoint, physician made a recommendation, physical therapist agreed. This is the only option in our case. It's the best option in our case. And this patient needs to go to acute rehab and we'll get her better. Thank you both so much. That was really well thought out and articulated arguments. And I appreciate the time it must have taken to do your homework and come up with those posts. We'll have a brief intermission now, if anyone needs a little bit of a mental break. If there are one or two questions, please type your name or your question in the chat box and I'll call on you. And then in just a few seconds, we'll start with our second case. All right, can I just make a quick comment in case we have residents and medical students on the Zoom today? So just it's really important to recognize that inpatient rehab, we're certainly capable of doing medical evaluations, particularly for new problems that come up. But in this case, in particular, I would be concerned that there was a suggestion that we do a whole very extensive workup in acute rehab. And this is a patient that, to me, sounds like she would very much benefit from a short acute care, like acute hospital stay, for further evaluation of her changing medical condition. And she would be an excellent candidate for an inpatient, you know, like a consult by a Pumonar physician to figure out what's going on. I think it would be really helpful to, you know, optimize her medically before bringing her to any rehab setting, whether it be inpatient rehab or subacute. My only caveat to that, Lauren, is I would say in a perfect world, I certainly agree with that. But most of the time, when these types of patients end up in acute care, all that's written all over their chart is please follow up as an outpatient. And then when they become outpatients, because of their immobility, they're unable to follow up. And so I do end up doing quite a bit of what was mentioned in my acute inpatient rehab, just simply because these patients have no access to that type of evaluation elsewhere. Yeah. And I might just add something, too. Just, you know, when we're talking about these cases, you know, we're all rehab professionals, right? So our inclination is to come back and say, well, of course, this patient qualifies for an inpatient rehab stay. Look at all these obvious reasons. One important thing to remember is that when you're trying to make the case that a patient should come to rehab, the burden of proof is not on Medicare. And the burden of proof is not on Medicare HMO, nor is it on the ALJ. It's on the rehab provider. And, you know, the argument that they often make legally is that if 51 out of 100 people would agree with you, then that would be the reason to approve a rehab stay. And if that's not the case, they won't. The other thing is that when you're, and I'm sure we'll go into this after the other case, is that a lot of the people you're arguing with may not be rehab professions. And so things that are intuitive to you, where you would automatically assume these different issues are obvious and things that should be mentioned in patient rehab are not obvious to the person you're arguing with nor the ALJs. So I look forward to further discussion as we get into it, because I think a lot of what I said, you might think was ridiculous when I said something about 40% being non-compliant, when I said the patient's too old and they need an easier plan of care, when I said stuff about the medical complexity and lack of need in medical management, all this stuff. Make no mistake that the people who you're arguing against are going to make those cases and the burden of proof is really on you to prove that what you're saying carries more weight than what they're saying in terms of a denial. Very well said. We'll come back, if that's okay with everybody, to another Q&A after the second case. Unless there's a pressing issue out there. And I think if anyone can throw the link to the CMS document mandating that the insurance companies follow the medical recommendation of the physician in the chat, that's asked for twice. I don't have it in front of me, but we'll go from there. All right, if there's no objections, second case. Mr. James Ronleb is a 63-year-old gentleman. He has a two-year history of metastatic liver cancer and he's referred to your rehabilitation center from a local acute care hospital. Mr. Ronleb was walking in his garage when he fell and tripped over a box. After the fall, he was in excruciating pain and unable to get up. He was found down on the floor in the garage by his family and transported to a local emergency room where evaluation was given for a left transcervical femoral neck fracture. Incidentally and unfortunately, Mr. Ronleb was found to have a new, previously undiagnosed liver metastasis lesion. The next day, Mr. Ronleb underwent a left hip hemiarthroplasty. The postoperative period was significant for expected pain, mild encephalopathy and constipation. He, of course, in the acute care hospital, physical and occupational therapy were consulted. They were able to work with Mr. Ronleb and they documented that he was mostly modest for his ADLs and bed mobility and basic transfers. He was more like max assist for things like transfers, sit to stand and ambulation. And it was due to left leg weakness, of course, some fatigue, but also high level of cognitive impairments with obvious sequencing deficits as well as pain, if I didn't say that already, excuse me. His past medical history is significant, of course, for the liver cancer. He was diagnosed two years ago. He underwent resection and chemotherapy. He's had some chronic low back pain and hypertension. Surgically, the patient obviously had the colon resection approximately one year ago. He also had a history of L4, L5 laminectomy due to spinal stenosis and low back pain about 15 years prior. Socially, Mr. Ronleb is a retired assistant principal and part-time basketball coach at his local high school. He is married and lives with his wife in a one-story home with no steps to enter. He has strong family support from his wife and daughters. Of note, he was a very heavy drinker and smoker, but has abstained from all substances for approximately 20 years. He shows good taste and was an added Cleveland Cavaliers fan for many years. So again, no familial diseases, just alcoholism. It does run in his family, and again, very good support from his wife and his daughters. All right, I will now turn the mic over to Dr. Lauren Shapiro, Associate Professor of Clinical, Professor of PM&R and Department of PM&R at Miami. Excuse me. Well, thank you. For me, this was a pretty easy yes. He seems extraordinarily appropriate for inpatient rehab. And in fact, if his insurance didn't approve it, I would feel very compelled to do a peer-to-peer, which is an even higher level of approval in my mind. And this is despite what is probably a very poor long-term medical prognosis. He does have very good rehab potential despite that. For starters, he has a very rehabable diagnosis in that he has a femoral neck fracture, which is a 60% compliant rule, which is not to suggest that non-compliant diagnoses are not appropriate for our setting, as many are. And we continue as a field to build the evidence basis to support their appropriateness. He has a very good potential to achieve a supervision to modified independent level with functional mobility and his basic self-care within a, probably about seven to 10 years. There are clear needs for both physical and occupational therapy in that he has both impairments in his mobility and self-care. He does require max assist with ambulation. It is possible he may use a wheelchair, particularly for longer distance ambulation, but I would expect that his mobility and self-care would improve within a reasonable period of time. There's also a potential need for neuropsychology to address the described cognitive impairment. In my mind, there's also very clear indications for the involvement of a physician beyond the need to manage his pain and constipation and potential encephalopathy. He has fatigue, which in this case is likely polyfactorial and that he also has cancer, and it may require a multimodal treatment strategy. In addition, in justifying the acute level of care, I think it's really helpful to talk about what complications he's at high risk for without appropriate treatment at this level of care. In his case, he is at risk for a number of complications, probably most notably contracture, and he's at elevated risk for VT given the hip fracture and his cancer diagnosis. It sounds like his home is accessible and he has a great family. So it's likely that he'll be able to return to his home environment as opposed to a different level of care. And he also had a really good premorbid functional status. Despite living with cancer, it sounds like he remained very active, which suggests something about his degree of motivation as well. So overall, again, I think this is an excellent candidate. I would also highlight that I'm not sure what his treatment options are with regards to his cancer, but obviously having an improved functional status would usually increase his candidacy for ongoing treatment of his cancer. And certainly on admission, I would definitely explore what his wishes were with regards to code status and further treatment and adjust my goals accordingly. Thank you. And next up, allow me to introduce Dr. David Steinberg. He, I'm not sure who else. There it is. Oh, one too many. Dr. Steinberg needs no introduction. He is the chair of the Department of Physical Medicine Rehabilitation at University of Utah and the executive medical director of the Craig H. Nelson Rehabilitation Hospital. Take it away, David. Craig, thank you very much. And welcome to all those who've joined us on the call. I recognize some names on the list and really wonderful. And Dr. Shapiro, you did a wonderful job and I just wanna congratulate you. And as was presented previously by Dr. Raj, this is not my personal opinion necessarily, but I was asked to be the counterpoint to this argument here. And so I'm going to point out a couple of challenges here with this case. For those who don't know, I spent quite a bit of time in a community teaching hospital setting that included over 20 years serving in a subacute skilled nursing facility as a rehabilitation medical director, as well as running a community level inpatient rehab. And so I've gone through and now at an academic center, I've had hundreds of cases of this nature over the years needing a strong advocate to help explain rationale for coming to the rehab program. However, in this case, I will take the position that Dr. Shapiro, for all of your conversation about this patient requiring a complex setting of multidisciplinary therapies and all those reasons that potentially things might go wrong, the truth of the matter is that this case is pretty straightforward. This looks like a hip replacement to me. He's relatively young, he's 63. I don't see much medical complexity in this case. I think we can all agree that uncomplicated hip replacements, you know, they used to go to rehab all the time in the 1980s and 90s, but we're under a different environment here today. And we've got wonderful resources in our step-down settings of subacute and skilled nursing settings, many of them with physiatrists being involved. After all, very few physiatrists really want to go into hospital-based care these days. So a lot of them are being employed by skilled nursing centers. And in our community, that's kind of the standard of care. So it's not uncommon for patients like this to go to skilled nursing settings. To me, seems like his needs could be met at a lower level of care with reasonable expectation of good functional recovery. I don't see particular services or intensity of services to quote your own academy's position statement that he needs, that could only be provided in an inpatient rehabilitation program. Subacute and skilled nursing, they provide therapies just like you're offering, and they're welcome to give patients more intensity if he can tolerate it. So I'm thinking, I'm kind of leaning more towards the SNF subacute approval. And, you know, you talked about the need for intensity of therapy. First off, I don't think he, I can't see anything documented that he has the tolerance for three hours of therapy per day. It's just not documented. The case before this that I was able to listen in on, also, you know, there's no proof that he hasn't had enough therapy to show that he can tolerate three hours a day. You pointed out yourself that he's got liver cancer, he's fatigued, he's got pain, he's got some confusion. I just don't, I don't see documentation that he can clearly do three hours a day. And the other thing is that, you know, my rehab center, your rehab center, we've got great rehab nurses. Why does this guy need a rehabilitation nurse? I don't see that he has those specialized needs for like a specialized, I think a med-surg nurse or a skilled nursing nurse could probably meet his needs pretty well. He doesn't have bowel or bladder problems. He doesn't have respiratory problems. I don't see any skin breakdown. You talked about the risk of having a contracture, but truth is, you know, he doesn't have a contracture and I don't see any behavioral issues. Even the documentation said his cognitive problems are pretty mild. So that's, you know, pretty common after surgery. You know, he's got to recover, right? So a lot of patients can have a little bit of confusion. That's not that big of a deal. Yeah, easy to manage those problems. And also, why a PM&R doctor? Why a specialized rehab doctor? His care seems pretty straightforward. I don't see unique issues that require a subspecialist. I think a hospitalist or a generalist could probably manage these problems. You know, after all, a lot of them are going to run rehab programs anyway. You know, so what does a PM&R doctor need to be involved with here? And Leuce also said he has good support at home. He has a wife, adult daughters. His home doesn't have a lot of barriers. I don't know, maybe a home care referral is the best way to go in this case. You like that I got a posture? I don't want to have to do a peer-to-peer against you anytime soon, David. Well, I'll open it up now, both to our panel as well as our participants. I would ask, since we do have more than 40 people on the Zoom at this time, if you have a point you want to make or to speak, just at least type your name in the chat so that we can try and keep everybody organized and not talking over each other. You know, I was just going to add one thing, David. You did an excellent job representing what the counter-arguments are from what we would consider misinformed or uninformed reviewers. You know, once I was doing an ALJ case and it was on a brain injury that they were arguing didn't need to come to rehabilitation. And the argument was that they couldn't participate in the full three hours of therapy a day. And I actually brought evidence, like I brought research articles, I brought practice guidelines to suggest that inpatient rehab was the appropriate setting. And, you know, for those of you who treat stroke, you also know like some of the recommendations now for stroke care is inpatient rehab is actually considered standard of care. And I'll never forget what the judge said to me. The judge said, thank you for that information. My job is not to evaluate the evidence, it's to enforce the law. So, I mean, so I think it's important to understand like, again, things that seem so obvious to us, those may not be the arguments that put you over in terms of winning the case and making sure they see your side of things. So I think the way David presented is exactly how people do it. It's very, very interesting. So group, we have a question from Dr. Epstein and Dr. Epstein, if you prefer to say it yourself, please speak up. But his question is how, when you're trying to articulate that a patient needs three hours of therapy when they never get into an acute or any other setting, do you extrapolate that into your argument or defend that? Can I jump in real quick? First of all, yeah, I did wanna say, David, that was a great job. It sounded like the ophthalmologist had a peer-to-peer recently with, you know, it was fantastic but yeah, it puts you kind of in a tough spot. But I just wanted to clarify the three hours of therapy, remember, three hours of therapy a day, that's for five days a week. You could stretch that for 15 hours throughout the seven days. That always shuts down that argument. Yeah, and the truth of the matter is that it is almost never the case that whether a patient's presenting in your office that looks like they should be admitted directly or they're even in an acute care hospital, it's virtually never the case that a patient has had three hours of therapy to kind of test them out. Now, back in the day, we did have the ability to admit patients for a rehab trial to see if they had that tolerance and then document it over a couple of days, but that's no longer permitted. So we have to be able to at least speak to that issue because it's a common retort from a peer-to-peer or someone else to say, well, I don't see evidence that they have the tolerance. It helps tremendously. If in the documentation on acute care, your acute care therapist put in the note, this patient has good therapy tolerance, I believe they can tolerate an intensive program three hours a day. And then as a physiatrist, it's not only the ability to tolerate it, but it's the necessity to have that intensity. So it's really being able to articulate why you think an intensive course of therapy can get patient home in a better, more expedited way that they'll benefit from that setting. Because a lot of the peer reviewers will point to skilled nursing and say, well, why isn't that good enough? They can give them therapy there. But for those of you who have worked in those settings, they're not equivalent. When I do these peer-to-peers and they bring out that statement, which is very a common remark that they make, I also highlight my expertise as a rehab physician, which is really doing what needs to be done medically to ensure the patient is really able to tolerate and benefit from the services we provide. Yeah, and I think to Lauren's point, it's very important to emphasize that you are a rehab physician, right? And not something else. So that way it gives you some level of credibility. The other part is, more often than not, the reason, I think to David's point, the reason that they give you a hard time, it's not whether you can extrapolate whether they can tolerate three hours a day, it's whether they require three hours a day. So it's a very, it's a slightly different argument. So it's very important to remember, it's not just like, it's not just going in there and saying, yeah, I think they can do the three hours a day. That's not the issue. The issue is why do they require the three hours of therapy a day or 900 minutes a week that are dictated by the rules and regulations by Medicaid? And I would add just one more point there, if I can. Obviously my background is in disorders of consciousness and that's a pretty unique subgroup. But one thing I bring up is that American Academy of Neurology supports inpatient rehab for disorders of consciousness. And I love to bring up in these arguments, if I can do three hours of therapy a day with a patient who is essentially comatose, do you think there's any way I can't get three hours of therapy a day with this young woman or young man who we're talking about? So usually I have to first define disorders of consciousness. Unfortunately though, because no one knows what I'm talking about. But bringing the therapy to the patient's level is really what we're best at. And that becomes the argument and the talking point then rather than three hours, what are we getting out of that three hours and how are we gonna maximize that patient's function as everyone already mentioned. So we have a question about whether a PM&R note has ever shown to improve the chance of getting acceptance. I don't know of any evidence or formal studies, certainly in my kind of gut, I think that that's true or hope that that's true maybe, but does anyone know of any published evidence for that? I don't know about published evidence, but I know from personal experience that, whenever I go and consult on a patient in a acute care hospital and I put my note in, that usually expedites the things. It expedites the process and we're able to get the patient a lot quicker to our facility. And then also you're able to do peer-to-peer a lot quicker as well, rather than to have them sit and get debilitated for the next seven days. I would say kind of similar. I don't know of any like formal evidence. I will say that our consult team is very good about going in and like really documenting all the rehab diagnoses. Too often these days, like a patient might be like on a hospital service for like a UTI or something and they're clearly on Sinemet or like they're clearly on a medicine for another neurologic condition and nowhere is it documented as a diagnosis. And that's a real challenge for our admissions liaisons because they may know the patient has Parkinson's, but they can't enter new diagnoses if it's not documented in the chart. So by having your consult team go and do a really comprehensive assessment, document all these diagnoses. As certainly in the ICU setting as well, making it clear that someone has like critical illness, neuropathy or myopathy that may not be labeled in their chart makes it a lot easier to get approval. So there's a question a little bit further on the chat that talks about why medical challenges, medical problems should and could be managed by a PM&R rehabilitation physician versus a generalist. And that's a point that I did not make in my counterargument, but I think Dr. Shapiro would agree that the case that we reviewed of a patient with liver metastases and cognitive problems after a surgical procedure is at increased risk of complications related to pain management. Yeah, a generalist could manage pain. That's not the issue, but a rehabilitation doctor knows the importance of timing and managing pain in a manner that's balanced so that you're not creating further complications with bowel dysfunction and confusion and making a selection of pain medications that is uniquely tailored to the patient's physiology and needs. In this case, we're gonna have to be very careful with potentially hepatotoxic drugs or those that have delayed metabolism for other reasons. And we have specialized training as a rehab doctor in managing pain during the rehabilitation process and working with the nurses for timing, for scheduling appropriately, for looking for complications, for avoiding the potentially adverse effects of pain management as one aspect. The other point that was brought up, I think both Dr. Alekseyev and Dr. Shapiro pointed out the risk of other complications occurring. And it may be hypothetical, but all of those potential complications can be proactively avoided with a highly trained subspecialist in PM&R and rehab, including thromboembolic disease, like you talked about. And that's particularly important in managing someone who has cancer as well as immobility after a hip replacement. It's not good enough just to give them aspirin. They're gonna need lobinox. They're gonna be needed to be screened on a regular basis. And the truth is, is that while physicians may be available in a skilled nursing facility, they're not required to be available. They may see a patient once a week or less frequently. And so the truth is, is that you're relying on an unskilled nurse or a therapist to keep track of whether a patient might be getting unilateral swelling and calf pain that could be a fatal PE within a short amount of time. And by having a rehab doctor with eyes on the patient, examining the patient every day, you can be very proactive in watching for those types of problems. Yeah, and I might add, just to agree with my three colleagues here, one tying to the consults, then the second tying to the rehab physician, this is where maybe it all comes together. Having a very good consult note from my rehab physician who understands those core morbidities and anticipated challenges and having those documented prior to admission then gives you some fuel to fight that case, whether it's through an HMO when you're trying to get the case justified, or if you're on fee-for-service Medicare A and B and you're in the post-payment denial phase. I think what happens sometimes is we as rehab physicians just assume everybody knows, hey, look, it's a cancer patient, they're in rehab, they're at higher risk for DVT, they're at higher risk for being catabolic, and I'm a cancer rehab guy, right? So I can probably talk hours and hours upon it, but all these things, the question is, if they have all these medical core morbidities, the one thing they always come back with is, well, why do you need a rehab physician? Don't you need a general medicine doctor? Don't you need an oncologist to address this, whatnot? The thing is, none of those folks are rehab professionals, so they can't actually take those core morbidities, figure out how to address them in such a way that it integrates with the rehab plan of care and then address how those core morbidities will then affect the outcomes as it relates to therapy measures, cognitive function, all of this kind of stuff. And so I think regardless of the discipline, right, if it's stroke, you might be talking about blood pressure management. They may say, well, anyone can manage their blood pressure. You can say, yeah, but I also know how the blood pressure affects our ability to deliver rehab care, what optimal blood pressures are, how it may affect cognition, how hypotension might affect cognitive function. In cancer, it's things like DVT, skin breakdown, sarcopenia, catabolic states, brain injury, spinal cord injury, they have their respective things, and then other diagnoses as well. So yeah, just, I mean, I think the key here is, to Lauren's point, you're a rehab physician, you have a subspecialty that's very important, and to David's point, you have co-morbidities, so you wanna make sure you integrate those. And to Carola's point, if you do the consult work and you can make that outline in the first place, you make that argument before the patient even gets to rehab, you probably have a better shot of overturning somebody's decision moving forward. I agree, it's helped me in ALJ cases with after audits and the appeal, to be able to say, it wasn't just my opinion. I had a second PM&R doctor who did the consult who came to the same conclusion. And that helps to create the weight of consensus beyond just the opinion of one individual. And in the case that really sticks in my mind was a case of a woman who was very much like the first case here, and initially was discharged to a skilled nursing center and had a very bad experience there. Poor responsiveness to call lights, so unmanaged pain was a big issue. Patient had a fall in the skilled nursing center because she had gotten up with low blood pressure at night. So she came back to acute care after that fall, and I saw her on consults. And I said, it seems like you're doing pretty well, I think you can go back to your skilled nursing center. And she literally freaked out, right? She had a panic attack because she didn't wanna go back. She was overwhelmed with anxiety and she literally held my hand and said, please, please, please, they'll kill me, don't send me back there. So I finally, I'm a nice guy, I listened, she reminded me of my grandmother, I said, I got your back here, I hear what you're saying, okay, we'll bring you to the rehab unit. And then later it was denied in a retrospective audit. It ended up getting in front of an administrative law judge. And I said, this was my professional opinion. I examined the patient, I did an evaluation and I felt she had a reaction that was close to a post-traumatic stress reaction. And it would have been, in my opinion, adversely affect her to send her back to a skilled nursing facility. And the judge agreed with me because I said it was my professional opinion as a skilled rehab doctor, that this was the correct setting for her. The counter argument was someone who was not a rehab doctor and had not personally assessed the patient and did not make that medical kind of judgment. So it's how you kind of couch those arguments that can, I think, and hopefully sway the argument. Yeah, and just to add to that, you still may make the best argument in the world and you may be absolutely right and somebody might still rule against you, right? So two important things, just if you're not aware, one thing is that with Medicare HMOs, you may notice that when you're doing peer-to-peers or if you go to ALJ cases and whatnot, a lot of the HMOs are now employing PM&R physicians or rehab physicians to make the counter argument, right? So that idea that I'm a rehab physician and you're an ophthalmologist, that takes a little steam away, right? If you have another PM&R doctor arguing against you, now it becomes a little bit tougher of an argument. The other thing is that when you're looking at, I know in the chat, there's been a lot of folks talking about a lot of different programs for audit. You may notice that now with Medicare A and B or at least straight Medicare, on a lot of these probe audits, on a lot of the new programs that you're doing, like the RCD programs, they're having a rehab physician specifically be part of them, right? And the argument is, if you have the rehab physician as part of them, then when they make the decisions, it carries more credibility than if it was a non-rehab physician. So if you're gonna argue, it's rehab versus rehab, and then you really have to have a compelling argument to make sure that people see your side of the story. All right, moving on. Next question that I see asked about medical necessity, and I think we more than covered that. The only thing I would emphasize is that when I am talking about medical necessity, for me, it needs to be rehab medical necessity, right? Because they would be in the ICU if they needed that much medical intervention, right? And so all the things that our panel has talked about, those are the things that carry weight. No one's expecting me to be the blood pressure expert or the glucose expert. I'm going home, was a retired nurse. Thank you, Dr. Jewittleson. I don't see a question, though. Has anyone gone in this forum through the CMS audit via National Government Services, or a respective audit, and my institution failed, passed the third round, not medically necessary and too high-functioning? Yes, I have personally done that. It was not fun. I think that we've touched on the topics that we've touched on, but I think that we've touched on a lot of them. I think that we've touched on the topics that are helpful there. Had a peer-to-peer that argued the difference between needing rehab physician and general medical, period, not accepting managing these medical issues, denied the rehab, lack of physician needs. Yeah, so to Dr. Thomas-Riparda, that's exactly what I was trying to hone in on, and I think our panel did a great job explaining it, but I always try and set the medical necessity up for these patients as, what are we managing as the physiatrists? So Dr. Alexeyev did a great job in the first one, I'm talking about all the possible workup that could go on, but more importantly, the things that were gonna happen day-to-day to improve the young lady's function actually got better. And then Dr. Shapiro knocked it out the park about all of the management needs and the risk for Mr. Ronleb. So those are the types of things I think, again, to focus on. Trying to claim that you're the glucose expert is not typically my approach. Go ahead, Lauren. So I primarily do inpatient stroke rehabilitation, and a lot of what I do is hypertension and diabetes management, but you can definitely argue, of course they have other rehab needs and maybe they develop like neuropathic pain and spasticity and other sleep issues and mood issues, but you can argue diabetes and hypertension, particularly diabetes. So if they're a new diabetic, teaching them to like, or their family to use a glucometer, how to, you know, their diet, there's a lot from a rehab standpoint. Often we talk about simplifying diabetes and hypertension regimens so that it's practical for someone with stroke-related impairments to carry out at home and so that they can comply with the regimen. All too often in acute care, right, they give them these crazy diabetes regimens. There is no way for a patient who is like, their family's trying to learn how to transfer them and to like puree their food. It's very, very difficult for them to carry out at home. By working with them so that they can learn self-management and simplifying the regimens to something that they can comply with, it really does help justify the higher level of care. And also we didn't really talk about dysphagia because our two cases didn't have it today, but that's another thing that really helps justify a higher level of care. There's a lot of ongoing evaluation that's required. You have to monitor their nutritional and hydration status. And whenever that is part of their rehab diagnosis, we just want to emphasize that greatly. And I had one more thing. I mean, those are all great points, but another thing that I always try to emphasize when I'm doing the peer-to-peer or what I'm explaining to students, residents, physicians, something to keep in mind is a lot of these facilities, acute rehabilitation facilities, right, they're either part of the hospital or they're freestanding. They have access to a lot of consultants, which some acute facilities don't, right? So whether you have an endocrinologist, which is in my hospital, internal medicine physician, infectious disease physician, right? So you have all these tools you could utilize in your hospital to tweak, fine-tune what you need to do, do some family training, things of that nature. So I always refer to acute rehab as an extension of the acute care hospital. It's like a step-down med-surg unit, if you think about it, with all the tools you could do and all the things you could provide versus a subacute setting. So that's how I usually like to refer to because think about a subacute setting, you don't have not only the consulting opportunities, except for maybe a few cases here and there, but you also don't have that education. The nurses are usually stretched very thin and things of that nature. But in acute rehabilitation, I think it's almost like I would refer to as like a med-surg floor. Right, so I would just circle back and I don't disagree with anything anyone said, but a lot of people are saying that they're really getting eaten up in the audits, talking about blood pressure and diabetes and hyperlipidemia. And while I think all our panel made great points, and I think those things add to the complexity, the things that I would really hang my hat on whenever possible are those more rehab issues, the cognitive deficits, the spasticity, the pain, and then add, layer those diabetes and hypertension on top of it because all of that together paints the complex picture, but there's gotta be a little bit of a rehab nugget there. And to go back to something Dr. Steinberg said, you may do that very, very well and still get denied. I mean, that is unfortunately the level we're in, but I think you have to do some of that. I would just add to that, like dyslipidemia, sure, because it's not gonna change much day to day unless like I have to stop their statin for some reason, but it's more how you document these medical conditions as well. So if it's just like continue metformin, yeah, that's not gonna really justify the involvement of a physician. But if you write something like, oh, patient just got their CTA, so I can't put them on oral hypoglycemics yet, we'll monitor their oral intake and renal function, and then likely start an oral medication, and we'll instruct in the performance of glucose checks. If you make it sound like more of a rehab plan rather than something that is written in the hospitalist note, those things will usually be acceptable. It really is a matter of how they're documented. Yeah, and to add to that, I would just say like to Lauren's point, if somebody had dysphagia, right, and they had diabetes, and you know they're not eating completely, and you have to really be careful on their blood sugars because their intake's gonna dictate their blood sugars, and that affects the rehab plan, you can kind of tie it all together. Just one thing I would say, looking at the chat, I know how discouraging it could be if you get denied, right? So you get these audits, and you get denied, and you think, oh my gosh, what do I have to do to get this right? Remember, the auditors are in play not to prove that you're right, they're to prove to you that you're wrong, right? That's the whole point of an audit. And so depending on your risk tolerance, depending on your perseverance, and your institution's perseverance, these are cases that you would wanna fight, and you're gonna wanna fight them as far as you can fight them because the reality is just because they said no doesn't mean they're right. And as you continue to go up the chain of folks who help make those decisions about whether something's appropriate or not for a rehab level of care, the higher up you go, the better chance you have of making a more complex argument, and have people really understand what you're trying to say. So it is painful, right? No question about it. It's discouraging, it's annoying, and it's frustrating, but just because even a judge might say something, just because they're a judge doesn't mean they're right. And so don't be afraid to fight that, and don't be discouraged by initial negative opinions. I agree. I wanted to just pick up on what you just said, which is that these can be discouraging, and it takes some skill in being able to be a patient advocate and a system advocate. And those skills I'm hearing all my colleagues kind of talk about require a certain amount of emotional intelligence because you're gonna be communicating and talking to other human beings. You have to read the room. Hopefully, I mean, you get advantages when you can do a peer-to-peer and you can connect with someone. One of my secret weapons in practice for many, many years was knowing Dr. Patel, who is the medical director for Blue Cross in Michigan, and we were buddies. And she'd call me up and say, hey, how are you doing? How's the family? And we'd kind of talk first. So we knew each other, and we had that basis of a relationship that then we can say, oh, let me just tell you about this one. I think we can get through this one in five days. You know, it's not as complicated, but I really do wanna have them here. But we developed a level of trust. So I think that's a skill that we could all kind of develop. You don't always have that opportunity, but I think in rehab, it's something that we should develop, communication skills. Secondly, not all of our communication is all warm and fuzzy. Some of it is around conflict. So understanding how to manage conflict and be a conflict-competent advocate is really important. And those of us who are in some leadership roles are often involved in some kind of sticky, wicked conversations with people where the stakes are high. So I'd strongly recommend if you haven't had some training or read some material about conflict management, it'd be really, really helpful to do that. And finally, I was just gonna comment that negotiation skills are critical. All of these dialogues are about a form of negotiation where you're trying to sort of develop a position and ask someone else to kind of move in your direction with providing resources or making some other kind of commitment to an agreement. So I think I just wanted to emphasize that. Communication skills, conflict management, negotiation skills are really important. And finally, don't take all this too personally. People are hired just like I took the negative argument. It doesn't mean I really believed it. So in some cases, you have to kind of engage in these dialogues recognizing that the stakes feel high at times because we care a lot about the patients and the outcomes, but don't take it personally if people are arguing against you and try as best you can to stay calm in the midst of the storm that you find yourself in because it can be very easy to internalize stress and that builds over time. I think everybody can recognize that. It's a very good point, David. I wanted to just add to that real quick. And one of the things you mentioned is relationship building and whether you build in those relationships with peer to peers over the years that you've practiced with them or judges with the ALJ cases, I think it's important to recognize when you have a case and when you don't have a case, right? So, you know, you can't jump on in every case and thinking, all right, well, this guy walked like 600 feet and this was an appropriate guy for acute rehab, and you're trying to prove the medical necessity. I mean, you gotta know and kind of pick your battles, so to speak. So sometimes I noticed through, and that's kind of trial and error as you speak, and you know, you let the judge know, look, I don't wanna waste your time today. This is the case, completely, 100%. I agree, this was not an appropriate case, but then right, the next case, you start to prove your point and they start to be more lenient. You start to develop more and more relationships with them. So next time they try to prove their point, next time they trust your opinion a lot more, same thing would appear to peers because you do run across the same people over and over again. Well, I just can't thank our audience enough. Everybody has really donated a ton of time and expertise and really made this conversation what it was. And so thank you to our panel tremendously. Thank you to everyone who turned in. Hopefully this was educational and thought-provoking in some way. It will certainly continue to be an interesting and timely topic as things evolve. And so we'll have to see where it progresses. It sounds like the conversation has slowed. Certainly the chat has. I'll let everybody log off and go home. I personally will stay on until the end of the session, which is 8.30 in case anyone does have comments, questions, or concerns that they wanna talk. But I just wanted to thank everyone from my panel to our participants and AAPM and all for putting this on. Thanks, Craig. I did see there was a question about when cases, the last one, if the case was not appropriate, why would you take it to an ALJ? And I think that's appropriate. I haven't been at an ALJ level in a while. Have one of you gone through an audit and a review recently? Yeah, we've gone up to ALJ level. And I think sometimes you see an initial case and you think you see it one way, right? And then you kind of work your way through it and you work your way through it. And when you get to the ALJ level and you're doing it one more time, and you're looking at the counter arguments that they might've made in the level one and level two, you might actually realize, like right before you're presenting the case that, oh, wait, you know what? Maybe this one's not as strong as I originally thought. Maybe that's a new information, things of that nature. But you also have to be aware of like, I think one of the challenges you have with ALJ cases is depending on who's driving your utilization or your case reviews, like for us, I don't get pulled in until the ALJ schedule on some cases, right? Because I'm a medical director of 170 beds. I don't see every single patient. So my assumption is my team has sort of done the due diligence and if they're pulling me in, it's a legit case, but I might come in later and say, you know what, I'm not so sure about this. And if that's the case, it's okay to step back just so long as everybody's on the same page. So it's not always me as the individual who's making that call. Sometimes you get pulled in on the back end and you have to make the call maybe right before the case goes right to trial. Yeah, likewise, I'm kind of the same boat. So sometimes I get ALJ cases from Phoenix, Arizona, or sometimes Texas. Clearly I'm not seeing all those patients, but since I deal with all the companies, ALJ cases, it's kind of a similar situation. I'm not aware of it until the actual call with the judge. So I prepare and I read through the case, but I never like to withdraw because that's what I mentioned before, is if you withdraw, you're not really getting anything. I'd rather go on and tell the judge, look, Your Honor, I don't wanna waste your time. For the sake of time, this is completely our mistake. This was not an appropriate patient, whatever the case is. This is not an appropriate situation. And by that, you gain their confidence and trust. And I noticed it almost every single time because a lot of these ALJ cases like scheduled back to back with the same judge. So because you gave that one up, the next one, you might not have much of an argument, but they'll give it to you just because you were honest and they respect that. So I remember a lot of these judges also, some have extended knowledge in terms of the healthcare world and some don't. So really how you approach it, it's a really human connection and relationship building over the years. Yeah, and sometimes, just in fairness, sometimes you don't even say anything. Sometimes the judge will come on and say, well, I don't know why we're discussing this. This seems clearly appropriate. And you're like, okay. That does happen. The other thing that when I had gone through the audit previously, there were a lot of technical denials because some element was not completed or it was completed out of the timeframe required. And I used to get very upset about those things and argue that those technical denials shouldn't have happened. But the bottom line is that those policies are in place. And for Medicare cases, it's just if it's missed by one of your colleagues or what have you, there's nothing to stand on. You can't argue that if you miss the three-day rule that somehow you can get that accepted. But that also puts a lot of pressure on us as program directors, medical directors to have processes in place to as much as possible be compliant, make sure that the H&P is done within 24 hours, make sure that all the elements. It was a lot more complicated when we had to have that pre or the post-admission physician evaluation. Now, with that having gone away, we still have the requirement to complete all those elements on time and to create good systems for reminding docs to get them done and avoid the missed IPOC. Could someone explain the ALJ cases, what exactly that means? Well, why don't you go ahead and curl. Now I was gonna say it's not a fun process but it goes through certain levels of appeals and level of appeal one appeal to, and then it gets to appeal three where you get in front of the judge and the phone and you basically have to, you know, it's on you to prove the case. Otherwise, it was already denied. And you have to convince them that it's, you know, there really wasn't a case, but it's the claim. It's, you know, they always say they're non biased and, you know, based on the previous decisions, but I find that sometimes to be not the case, which creates some challenges. I've seen a lot of pro, sub acute, you know, opinions and things of that nature, but it's basically you one on one with the judge if you're lucky. And if you're very unlucky you have an expert physician that's testifying and you have an expert person testifying on behalf of CMS. Yeah, and just so you know like the ALJ stands for administrative law judge so these are judges that are employed by the government specifically Medicare hires them to make independent decisions on on different aspects of care delivered for any Medicare beneficiaries. And to Carl's point, sometimes you're not really sure what you're going to get sometimes you have folks who are very much patient pro patient and look at the benefits and try to support why a patient needs them sometimes you have folks who are more pro Medicare and they might assume that because you're coming to that case you are, you know, the greedy rehab provider who's just trying to take resources away from Medicare and make your case when when clearly a patient should be at a different level of care. I think it's an important thing to know when you're dealing with the ALJ there's an added level of complexity, especially if you're dealing now more with the Medicare HMOs and you get to an ALJ level for different scenarios. And there's a there's another bias implicit in that which is some judges look at it as though the Medicare HMOs are the greedy ones who are not executing Medicare correctly which maybe works to your favor. But it's just important to understand the dynamics if you ever do go in front of an ALJ that it's, you know, I think we all, you know, if you watch TV you think oh yeah, you know, you watch all these, you know, shows that have judges and lawyers and things and you think oh well you know it's a judge they're independent they're going to be unbiased are going to make a fair decision. Judges are people too. They have their own biases. And, you know, that's not always as clear cutter as independent as you might think. Thank you. That was really helpful. Just to kind of make sure I understand it sounds like a peer to peer occurs when you're trying to get them to inpatient rehab and then ALJ more comes to light in an audit situation and there's trying to say no that wasn't appropriate we're not going to pay you appeal you're like yes it was this is why they deny you appeal against like multiple appeals then you get to the ALJ level and that's when a judge helps make the decision. Perfect. Thank you. Yeah, I'll put in the chat if you go to the CMS.gov website there's information about how to make appeals and grievances. Some of that is focused on consumers being able to appeal because the patient themselves has the right to appeal a denial. And there can be a representative. There's a, there's a very detailed process and I, I was also clueless when this first happened and we got a letter that notified us that we were under audit or that they had denied cases, and our hospital attorney was able to kind of walk me through the process and help me understand what was required in terms of our, our requirement to notify them and their timelines that are required to appeal. And then there's multiple layers of appeal that that occur, and successfully we, or successively we get notices that your appeal was denied and then if you disagree, please file this you know follow this process to, you know, appeal again, and the final step is getting in front of the administrative law judge. And at the time, it was like a phone conference that was set up nowadays I think it'd probably be a zoom call and they're very backed up so it can take years before these things are actually kind of like, you know, have a hearing. But it can be very time consuming, stressful for all parties involved. And as someone stated in the, in the chat. If you get your hand slapped and you get a bunch of denials, your organization may decide that it's not worth it and they're going to make policies that say we're not going to admit these patients we don't want denials. At the same time, you might be in an institution that says you know what, we're going to take the risk. We're going to just you know admit everybody, you know, and maybe they won't, they won't challenge us and we'll get patients you know approved and we'll make more money because we took a bunch of patients that didn't really need it but they got through. And that's also puts the physician in a risky situation. So, as, as a medical director or inpatient rehab doctor, it's your responsibility to, in the long run, you should be making these admissions decisions, not an administrator, not your hospital, or the finance people. Ultimately, it's your reputation and your license that you're putting on the line and you should be able to make decide who meets criteria and who doesn't. Yeah, that's super helpful. Sorry, sorry to interrupt. Thank you. Thank you for the excellent question. So we'll wrap up now. Thank you all so much for coming. If you're anything like me, maybe in a day or two, you'll have more questions that come up, please throw them on the FIZ forum. I know we all check that from time to time. It's a great way for everybody to get in touch. We will certainly get a good panel together and address it. So thank you, everyone. Have a great night. Thank you for joining us on this Wednesday and, and be safe. Transcribed by https://otter.ai

rehabilitation physicians

medical necessity

intensive rehabilitation therapy

patient care

acute setting

peer reviews

ALJ cases

complex medical conditions

care coordination

documentation

conflict resolution