Hello, everyone, and welcome to AAPMR's Member May Series, Fighting the Good Fight, Insights on Inpatient Rehabilitation and Admission Changes. Just a few very brief housekeeping notes here. The views expressed during this session are those of the individual presenters and participants and do not necessarily reflect the position of the AAPMNR. AAPMR is committed to maintaining a respectful, inclusive, and safe environment in accordance with our Code of Conduct and Anti-Harassment Policy, which is available at aapmr.org. All participants are expected to engage professionally and constructively. This activity is being recorded and will be made available in the Academy's online learning portal. An email evaluation will be sent after this activity with a link to bring you to the recording and evaluation. For the best attendee experience during this activity, please mute your microphone when you're not speaking. To ask a question, please use the raise your hand feature or use the chat feature to type your question. Thank you very much, and now here's the Session Director, Dr. DeTomaso. Hey, everybody. Thanks so much for joining us on a Wednesday evening. I know everybody's incredibly busy, and so we really appreciate you taking time to talk with us about things we've learned for inpatient rehabilitation admissions. As already mentioned by Mr. Graves, you can certainly raise your hand or, better yet, put the question in the chat, and we'll get to it just as best we can, but if you're like me, usually the best questions come to you five, ten, maybe five hours after the talk is over. If you want to reach out directly to me, I've included my contact information, but what I would really encourage you to do is to post it on the forum. This talk is a manifestation of the inpatient rehab community. We are active on the PHIS forum, and this was a topic that was requested there. If you have other follow-up questions or if you'd like to propose further talks, that's really the best place to do it. Next slide, please. Every PowerPoint, for some reason, has to have objectives, of course, and these are ours. We're going to talk about the basics of inpatient rehabilitation. We're going to talk about the new opportunities and changes that come with the inpatient rehab choice determination program from Medicare, and we're going to look at different ways to deal with private insurance, primarily through retroauthorization. Next slide. I'm Craig DiTomaso. I'll be your moderator, and I have a very esteemed and accomplished panel. We'll introduce everybody quickly, and then I will turn it over to them. Next one. That's me, Craig DiTomaso. I'm primarily inpatient, but I also do acute care and skilled facility consults. I have some academic titles. I work as the chief clinical officer for U.S. Physiatry, and I do have some disclosures. I've been consultants for multiple robotics companies and post-acute care companies. Next slide. Shannon Smith-Hamilton is the medical director at Emory Healthcare in Decatur, Georgia. She also serves as the Georgia regional director for U.S. Physiatry and has accomplished a tremendous amount and has great success there in Decatur, which she'll talk about in just a minute. Next slide. Dr. Keith Foster is a regular to these talks. He is the chief medical officer for Baptist Bethesda East and West Hospitals. He is a distinguished physiatrist and, again, has contributed quite a bit to the AAPMNR and to these talks. Next slide. And last but not least, Vishwar Ra. He is the chair of PMNR at Wake Forest. He's the director of Carolinas Rehabilitation and the chief of cancer rehabilitation and has been an incredible asset to AAPMNR as well. Next slide, please. As you probably know, if you're engaged in this talk, a patient is usually identified somehow as a rehabilitation candidate, either by an internal medicine physician, a PMNR physician, a case manager, whatever. Some type of rehab personnel, either a clinical liaison or physician, executes a pre-admission screen. That patient then matriculates, hopefully, to a rehabilitation facility where the rehab physician does an H&P note. They do an IPOC within three midnights. That patient then executes the rehabilitation program as prescribed by the physiatrist. The rehab physician then documents a discharge summary. The rehab facility submits all of that information to a payer, and then they get paid, and that's the typical flow. But lots has changed in Medicare since this original kind of flow or outline was created, and so we're going to look at how that's changed and how we can do better. Next slide. Just as a reminder, CMS has pretty, it's the right word, nondescript guidelines. If you look at the source material, just that the patient really needs a multidisciplinary team, that they benefit from that interdisciplinary therapy, that they have the ability to improve, that they have medical management needs, and that an interdisciplinary approach is required for optimal management. Next slide. And when we look at denials, the things that commonly come up are the lack of medical complexity, the lack of 24-hour nursing needs, the lack of the high-intensity rehabilitation services, the interdisciplinary approach is either not well-documented or not seen to be required for that particular patient, the care plan is not considered coordinated, there are practical improvements that are unlikely for that patient given their situation, or the goals are not realistically defined. And those are the things that typically come up for those of us who are involved in the audits. Next slide. So this is all evolving, as I mentioned, and I think I've assembled a team of experts here, and hopefully you'll find their presentations to be enlightening and educational, and so I will turn this over. Dr. Shannon Smith will go first. Okay, thanks, Craig, and thank you for the wonderful introduction, and hello to everyone. Yes, my name is Dr. Shannon Smith, Shannon Smith-Hamilton. I am medical director at the Emory-Decatur Hospital Acute and Patient Rehab Center in Decatur, Georgia. I started being a medical director in 2018, and Emory-Decatur Hospital is more of a community-based hospital, so our inpatient rehab center is more kind of community-based. We get referrals from both community-based as well as academic facilities. So when I started seven years ago, I noticed that the day of onset to admissions was very high, meaning the day the patient was admitted to acute hospital to referral and then finally getting admitted to inpatient rehab was over two weeks or so, and I was kind of curious to why specifically that was happening and how we could specifically decrease the barriers to coming to IRF. Next slide. So a couple things that I saw specifically to barriers to coming to us. Number one, the delay in therapy evaluations, which overwhelmingly leads to a delay in the referral basis, so from case management and social work. So if there's not appropriate communication between therapists, there won't be any communication ongoing between social work and case management as well. Number two, medical changes, and that was definitely on an acute-to-rehab basis. Some things would happen to obviously to the patients, but we wanted to specifically look and see if we could actually manage some of these acute medical changes specifically on rehab, which allows for the patient to come at a quicker time and for insurance to approve it. The infamous and what I hate specifically, the case management blast referral, right? You have the pressure to discharge a patient, and the case manager sends a plethora of discharge dispositions, right? Are they going to IRF? Are they going to skilled nursing facility? Are they going home with home health? This automatically pretty much denies a patient coming to inpatient rehab because obviously if they see their needs can be met at lesser male care, that they don't specifically need to come to inpatient rehab. So we need to specifically discuss to our case management team not to do that. And obviously the peer-to-peer, the denial. So how can we specifically empower our referral basis, our hospitalists, our physicians, our providers who are wanting these patients to come to rehab? How can we provide them or empower them with the tools to complete appropriate peer-to-peer? Next slide. So one thing we wanted to take a look at in TASC is really getting to know your referral base, the who, what, where, who, why. So who are you getting referred to? Are they coming from a community-based hospital or are they coming from an academic hospital? Are there areas for improvement? And you can obviously target this to your own inpatient rehab referral basis. Are there specific specialties that are actually more targeted? Are the neuro team actually cutting you down specifically for referrals versus any other team transplant? Transplant teams, cardiac teams, ortho teams. Who's actually specifically is your inpatient rehab facility being targeted? What is specifically the average day of referral? When are specifically your patients getting referred? Are they getting referred early? Are they getting late specifically when case management is trying to discharge the patient? What is the diagnosis or most common diagnosis that you're seeing specifically that are coming through through your IRF? This also deals with Medicare compliance and obviously we'll talk more specifically about the Medicare compliance rule and maybe there's some room to change specifically who you're seeing on inpatient rehab. And of course, the whys. Are the therapy evaluations getting done in appropriate time? And once again, is case management getting more disposition pressure versus actually truly seeing what the patient needs from an IRF perspective? Next slide. Also, not only knowing your referral basis, but get to know your own specific stats specifically on your inpatient rehab comorbidities. Things such as your case mix index, and that's obviously something through Medicare that actually targets, if you don't know what a case mix index is, your average complexity specifically, as well as your comorbidity tiers. Obviously, the more complex a patient is, the higher the case mix index, the higher reimbursement rates as well. Once again, thinking outside of the box at some of these nontraditional patients. Can they actually specifically come to rehab and can their needs actually be met? And once again, those average length of or onset days, how can you specifically target and decrease those days from days of admission to when a patient actually comes to rehab? Obviously, delays for referral and specifically when medical stability is deemed is not necessarily best for it. Next slide, please. The therapy evaluations, and I tell specifically on my referral basis, once they feel that that patient hits the floor and most likely will need rehab, do not delay those evaluations happening. As long as they are medically indicated and appropriate for treatment, it should happen specifically on or close to day of admissions. Certain diagnosis should automatically obviously trigger therapy evaluations. Obviously, your bread and butter neurological, your brain injury, your spinal cord injury, your strokes, et cetera, your major multiple trauma. Anyone who gets in a type of accident, has at least two fractures, that should also be targeted. Targeting those trauma patients as well. And then our cardiopulmonary disorders. Patients, for example, who have advanced or severe COPD or CHF, those should also be evaluated by therapy as well, too, to see specifically what they need from a cardiopulmonary standpoint from rehabilitation. And once those therapy evaluations are completed, obviously, the recommendation should be documented in a timely manner and discussed with the case management and or the provider as well. Next slide. So, updates to case management. Once again, sending those referrals to both IRF and SNF can actually delay appropriate discharge. Remember that being at an inpatient rehab facility costs almost as much as being on a daily basis being in an acute facility. So, insurance providers will want to push someone to a lesser level of care and not requiring as much and costing as much. So, why specifically are you sending case managers or sending IRFs and SNF referrals at the same time? Kind of lets the insurance company know that it's okay to send to a lesser level of care and not necessarily paying out as much as it needs to be. Your liaison needs to be the sale person for IRF, right? So, they need to sell the needs specifically of why this patient needs to come to IRF versus going to SNF. So, definitely target them, making sure that the therapy evaluations are completed, the updates are accurate, and collecting any specific data. So, you do need specifically help from your liaisons or your provider who's completing consultations to get that communication specifically with the case manager and the provider for a referral base. Also, thinking specifically about changing medical status. So, can some of these medical status, sometimes things are delayed because of the fact that certain things may change specifically on acute side before they come to rehab. So, for example, if a patient needs a transfusion, can you do that specifically on acute and patient rehab but not without delaying or interfering with therapy? So, this also lets me know that, yes, the patient needs acute and patient rehab for medical complexity realm. So, if a patient is hypotensive, can they get IV fluids or medications that they need to actually help out versus waiting for that blood pressure to be stable prior for them to come to rehab? Next slide. So, complex subgroups that we've specifically considered on our IRF population, we've got, you know, definitely good results in. They have gone home versus going to skilled nursing facility or any other lesser level of care. So, organ transplant patients, if you feel that your staff can specifically take care of them as well as oncology patients as well. Patients who are immunocompromised, obviously puts you in the higher CMI as well as the tier level as well. LVADs, that's those left ventricular assistive device patients. We've actually got a huge increase in patients who need that from a cardiac standpoint. So, just showing, and our nurses have been trained on LVAD care as well, too. So, as well as been cross-trained on some of the transplant as well as oncology patients. So, training your staff, too, can also lead to these more complex patients coming through and getting higher reimbursements from an IRF perspective. So, patients also greater with the BMI greater than 50, as well as advanced age. You know, our patients are aging. We are all aging. So, you are going to see those patients, specifically who are 85 and over and have these medical comorbidities. So, once again, really gearing and targeting on the medical complexity and the need for the patient to stay in IRF to address these issues prior to going to anywhere else. Definitely, definitely hype that up and talk about that as well. Contact precaution patients. So, which also can increase your CMI. Patients with candida RS. That's a big one that Medicare has also looked at as well, too, as well as these multi-resistant drug bugs. So, you know, the complicated, the E colis, the VREs, things of that nature can also increase your CMI and gear patients to come to inpatient rehab versus going to a SNF or any other type of care. If your IRF can actually take trach patients, drains that just need to be flushed, you don't have to wait for them to be removed and you can actually manage them specifically on your unit, as well as PD or hemodialysis patients as well. And patients requiring moderate wound care. So, for example, patients that may or may not need some wound care changes on a daily basis, not taking over, you know, or not interfering with therapy time. Patients who need WoundVac or WoundVac changes or things of that nature. If your staff is appropriately trained with that, you can potentially take them and that can increase your CMI and your tier levels as well. Next slide. So, completing peer-to-peers. You know, that's kind of the vein of our referring physicians and our providers, too. You know, they always get the call of, hey, I want this patient to come to inpatient rehab, but, you know, the insurance company or they've denied them. What do I do? What do I say? Because, you know, they have not been trained in that. So, once again, you have to be an advocate for your patients or your patients who are coming to. So, I've kind of instituted like a little bit of a cheat sheet to kind of let them know what are the points that they really need to complete these peer-to-peers for these patients to come to inpatient rehab. One of the big things that I see is to tell them, make sure you know when the peer-to-peer has to be completed, right? Because there's always a time frame for that. So, sometimes, you know, they'll give you two days, sometimes one day or whatever. So, make sure that you know that timeframe. Make sure that they talk to the case management about that. And set a reminder, too. I always tell them to put them in the phone. So, this is the time and put it in red, you know, to complete this peer-to-peer, specifically to get your patient over to us. Make sure that the reviewing clinician who's completing the peer-to-peer is qualified. So, most insurance carriers state specifically in their bylaws that clinicians reviewing prior officer peer-to-peers must have expertise in reviewed areas. I put specifically on the cheat sheet to let the providers know, hey, when you're completing this peer-to-peer, ask very nicely, hey, do you have experience with inpatient rehab? Are you, you know, are you necessarily trained in that area? If you are not, you know what, hey, I would like to talk to a physician who specifically is trained in this area or knows specifically about rehab, because you want somebody actually to be a peer of this, right, to actually, you know, target and understand specifically what's going on and what the needs are. This is the next portion is what I specifically put on the cheat sheet for them to complete. So, making sure they know what the diagnosis is. Make sure that they target that medical necessity of the patient still being seen by a physician or a group of physicians who are going to treat these needs. But guess what? The patient also needs at least two out of three therapies to complete rehab. And just really talking about the multidisciplinary approach. And also gear up the fact that the patient, the risk that the patient may face without getting inpatient rehab. So, if a patient goes to a skilled nursing facility, if this patient already has wounds, is the risk that the wounds may get bigger? Are the patients or the risk that the patient who is a COPD candidate, their COPD may not be managed by the certain medications or pulmonary is not there to complete it? Really, really talk specifically not only the benefits about coming to inpatient rehab, but the risk about not coming to inpatient rehab, what specifically may happen. And obviously, if they do get a denial, make sure that they document the reason. So, if something needs to be appealed, we can help out with that. Next slide. So, in summary, just making sure that you know specifically who you're getting referrals to. Open communication is key, right? This is a business. We want good rehab patients, but we also want to have patients who have successes as well, too. So, making sure that you communicate with your referral basis of what you're looking for, you know, what your needs are. And also to definitely talk about please refer early, right? Because we can actually help out, get the patient in quicker. So, the earlier the evaluation, hopefully the earlier in the rehab admission as well. So, make sure that you obviously give them the strategies to complete an appropriate peer-to-peer. And take the analysis and learning experience, not only for inpatient rehab, but the referral base. And just keep an open communication, and don't always forget to be an advocate and a champion for your patients that are coming to rehab. That's all. Thanks. All right. Thank you very much, Dr. Schmidt. That was fantastic. Tough act to follow. So, I'm Keith Foster. I'm Chief Medical Officer at Bethesda Hospital East and West, part of the Baptist Health South Florida system. We have a 36-bed inpatient rehab unit inside my hospital. And I'm a physiatrist by trade. I still dabble in physiatry, even though I'm in the administrative role. We'll go to the next slide. I was also quite involved in the Rehab Choice Demonstration Program when it rolled out in August of 2023. I was one of the initial docs reviewing cases for them. So, one quick note, kudos to the AAPM&R. For those that don't know, the AAPM&R and the other advocacy groups really pushed back when Medicare started this program and made sure that a physiatrist was involved in any denials or reviews that occurred. So, I personally think it made a huge difference. I worked with the team in the Medicare contractor group, and they leaned on me a lot. There was a lot of things they didn't know. There was a lot of, you know, real-life physiatry input that I was able to give that made a big difference in how this program was structured and the other physiatrists involved. So, you know, it's a great, great point for advocacy for AAPM&R. It made a big difference. So, for those that don't know, it started in August 2023 in Alabama. It's expanded to Pennsylvania now, and there's other states, you know, on the docket. The program essentially, in their thought, reduced the number of Medicare appeals, improved compliance, and did not alter the benefit and should not delay care to Medicare beneficiaries. But it did review some of the general guidelines to make sure that the people that were in IRFs were appropriate. It is important to note that this only occurs for straight Medicare patients, not Medicare Advantage or any other insurer. The facility had a choice to either do pre-claim review or post-claim review. We can go to the next slide. After a six-month period, the IRF had an opportunity to decide whether they wanted to continue with pre-claim review, select post-claim review, or do spot checks based on their compliance. The next slide. Pre-claim review, which was the majority of what I did, really basically looked at a chart review of a patient that was reviewed within the first 48 hours of their admission. Patient arrived to rehab. They got their initial H&P, typically had an EIPOC and a bunch of therapies, and then the chart was sent over electronically, including the pre-chart, if we had it, to review whether the patient was appropriate for rehab. Just like any other review, we were looking at the prior level of function in the PAS. We were looking at what was the requirement for rehab, the expected level of improvement, the risk of complications, the medical necessity, the anticipated length of stay, the therapies needed, and some of the bread and butter, conditional denial type thing, technical denial stuff. Was there a physician signature? Was there a date that occurred before the actual admission occurred? All that kind of stuff. We reviewed the H&Ps, the skilled notes, the orders, and interdisciplinary team notes, if they were available. And really, the piece was to look, did everything match? Was it a real individual story? Could the patient participate in therapies? Was there a thought process that occurred before the patient came to rehab to show that they needed the three hours of therapy and they had a medical need? You can go to the next slide. Thank you. So, similar to other insurance-driven reviews, a nurse reviewer grabbed the information for us, did an initial screening, determination was made to approve or not. If it was not, or if it was more information, it was sent to the physician reviewer. So, no cases were ever denied without a physician reviewing it. The physician was a PM&R doc. Many times it was me. There was another doctor involved who was the medical director. I did this part-time to help out as they were starting the program, but there was at least one other physiatrist that was full-time. And then the physician receives the same information the nurse does. It's really quite a robust, full chart. Sometimes thousands of pages, as you can imagine. It's like getting a transfer from outside hospital. You get thousands of pages of sometimes the same stuff over and over again. And you either affirm the IRF care saying, yeah, it looks like this was appropriate, or we can decline slash request more information. And really, we never declined. It was always right now, based on what we see today, I don't have enough information to say that this makes sense. Something's missing. You know, something's going on. And then that information was sent back to the IRF for more information and detailed questions or concerns. Next slide. So, you know, a couple of different things I learned just being a general physiatrist overseeing this program and helping with it, and I think there are keys to people who are undergoing it. You know, the biggest denial was really inconsistent documentation. We saw charts that really just didn't make sense. You know, if you were even a layperson, you couldn't really put the pieces of a Tetris game together. It just didn't all click. There was either, you know, goals of independent in 10 days for someone that was total care or a need for PTOT speech with no speech noted and never ordered, or, you know, the opposite I saw where speech was on board but never really documented. There was no understanding of why. PAS would list a whole bunch of diagnoses that are not really supported by clinical evidence or documentation. You know, a lot of these were some of the, like, clinical strokes, I like to call them, where imaging was negative, which is fine. We've all seen them in our career, but then the notes wouldn't really justify any of that. There was no understanding of, you know, the physical exam matching. PAS was either incomplete or unclear therapy evaluations. There were some patients that had a fall in a primary care office and then ended up in rehab. There was really no clear connection as to what happened. Patients that were in home health services that ended up in rehab with not a real clear connection and then the ER visit to IRF, which we've all seen patients that are appropriate for that, but it really lies onto the physiatrist to document what the medical need and the rehab needs are. And a lot of times that just wasn't present. Patients unable to tolerate therapies, which again, we've all seen patients that need a little ramp up or need, you know, seven days of therapy to start, spread out, but really very limited documentation for that. And then unstable on arrival with really, you know, no real clear plan or too low level altogether with unrealistic goals. And then, you know, again, the total care to modified independent permanent disabled patients without a clear discharge plan are really goals for therapy. We can go to the next slide. So for the main piece for recommendations, you know, I always tell people you're the captain of the ship, right? You're the physiatrist, regardless of, I know a lot of models out there are switching to more have the physiatrist be a consultant. You're still captain of the ship. The patient is still there at the end of the day for your expertise, not the medicine admitting doc, not the hospitalist, your expertise. You have to tell the story because, you know, as we saw in the peer to peer piece, our medicine partners can't do it. They don't understand the language. They don't understand what needs to be written. And I think it's really important that you put that on paper, quote unquote, or in the computer. Templated notes are like the devil for things like this, right? Because you have such cookie cutter medicine, but we all know rehab is not cookie cutter. Every patient is really individualized, and it's so important that we put that piece together. You know, oftentimes incorrect therapies and leave the reviewer wondering how personalized the rehab plan is, right? Because if you say PT, OT, speech, rehab, nursing, rehab, psychology on every patient and they're there just for PT and OT, that doesn't help anything. And it just leaves us with, you know, wondering what else is actually real in notes. Big piece I saw was consulted notes that had no matching at all to what the rehab doctor was saying. So sometimes there was some decent medical complexity in the notes from a medicine doc or a hemat doc, and the rehab note had none of that in there. And again, I look to the rehab doctor to be the captain of the ship and really be overseeing the plan and making sure that patient is stable to do therapies. No different to the reviews I do for acute care, non-rehab is copy and pasting doesn't show anything. You know, there are often cases where, you know, and I see this on the acute side, like I said, you know, CBC will follow closely and then it's not repeated for three weeks or it's repeated and it's never mentioned, even when it's getting worse. You know, the medical complexity is there staring in the face, but it's never really documented by the physician. Or my favorite was we'll follow closely and there was never a CBC ever. So and then we'll go to the next slide. So the biggest piece is really just justifying what the need is. We all see it. We all do a great job kind of making sure that the medical complexity is there. And what are you adjusting? What are you monitoring? If someone has low blood pressure and you're there making sure they can participate in therapies and you're ordering stockings and you're adjusting their medication, put it on paper. I can't infer what you're doing in the chart. I just get what's sent to me. So making sure that, you know, you're showing what can only be done at IRF, why your three visits a week are so important at minimum. Most of us see the patient every day, but not everyone gets to Modified Independent and that's OK. I think, you know, it's a shame that all we do is put, you know, continue therapies till mod I. And we don't talk about, well, the goals are min assist and I'm going to train the spouse on caregiver training. We're going to work with an aide to do ADLs. And that's great. You know, no one else can speak to that but us. That's our specialty. And then, like I said, if it's a low level patient and they're coming for quality life or caregiving training, if it's an end-of-life brain injury and we know that we can get them quality life when they get home because we're going to train the family to be able to care for them, I feel and, you know, I think it's justified. That's what we do. We're a quality life specialty. But if it's not on paper, it just looks like you're taking a total care patient and discharging them home in 10 days with total care. Reviews and comment on the therapy notes, you know, if therapy puts that the patient was unable to tolerate therapy today because of confusion, you can't just write continue PTOT. So that would be something to tie it to the whole day's events and then also tying it to the pre-admission. There were so many pre-admissions that I saw and I even see, you know, now that are just not tied to what's going on in the day-to-day. And it's okay to see something. We've all gotten a surprise patient that looked nothing like their pre-admission. Just talk about it. Write it in your notes. You know, patient more confused today, will follow with medicine, may need further work up for encephalopathy. But without that, I'm just left looking, wondering what's going on. And then the physical exam piece, this is like the bane of existence for those of us that teach and deal with, you know, residents and med students is if it's not in the exam, it didn't happen, right? I mean, there were so many patients I saw that had critical illness myopathy and five out of five strength throughout everywhere and no neurologic signs and write CVAs with no, you know, with noted hemiplegia, but then they had normal strength on the exam throughout the entire rehab stay. Encephalopathy with speech needs, alert and orient times three with no difficulty or my favorite the left BKA with sensation pulses and muscle strength intact bilaterally. So really just taking a pause from the rush that you're in to just make sure everything matches together. You can go to the next slide, please. So again, just in summary, you're the expert. It's your story to tell. If you don't tell it, you know for sure medicine's not going to, it's not what they need to do. Just like you wouldn't be expected to adjust antibiotics on the pneumonia that they're dealing with. It's very important that we tell that story, review the chart, make sure that everything makes sense when you close your note. Does the pre-admission make sense? Does it match with your consultant notes? And if it's okay, you know, it's okay if things are not going how you planned, but you got to talk about what your plan is and what's your pivot point. You know, if patient's struggling with therapies, but you're going to, you know, work on adjusting pain meds today and hope that over the next couple of days they're able to do more. That's great. It's okay. You know, cookie cutter templates, IRF is not cookie cutter. You know, SNF is. The SNF does the hour of therapy once every once in a while and minimal medical necessity, but we're better than that. And ensure accurate documentation from the pre-admission screen straight to the discharge summary. And again, I think, you know, we do this better than anything else. Look at the whole patient. It's okay to think outside the box. Just make sure you put pen to paper as to why you think the patient would do better in IRF than another less intense setting. That's really what insurances these days continue to focus on is, well, we could do this in a SNF or we could do this at home health, but, you know, trying to make sure that you justify why they're in the inpatient rehab and how important it is to have that interdisciplinary team. Next slide. All right. Thank you very much. We'll go to the next slide. I think we have Dr. Raj next. Yeah. Thank you. Thanks, Dr. Foster. Thanks. Thanks, Dr. Smith. I think both very informative talks. So I'm actually here to talk a little bit about denials and appeals for Medicare Advantage patients. This has been an issue that's been ongoing. And I think for most of you in inpatient rehabilitation, you're seeing a higher prevalence of patients who subscribe to Medicare Advantage rather than traditional Medicare. And along with that comes several challenges, especially regarding throughput from patients who are in acute care who then need to transition to a post-acute care setting. Next slide, please. So just as a caveat, this is an extrapolation of a talk that our team gave at the AMRPA conference in 2024 regarding the same topic. And so if you were there, you probably had a little more depth and we'll try to summarize some of the talking points and also reflect some of the key issues that you need to be aware of if you go down this route regarding appeals of Medicare HMO denials. Next slide. So the objectives are fairly straightforward, but I just want to give you a little preface regarding why we had to go down this route. I mean, as I noted, many more patients now are subscribed to Medicare Advantage plans. And although Medicare Advantage plans are advertised to provide the same level of benefits as traditional Medicare, there are several challenges that are associated with it, especially as it relates to the authorization process for post-acute care. So when we were looking at some of the challenges we had, especially in North Carolina and the South, as the number of Medicare HMO patients started to increase, we started noticing more challenges in our acute care settings where individuals were coming in with catastrophic illness or traumas or things of that nature. But because of their plan, we had challenges being able to transition them out of the acute care setting, thus backlogging patients in acute care, preventing new patients from coming through the emergency room, because there simply wasn't bed capacity. And so what prompted us to go down this route in this program was specifically to address this throughput issue and to be able to free up more of those acute care beds to make sure that the acute care demand can be met, but then also be able to utilize our rehabilitation beds more effectively. Next slide. So as I mentioned, traditional Medicare, for those of you involved in approval processes for patients going inpatient rehab, it's fairly straightforward. You evaluate a patient in acute care usually, you fill out the pre-admission screen, you make sure that you've met all the criteria for admission per Medicare, and then you can admit the patient to your unit or your facility. The catch on this strategy or this plan is that although you can admit people in a timely manner, there is a risk for denial of the patient, what we call post-payment denial. So after the patient stays maybe several weeks to months later, a contractor can review the case and then try to determine if you made the appropriate decision. However, if you have traditional Medicare, the key point is that it doesn't necessarily delay throughput. So if the patient's ready to go from acute care, you can pretty much bring them into your inpatient rehabilitation facility. The challenge with Medicare Advantage is that pre-authorization is required. So although Advantage plans are asked to follow the exact same rules as traditional Medicare, it still has to go through a review process. And routinely, when you put a patient through or try to get a patient approved for inpatient rehabilitation specifically, for some of the reasons previously mentioned by Dr. Smith, some of these private corporations that run the Medicare Advantage plan will say no, maybe because they think the cost of care is too high to inpatient rehabilitation, or they may have several other denial reasons like we saw with Craig's slides earlier on. Next slide, please. So the challenge then becomes, it's actually multiple challenges. When you have a patient who's in acute care who hasn't been approved, you have avoidable acute care days, which means that patients end up sitting in the acute care hospital longer and longer and longer, thus creating a throughput issue, but also creating a significant amount of frustration for patients and their families who are simply just trying to get to the next level of care so they can begin their recovery. Often, as Dr. Smith noted, you'll have teammates from the case management team or social work team who then blast out referrals to multiple discharge dispositions to try to get patients out as soon as possible, which might include skilled nursing facility, might include home health and others. The challenge there then becomes, now you're competing with multiple other facilities, even though the patient may be appropriate for your level of care. And ultimately, when you put all these things together, the patient doesn't typically come to inpatient rehab. So that creates several challenges for us on the inpatient rehab side who are trying to provide the appropriate level of care but simply can't get that authorization approved. Next slide, please. So let me preface this because I think it's important to understand our program. Our program is focusing on patients who are denied by Medicare Advantage plans and a strategy to overcome that. When you're looking at patients who are denied, there's two pathways you have to appeal the denial. One is a contractual pathway. That's one where we as providers might appeal the denied claim. And when you do that, here we list it fairly concretely, but it's a little bit variable according to which Medicare Advantage plan you're using. It's not as standardized. And so there are some challenges going down the contractual route, especially as it relates to administrative denials and your ability to appeal those. And we'll talk about that a little bit later. But then on the flip side, there's also the opportunity to appeal denial on behalf of the patient. So it could be the patient themselves who file the appeal or it could be another person who represents the patient if the patient is willing to authorize you to do so. And if you do do that, then actually the method of appeal is much more sophisticated. There's actually five levels of appeal, starting with reconsideration after initial denial and a secondary appeal to an independent review entity or a qualified reviewer. And then after that, there's a third level of appeal, which goes to an administrative law judge. And we're going to talk about that in a minute. Beyond that, then a fourth level will appear to the Medicare Appeals Council. And then if you're still not satisfied and you want to fight the case, you can go all the way up to federal court. So there are opportunities to appeal your denial. But in our case, because of the throughput issue, we found that there were actually several challenges regarding this appeals pathway. For example, if you had a patient in acute and you went for a standard authorization, the Medicare HMO plan may take up to 10 business days before they give you a decision. The reality is that an acute care hospital is probably not going to wait 10 days for a decision to decide where the patient's going to go, especially if they have alternate discharge plans. There are other ways to expedite that, but we'll talk about that as well in a second. But the reality is that in order to get a patient to move along more quickly, you have to have a process that can even move quicker than expedited appeals or standard appeals. So in our strategy, in our plan, the way we admit patients is we screen the patients. We look to determine if they're appropriate for our level of care. We submit for authorization. And while authorization is pending, we actually transition the patient to inpatient rehabilitation. Then we go through the appeals process if the patient's denied while they're receiving care in our facilities. So next slide. Okay, so just briefly to talk about administrative law judges, if you're not familiar with who these individuals are, they are sponsored by the Office of Medicare Hearings and Appeals. So these are individuals who were lawyers, who are now judges, who are appointed to specifically address claims regarding Medicare. They also serve many other purposes in the government, but these judges specifically work in the Medicare realm, and they look to determine the appropriateness of services furnished to beneficiaries under Parts A, B, C, and there should be a D there. And so when we're looking at inpatient rehab benefits, we're really looking at Part A. They also look to address any Medicare benefits and disputes on Part B and Part D premium surcharges. Now, the important thing to know about administrative law judges is that they are not physicians, and they're not necessarily clinicians. So administrative law judges are asked to make decisions on the appropriateness of benefits and the appropriateness of care based on testimony, based on submitted documentation. But it's extremely important as you're doing appeals that you have a very strong case and you can help try to justify it, because frankly, the administrative law judges at times will give interesting opinions on whether they think a patient is appropriate for your level of care. And I'm going to talk about that as we talk about the appeals process. So next slide. Okay, so when you go through the appeals process, like I talked about earlier, you can go through a standard authorization process. Challenge there is that the HMO plan may have up to 10 days to give you their initial denial. So right away, you see what the problem is from the acute care side. Then the problem is if you decide to appeal that denial, it might be 10 plus more days for a second decision. And then as you go through each level of appeal, assuming the patient stays in acute care, it could take weeks to months before you get the final decision. So that's probably not a satisfactory answer. And so for a lot of folks who actually go through the process, I would say in our case, at least historically, we found that when you got past level one, 35% of the patients at that point sort of stopped their appeal. So what I mean by that is as you're going through the process, you get to that level one, you get the initial denial, then the level one denial. After that, there are only 35% of patients that went beyond that. That's what I was trying to say. So only 35% of patients actually went beyond that level. So 65% of patients actually stopped and then found an alternative discharge plan. So one way to try to speed up the process is to put in for an expedited authorization and an expedited appeal. The difference is in an expedited authorization, the Medicare Advantage plan by law has to respond to you within 72 hours of your submission. And then on the level one appeal, they also have to give you a decision within 72 hours of the appeal. The way you justify an expedited authorization is to make sure that you have a medical justification that explains that the reason this has to be expedited is because if it is not, it will cause undue harm to the patient. So for example, if they stay in acute care hospital for three, five, seven, 10 days, you're at risk for hospital acquired comorbidities, DVTs, pressure ulcers, things of that nature. And so it's medically appropriate to request the expedited authorization because you're worried that by staying in acute care, it'll cause the patient more harm. Next slide. So in our process, we actually do go through all these levels of care and mindful that the patient after, even if they're denied or when they're still pending authorization, they've already made their way to our inpatient rehab. So we actually have gone through several levels of care all the way up to ALJ and actually for a few cases, we've gone beyond ALJ and we're going to the Medicare Appeals Council. The challenge with this process is it does require some amount of time, requires resources and effort. You have to have a utilization department that's very comfortable with the rules and very comfortable preparing appeals and providing the justifications, you know, like we talked about earlier to overcome the denials that might state that a patient's not appropriate because they don't have multidisciplinary therapy needs. Maybe they would say that they don't have appropriate medical necessity. Maybe they would say that they can be served at a lower level of care. So you have to have a team that's very comfortable addressing those issues. You also need a physician team that's very comfortable speaking to the medical appropriateness of the patient and why a patient would benefit from the inpatient rehabilitation level of service. And when we talk about medical necessity, it's not always like super deeper medical complexity where somebody is on IV fluids or receiving IV antibiotics or has major wound care needs. There's also medical appropriateness associated with the rehab diagnosis itself. So, for example, if you admit a stroke who has dysphagia or hemiplegia, spasticity, these are medically relevant issues that can be addressed in the inpatient rehabilitation setting. And so you just want to make sure you're really comfortable with the arguments for the patient you're admitting. Next slide. Okay, so in our experience, when we've gone through these authorizations and appeals, what we found was in 2023 and 2024, close to 50% of our patients were approved. But what that also means is at the first level of submission so they weren't denied necessarily. And that's even for the patients that we brought in while authorization was pending. Now, the challenge with that is that 50% of the patients were not approved. So when you look at it that way, we did move forward and try to appeal and make sure we went through the appropriate processes. And after we went through level one appeal, we actually still got a significant amount of patients approved. So in 2023, it was 42%. It dropped a little bit in 2024. And I think that was because at that point, once the Advantage Plans understood what we were doing, they decided that, several of them decided that if they felt strongly the patient wasn't appropriate for inpatient rehabilitation, that they would fight the case along with us. And then that would push the case downstream further. But in spite of all of that, when we did initial off level one appeal, level two appeal, and then we got to the ALJ level, what we found was that we were only bringing anywhere from three to 7% of the patients to the ALJ. So really what we're saying is 90 plus percent of patients were able to get approved before we even got to an administrative law judge. So I think that's an important point. So if you have enough confidence and you have a team that's very well prepared, you'll probably have a reasonable amount of success assuming that your justification is appropriate. Next slide, please. Okay, so the challenges and opportunities here. If you're gonna go through this process, you definitely need legal assistance because when you do get to the ALJ level, there's many things that come up, especially with the Medicare Advantage plans who bring their own set of lawyers to argue the cases. And we as physicians, if we're trying to make the justification for inpatient rehab, we simply don't, many of us don't have the legal background to be able to argue precedents, argue legality. We can argue clinical, but we can't argue the nuances of legal cases that would potentially get a case thrown out. You also have to understand the administrative denials and adjusting timing. So administrative denials are where somebody might say that it wasn't appropriate for you to bring it in. You didn't follow the appropriate processes. And because of that, it's not a clinical decision that's being made. It's an administrative decision. And if that's denied, you really don't have a recourse. So you have to make sure you protect yourself against that. And in our process, I think we have a lot of confidence we do. You have to work with your qualified independent contractor, or at least understand how to work with them at level one, level two, when you're doing the appeals. You also have to understand that judges have different interpretations. And so, I've had judges who have agreed with the medical necessity justifications. I've had other judges who've made the argument that we shouldn't be admitting a patient because let's say they were 90 plus years old or 80 plus years old. Their argument was that just because of their age, they simply couldn't do the three hours of therapy a day, which may or may not be valid. Even if your documentation showed that they did, sometimes folks will make justifications and say the patient could be served at a lower level of care, skilled nursing. And even though you're arguing that it couldn't because of the frequency of rounds at skilled nursing or the ability of nursing support there, they simply make the decision based on whatever their preconceived notions are of that level of care. And then the other thing is you have to adjust your workflow. So traditionally, like Dr. Smith was talking about, when you go through your pre-admission screen and you're trying to approve people, we're used to the situation where somebody's denied and then after they're denied, you go through an appeals process peer-to-peer and that kind of thing. In our process, you're bringing them while the off is pending. So the idea is that you make the decision to say they're appropriate, then we bring them in, then we deal with all that on the secondary and on the rehab side. Next slide. Okay, so just a few key points. There was a change to the Medicare regulation in July, 2024. It may have had something to do with the cases that we're going through. One thing to be aware of is that an enrollee or a Medicare beneficiary has the right to request plan approval either for pre-service, that's pre-authorization, but they also have the right to request plan approval while concurrently receiving the services. So that helps justify our case when we are appealing the authorization or the denial of authorization while they're currently in inpatient rehab. So that helps to get rid of the administrative denial part because that's part of the law. The second thing is that a plan, a Medicare beneficiary has the right to request benefits that they think are appropriate for them at their level of care, period, right? So if it's a patient request and they think it's a benefits issue and they have a medical need for it, you can't necessarily administratively deny that. Next slide. And then the other part of this is, again, if you get to that point where you go to an ALJ and at one point the Medicare Advantage Plans would argue that it was a process issue and would say this requires an administrative dismissal knowing that if the judge granted it, we had no mechanism to appeal, many of the ALJs actually said, no, we're not gonna call it an administrative dismissal. This is a patient benefit issue and we're gonna hear the case. So that's really important because you should be allowed to hear the case, especially if the patient believes they deserved the benefits in their Medicare plan. The other thing to remember is that you're not arguing about payment. So it's not a question of a patient coming to rehab and you think you should get paid for that. What you're arguing is that the patient deserves the benefit afforded to them. If it's ruled that they do deserve that benefit, then the payment falls into place on its own. Next slide. Okay, so just finally, success. So in this case, we're gonna argue that it was an administrative dismissal and it was a success. So in 2023 in the Charlotte region, we admitted 333 patients. Overall, we had 94% approval rate. And when you look at the impact, it was about 1700 days saved out of acute care, $1.4 million if you look at what the cost is of staying in the acute care setting. In 2024, we expanded the program throughout our network. The number went up a little bit. Our approval rates went down a little bit and I think that's because there was more legal battles there between Medicare Advantage plans and us, but still the impact was significant. And in 2025, this was an early slide in 2025. That was for January and February, or let's say first quarter. We're already on track, if not exceeding what our goals were in the previous years and we're having great success. So there is a true financial impact benefit to acute care and then subsequently still success with approval rates. Next slide. Okay, so that pretty much ends my talk. So hopefully we just kind of showed you a different mechanism to try to fast track admissions from acute care, understanding the appeals process, understanding the utilization needs and understanding the arguments that have to be made and showed some success with that. Next slide. Yeah, and if anyone ever needs to reach out, feel free to contact me. That concludes my portion. Thanks everybody. Thanks everybody for being an outstanding audience and of course for our panelists for taking so much time and energy out of their days and their lives is for this education. Came up with a few takeaway points. I think my takeaway for Dr. Smith's presentation was really be thoughtful, open and honest about your pre-admission process and factors that may be limiting it. For Dr. Foster's, the CMS of your choice is likely gonna make its way to your state unless they decide to change the program drastically. So how are you gonna prepare for it and make sure that your documentation and your care is up to snuff and that you're successful when that review occurs? And then for Dr. Raj, of course, is retro authorization the right fit for your rehabilitation hospital and healthcare system? And hopefully you understand some of the benefits and also potential pitfalls after that very thorough evaluation. But the important part here is we wanna answer your questions. We have probably about 15 minutes left. So the panel and I will hang out for the next 15 minutes. You feel free to unmute yourself and ask them verbally or if you'd like to write them in the chats, I will read them and try and direct them to the appropriate panelists that's able. So I'll continue to blabber until something comes up. But again, thank you so much for all of this. Thanks to AAPM and all for putting this on and investing in the future of inpatient rehabilitation. I think we're all very passionate about that. Obviously, that's why we do this and hopefully you are as well. Thank you. A question I have is, Dr. Smith, I can speak from previous experience. I've done an awful lot with LVADs and I know there's often a tremendous amount of anxiety and fear from both the nursing staff and the therapist when you start to admit those types of patients. Can you talk about maybe some strategies that you use to help to quell those fears and show some leadership as you engage those more complex patients? Sure. So what I've done specifically is talk with the referring physicians, so the referring panel. So what specifically are some of the things that they're seeing with their patients as far as stability-wise, if they're coming back to the hospital or not, hopefully the answer is not, and how they specifically failed some other forms of rehab. So they didn't do well in at-home health or they may have qualified for SNF depending on if LVADs are taken at that specific facility. So I really try to let them buy in specifically that the care, we can provide that care. So it's training, obviously looking at an LVAD or some of these other complex patients with drains and some other things too. So just better collaboration specifically with the referring physician, the referring providers, and that word actually gets out. So when those patients start coming to us, they're seeing, oh, they are making wonderful functional recovery and functional gains. So it's definitely a collaboration with talking with the referring provider, talking with our nursing administrators, our charge nurses, and some of the other things that specifically gets trained. It takes some time, right, to buy in. So as long as they, it's kind of working from the top down. So making sure that the providers are okay with it. If you have consulting physicians like cardiologists that are actually also comfortable with managing these patients as well. I know I'm specifically talking about LVADs, but any of these more complex patients. So just making sure from the top down, from the provider, then on down to charge nurse, to the actual nurses actually taking care of the patients. So like I said, it can take some time, but it is definitely beneficial. Yeah, I think that's a good point. I'll just add on, because I took care of mostly LVADs, oncology patients and transplant. These teams are so eager to have a safe landing spot for their patients. They will come and educate you. You know, where I was, we started taking transplants from another outside hospital that did not have rehab. They came on staff with us. They would come around with us. You know, the level of care that these patients get outside of inpatient rehab is so low compared to what we provide. They are so thirsty to have a partner and a friend. You know, I think we had the first one patient that came, did so well. And then we had like 25 referrals the next day. They just sent everyone to us. And, you know, to the point that one of the social workers was like, can I come and visit your site? I have no idea what you're doing, but the doctors keep telling me I can only send the referral to you guys. And this is where this patient has to go. So I think it's, you know, leverage your referral team, bring them on site, show them what you're doing. They will educate you. They all have robust education programs for their patients. They'll educate your nurses and make them feel more comfortable. And these patients tend to be the healthiest they've ever been in their lives, right? They either just got a new organ or they've got an LVAD device that's pumping better than their previous heart was. So I think they're one of the best patients to take care of because they're the healthiest they've been in years oftentimes, so. Yeah, I might just add, you know, this ties in actually very nicely with maybe the first chat question because, you know, there's no question that as Medicare rules are being enforced and folks are trying to, I mean, let's be forthright, right? I mean, the reason that there's audits and there's reason that there's denials is because there's an expense issue from Medicare, right? I mean, healthcare is becoming one of the highest cost issues in the federal government. Folks are always looking at opportunities to try to reduce costs. So they're, you know, always gonna challenge things that they perceive to be higher levels of care, higher cost levels of care. And the patient populations like LVAD, oncology, transplants, this is the direction that inpatient rehabilitation has to go, right? Medical complexity, medically complex patients, even though they're not necessarily identified in the 60% role, those are the patients that are gonna need this higher level of care, more intense physician supervision, more intense nursing and therapy supervision to improve overall functional performance status so they can return to the community. But to that first comment about, I like how it was called Medicare disadvantage plans. One of the challenges you experience then, and I've experienced this multiple times when you go through the appeals is that, yes, you have these very complex patients, but they don't need a rehab physician, they need a cardiologist, they need an oncologist, they need someone else. And it sort of bites at the core of what we do, right? We're physicians who can handle things. We have to coordinate care and whatnot. So I would say that even though this is the patient population that we're all gonna be trying to serve in the future, we have to have very reasonable arguments about why you need subspecialty care in addition to rehabilitation physicians to collaborate to improve the patient's overall plan of care. So I won't be so bold as to say why I think it is, but I would say that that question of why do you need a rehab physician is extremely relevant. And it's a very important question for us to be able to answer, especially for these patient populations. Yeah, it's such an important point. And I think, my personal opinion is this is the value of a robust consult service. If it's possible where you're at, start early, see the patient in the ICU, develop a plan with the team, because it does help justify in that acute care chart that gets sent over. If you're nurse liaison, the only one documenting an acceptance, then six therapists say sniff in the earlier notes, you have zero chance of getting anything approved. So a robust consult service is great. And I think, to my point on the slide, as I've seen some of the trend across the country where the rehab doc becomes a consultant, I mean, that may work for a lot of people and that's fine, but it makes you need to do a little more work to justify what you're doing. And I worry, as we do that, do we start devaluing our specialty as a whole? And that's just my own personal soapbox, nothing to do with APM&R, but it just, I think it makes those docs that are a consultant need to work a little extra hard to make sure they show their value, which is a shame, but I think it's probably something that I worry about. Yeah. Yeah, I think that was a really great around the horn from the panel on that. We kind of bled into the second question about families initiating the appeals. I think different rehabs handle that different ways. I know some rehabs will actually have the patient and their family sign that they are gonna empower the rehabilitation team to be their appeal point person, even though it's coming from the family. Does anyone else have a particular example or wanna discuss that further? I would say just anecdotally, I do see that it appears that families tend to have a little more oomph in the initial appeal process. I can't speak to Dr. Raj's lengthy and legal debate. It's fantastic you guys are doing that, and it's really amazing. From someone that oversees an acute care hospital, I love it, because it helps me get the patient out, obviously. And we certainly, unfortunately, can't wait 10 days. We can't wait two days sometimes. So I don't know. I think there's value to that. I think it's gotta be a family that understands the difference, which a lot of times it is, right? It's a family that either knows someone in rehab or the patient went to rehab before and did great. I think those are excellent patients to allow to do the family appeal. I just worry sometimes it's hard for them to talk the talk. And I know they won't be speaking to a physician reviewer. They'll often times with the family, but there's still guardrails in place to limit what they're able to do. But I do think there's value in it, for sure. I think also sometimes if the families are involved, and sometimes we do get families involved, talk about the piece of return to home more than anything else, that you are a family member, this patient, your loved one was previously independent. We are here at the rehab unit learning about this process. So learning about these catastrophic injury that happened to my family member, we want to take them home. Sometimes you kind of have to string it along specifically with the family members. And sometimes we've seen insurance companies do take a listen to that and say, hey, they're involved in family education. They wanna be trained on this. So sometimes kind of swinging it from them. They don't have to be MDs. They don't have to be providers, but really, really advocating for the patient to go home and that the rehab unit is educating them to go home in a safe manner. I think that was a really great point, Dr. Smith. Thank you for adding that as well. Working down this one is specifically for Vishwa asking about cost savings and if you have any more information about where those cost savings come from. Is it just for the acute care? If you can see that from Dr. Shah and answer her question. Sure, yeah. So just quickly, not to get into too many details, but the cost saving, one is from acute care. So the millions of dollars is definitely acute care cost savings. But the question of the five to 10% of patients that didn't get approval for IRF after all the levels of appeal, when you do the math and you look at the number of patients that you proved access for, depending on what your business model is, you will more than make up for that five to 10% loss. So you have to kind of have that business sense of, I don't know if you guys ever watch Shark Tank, right? They say, what's better? Is it better to have 100% of a grape or part of a watermelon? This concept is you have part of the watermelon, so you're gonna benefit from the increased volume. So any potential losses you have will likely be offset by the increased volume if you can pull it off. Dr. Raj, is there like a break even point? So, are you looking at like 10% or less denials to break even or 15% or less or? Yeah, I would say that, yeah. I don't wanna give you a percentage because I don't wanna like everyone to hold me to it. But what I would say is that when we look at our balance sheets and we look at where we end up, I can tell you that after initiating the program, in spite of that five to 10% denial rate, we're actually far ahead on margin. I think it makes a difference if you're part of a healthcare system as well, right? Because as someone who oversees the acute side, I'll eat some of those losses, knowing that I opened up multiple beds every day, one way or the other. So it definitely, like he said, it really depends on your mission, your values, and also kind of what you're partnered with. If you're a partner with the acute care side, you can probably get a lot more risky because the benefit on opening up acute care beds and placing people from the ER is higher. Yeah, that's exactly right. My apologies. Coming from standalone private for-profit rehab centers, we also look a lot at what our cost matrix is like. So if it's a particularly low cost patient, maybe it's someone we'll take a chance on earlier. And then also how does our referral volume change because of that? If we're taking people before we have authorization, are we getting more referrals and getting more of that watermelon, so to speak? And so your local economics are gonna be incredibly important in making those decisions. And this panel is smart as the three individuals are here. I don't think they can give you a better answer than that. Dr. Min, I'm sorry. I think the next question would be, have y'all seen instances of social workers who were empowered to initiate the insurance appeals at the rehab context for patients with disability giving lack of support? And again, I think social workers do do that. And then I think a lot of the for-profit centers will have the patient sign over the right of representation to the rehabilitation hospital so they can pursue that. Anyone else have other perspectives and more information on that? Yeah, just a thought. Yeah, I think some institutions do empower social workers and case managers to do this, but at least in our healthcare system, what I've found is that our social workers and our case managers are so overwhelmed with patient volume, and they're so overwhelmed with the pressures that they're enduring in acute care, whether the pressure's coming from our acute care teams who are trying to help with length of stay, if it's from the providers who are trying to move patients along, if it's from all the post-acute care folks who keep coming to them and trying to get referrals that sometimes their bandwidth is so limited, they just don't have the capacity to take it on. Once again, I'll say thank you, everybody, for the wonderful questions. Thank you for being involved in this discussion tonight. Please let your friends know if they'd like to review it. It will be available via the online portal through AAPMNR, and then if you have other questions that come to you in a day, a week, a month, whatever it might be, please post them on the PHIS forum. I think it's a great group. It's been very supportive for the most part, and it's an easy way to connect and contact your peers. Good night, everyone. Thank you. Thanks, everybody. Good night.

inpatient rehabilitation

admission processes

Medicare Advantage

referral bases

therapy evaluations

CMS Rehabilitation Choice

denials and appeals

case management

documentation

insurance denials