Okay, I have the go ahead to get started, I'm Lauren Shapiro from the University of Miami and I'm the current chair of the inpatient rehab member community. I'd like to welcome the members of our member community tonight, as well as those joining us from the inpatient consultants group, as we're co hosting tonight's event. Our topic tonight is not admitting defeat overturning rehab admissions decisions. Before we get started, just a few community announcements. We're beginning our search for our next member community chairs, the new elected leaders will start in October and the call for nominations will be later this month. The member community chairs can serve a maximum of two two year terms. If you have any questions, please feel free to reach out to either myself or the inpatient rehab group, or my colleague Dr. Balbuena for the inpatient consultants group, our emails are both here and we'd be happy to answer any questions you might have. If you're considering leading one of these communities. We also have opportunities to submit for a live session at the upcoming annual assembly in the fall, collaboration between communities is strongly encouraged, if there are any topics or speakers you would like to see, please send us your suggestions, either via email through the chat tonight, or post them on fizz forum. We do have the potential opportunity to collaborate on a session that will look at the appropriate use of advanced practice providers and PM and R, and that certainly may have relevance to our member communities as well. If that's a top. If that's a topic that may be of interest, please let me know as well so we can join forces. A few housekeeping notes before we get started this activity is being recorded and will be made available on the Academy's online learning portal, you can claim CME credit there we're approved for 1.25 hours. All of those who registered for tonight's event will get an email instructing them as to how to obtain CME for the best attendee experience during this activity all microphones except the speakers have been muted, please use the q amp a zoom feature to post questions to the panelists. Lastly, we recognize that this is a topic that a lot of us are quite passionate about and have horror stories that they want to share tonight's event, maybe we may be a little bit limited on time, but we do invite all of you who want to share your stories or strategies to join the conversation on fizz forum objectives for tonight's event, we'll discuss trends in insurance authorization practices as they pertain to earth's ideally better identify cases likely to be denied prior authorization on the first attempt, and then describe strategies for getting insurance decisions overturned on appeal. Just very briefly in terms of background more Americans are enrolling in plans that require prior authorization for inpatient rehab. This has resulted in a greater need for us to complete peer to peer calls, unfortunately sometimes the guidelines they're using to deny or care is not always very clear. And we're seeing a lot of delays and and difficulty admitting very appropriate patients to our settings am RPA did a survey regarding Medicare advantage plans in 2021, and they found that 53% of initial requests for prior authorizations were initially denied when additional effort was provided by the patient family or rehab team 28.9% were ultimately approved, but this came with a waiting time of an average of 2.5 days for an approved request. Also important to note that according to MedPAC Medicare fee for service beneficiaries are 4.4 times more likely than those in managed, I'm sorry, a Medicare advantage plans to receive earth care. Just please also note that the APM and are joined the regulatory relief coalition in May of 2022. So those of you who have stories of patients being denied necessary care. You can share that by going to regulatory, or I'm sorry reg relief.org and they are collecting these stories and hoping a building a better case that as to why there needs to be reform. Disclosures for tonight's event. Dr. Dawson will be our first speaker serves as a clinical reviewer for Maximus all panelists provide at least some clinical care and earth, which may be somewhat of a conflict of interest, but that's why they're here tonight. Otherwise no relevant financial disclosures. So a few audience polls just to get started before we move on to the talk and I'd appreciate if everyone can answer. Do you believe patients are increasingly initially denied admission for earth despite having appropriate diagnoses rehabilitation needs and medical necessity. Yes, no, I don't know, or no basis for comparison. Okay, so it looks like just about everyone says yes or they don't know or don't have a basis for comparison, not very surprising. How often are you or your team, able to get admission denials overturned on appeal. Always usually often rarely or never. All right, so some variety there though the it's still moving a little bit, but some people are usually able to get them overturned, but most people are at least occasionally able to get them overturned. All right. Let's see. This is kind of blocking here sorry, how has the number of peer to peers you've had to do just to continue authorization for people already in earth for an appropriate stay changed over the last five years increased a lot increased a little stayed the same or decreased. All right. All right, so most people are reporting that an increase that least a little if not a lot. When a peer to peer has been requested how often do you get called during the window you gave them that you were free. Always usually sometimes rarely or never. All right. Wow, someone, three people have always I think I meant, never, to be honest with you, they love to call me at night or when I'm doing Botox and clinic. Okay, and then last but not least, have you been contacted for a peer to peer outside of your usual work hours nights and weekends, yes or no. Here we go. Okay, so majority still know but a good percentage are saying yes, and, you know, only within the past year have I started getting calls on weekends which has been kind of problematic I've been doing laundry and I'll get a call from a medical director. Okay, so we're done with the polls. Thank you for participating and going to move on our first speaker recorded a video for us because he wasn't able to be here but I'm glad he was able to participate. At our networking session in Baltimore last fall, the group really wanted to hear from physiatrists serving as medical reviewers medical directors within insurance companies. We did reach out to the individual at Nava health and we were unsuccessful. But Dr. Dawson was very kind enough to present to us he is a clinical reviewer for Maximus and is involved in the appeal process, and also serves as a locum tenants physiatrist and inpatient settings. So I'm going to play his little as being a clinical reviewer for Maximus entail. All Medicare Advantage plans have an internal and external review process. I'm sure most of the providers listening are familiar with, you know, peer to peer, they're appealing or even expedited appeal. And then after, you know, the first step is kind of the peer to peer, and then, you know, expedited appeal. And then after when it goes to for external review is when, you know, that clinical information would come to us that, you know, a Maximus, you know, would be able to review it. And then after when it goes to for external review is when, you know, that clinical information would come to us that, you know, a Maximus, there's different departments, you know, of course, I work for rehab. So I review any information that's pertaining to a determination for post acute care, whether it's, you know, sniff inpatient rehab, even home health and I do some other things. The next step after that is actually it go would go to a judge, which I were not involved in that process. That's kind of the what Maximus does in a nutshell, is they would review any, you know, it would review any clinical determinations made by commercial payers or MA plans, kind of the third level of review. First, as a clinical reviewer, do you have any general recommendations for providers and peer to peer discussions? Sure. Well, of course, it's going to somewhat be case by case, but I think the number one or the most important aspect in any kind of appeal would be knowing the reason for the denial. So that's not always simple. You know, most of the information that, you know, your case managers receive back that they tell you is something generic, something like patient doesn't require, you know, close physician supervision or it's, you know, patients needs can be met at a lower level of care. So a lot of times they're generic and sometimes knowing the reason or, you know, being able to know the reason for why the case was denied in the first place is kind of maybe almost ESP for what, you know, why the certain medical director really denied the case. I think that's really the most important, you know, factor. I would say the second factor is really knowing the correct rehab diagnosis because that's really how the criteria or the guidelines used by, you know, commercial payers or Medicare Advantage plans. It's how they screen, you know, is the case, the simple pulmonary debility, you know, after acute respiratory failure or is it anoxic encephalopathy? Is it critical illness myopathy? Those things, you know, those, the diagnosis will really make a big difference in how the criteria used are going to screen your case. I would say probably the third factor would be to make sure that all, all recommendations are really in agreement. I think, you know, a lot of, a lot of rehab providers or medical directors will ask, you know, what did therapy recommend and whether they recommended SNEP or IRF. But really, you know, it really mattered that what the consultants on the case said also matters. So if you're, you know, if you're trying to debate a peer-to-peer and it's a cardiac debility case, well, if the cardiologist on the case said that the follow-up could be done outpatient, well, then your medical necessity is, is blown, you know, right there. So it can be more complicated. I would say probably the fourth factor would be really let the reviewer speak as much about the case basically as they, you know, as they can. Typically in a peer-to-peer, they'll, they'll start that conversation with telling you what they know about the case. Sometimes they'll tell you right after, you know, why they denied it, which I guess goes back to kind of the first reason. But really make sure you understand, you know, why they, they denied it. So let them speak as much as, you know, as they're willing to, I guess. And you can, it's okay to test their knowledge of the case, you know, not to be argumentative, but, you know, did you see this factor or that factor? And then I would say the last, you know, the last thing I'll talk about is probably why most providers are, you know, will be listening to this today is, you know, arguing medical necessity or why does a case need post-physician supervision? I think this can be frustrating for providers during peer-to-peer because, you know, they may, they may typically argue the, you know, the labile blood pressure or, you know, labile glucose. And, and then the, you know, the medical director, they're, they're discussing the case. But we'll say, well, that should be done in acute care before they come and then they can go to SNP. So I think this is probably the most frustrating for providers in peer-to-peer, but let's kind of go back to chapter 110 of the Medicare benefit policy manual, which states, you know, which states IRF is not to complete, you know, a medical episode. Most providers see that as, you know, seeing, you know, tests or, you know, or those types of things need to be done before a patient, you know, comes to IRF. But really anything that has to do with the admitting diagnosis, you know, really should be that part of the care should be complete, or that's at least how CMS, you know, and how these, you know, commercial payers, how, how they, you know, how they see this. So if you're arguing, you know, some sort of medical necessity that has to do directly with admitting diagnosis, you know, it's not going to get you very far. Unfortunately, you know, at least I was never taught a lot of these criteria guidelines, whether they're interqual, filament, you know, all these guidelines, they weren't really part of my residency. So, you know, a lot of this, you know, a lot of that training using those came after the fact. But the way commercial payers see this is, you know, unfortunately, it's what they're paying for. So any, you know, so for the reasons why they currently meet inpatient, you know, care, and whether it's med surg, step down, if you're arguing, you know, medical necessity as it pertains to those diagnosis, it's just not going to get you very far. So an example of that would be, you know, I wouldn't argue post-op anemia with a hip fracture, or if they're admitted for orthostatic, you know, hypotension, arguing blood pressure just isn't going to get you very far. It's probably harder, you know, when you're talking about that, you know, the aspects of a case is probably the things that aren't actually documented well will get you a lot farther. So if you have a, you know, a stroke, a patient that has a previous stroke, but they're, you know, they fell at home and they're in with a hip fracture. Well, I'm sure they probably have spasticity and other things that no one's documented. But, you know, those, you know, those types of, you know, of conditions, you know, talking about those will get you a lot farther, especially because they'll view this as why does this patient need to be seen by a rehab doctor, you know, three times a week. So if you're, you know, if you're arguing medical necessity, it's going to be advantageous, you know, for you to argue, you know, rehab diagnosis, you know, in general. So a recent case of mine is an 82-year-old female, has a medical history of COPD, hypertension, diabetes, with acute right MCA, CBA, now with left hemiparesis, nicolect, dysphagia. Hospital, of course, was significant for labile hypertension, hyperglycemia, and hypoxia. Functionally, the patient was, you know, Mindemax assist with self-care, mobility tasks, and good participation in therapies, physical therapy, occupational therapy, also had cognitive deficits, so it was speech therapy. They, as far as, you know, discharge planning, they had a, there was a supportive family, 24-hour supervision was in place. And then, unfortunately, that case was denied. So, you know, when, anytime there's a case I really think is a sort of slam-dunk case, that's really when I'm going to question that, whoever I'm discussing the case with, what are their concerns, even before I, you know, would begin, you know, to the discussion. So, like I recommended, you know, I did ask the director to voice their concerns after they talked about, you know, their understanding of the case, and their concern was for, you know, medical supervision. And then, instead of, you know, arguing the blood pressure or the blood sugar, you know, I argued, you know, more about, you know, the spasticity, more of the hypoxia, things that aren't, you know, aren't directly related with that, you know, specifically with the diagnosis-related group. You know, I said, you know, of course, the Neurological Association recommends patients with acute stroke, you know, who have comorbidities, you know, they would, they would go to IRF, you know, over SNF. So, there wasn't really another place for that. We kind of went back and forth a little bit to the point where I believe he said that the patient could pick up an AFO, you know, off the shelf at a Walmart, which is kind of funny. But, you know, I argued, I really hammered in that spasticity argument more, and why, you know, that requires the management of a rehab physician, why, you know, patients that have spasticity really need close monitoring initially to prevent, you know, complications like contractures, and that, you know, the patient really needed, you know, both orthotics and medication management. And eventually, he gave in, although he only gave me three days until we had to resubmit for, you know, for more time, but they, he did eventually give in. So, I think that's a pretty good example of a case. Great. So, our next speaker is Dr. Matthew Ryder, who serves as Medical Director at the Siskin Hospital for Physical Rehabilitation in Chattanooga. Hey, guys. Everybody hear me? Well, I haven't done this before, so it's nice to see everybody, but my role is kind of unique. Like Dr. Shapiro said, I do work at Siskin, which is a nonprofit hospital in Chattanooga, the largest in Tennessee. We have 96 IRF beds and 37 SNF beds, so it's a pretty large facility, and we cover multiple levels of care, so I'm not necessarily biased against either one. And we also have five outpatient clinics currently. And in my other role, I serve as the president and managing partner of our private practice, which is Siskin Physical Medicine and Rehab, which is a PLLC. We have about 15 full-time and part-time providers, and we do have a lot of APPs as well as physicians. And we're a full-spectrum outpatient PM&R clinic, providing everything from complex spasticity management with toxins and baclofen pumps to even chronic pain, osteoporosis, stroke follow-up, brain injury follow-up, things like that. You can go to the next slide. So, Dr. Shapiro asked us to talk about some practice trends, so these are just some unique things that I've seen in our area. As has been mentioned, and everybody knows, Medicare Advantage is the primary instigator of the majority of our problems. So, what we saw back in August of 2022 was our primary referral source next door, connected by a skybridge, began this initiative. Like every hospital, we're struggling with nursing supply. They were struggling with getting open beds, and so they're like, fine, these Medicare Advantage patients, we're not going to work. We're not going to even send any of them to IRF. We're not going to have to worry about appeals that way. We're just going to send them all to SNF. So, obviously, that's not what you'd want for your mom, your dad, yourself, your spouse, anybody else. So, we began a media advertising blitz. Our CEO and I met with about every physician in the area. My marketing director and myself, we were on every TV channel. We were on the radio. We had signs, banners, billboards, everything to try and educate patients, because legally, they do have a choice. And if they do meet criteria for IRF, then they should be able to get that. And we've seen our Medicare Advantage referrals tick back up, but it took a lot of work and a lot of pushback, because what this is going to do is it's going to bite them in the rear end, because when you send patients to SNF and home too quickly, you'll start to see that return to acute care ratio go back up, and they'll be in the ER before you know it. There was a hospital system up in Michigan that saw that, and they eventually changed their policy. So, hopefully, that won't happen here, but it's led to an opportunity for us. We've just had increased denials for IRF and given us increased opportunity to do appeals. And the other thing that we've done recently is we started an acute care consult service back in November. It's been very successful. We're seeing about 20 consults a week right now, which is up from where we started, and we're a very new service. One of the things we're seeing on this service is we're seeing these preemptive peer-to-peer requests, primarily by Humana and United in our area, which are Medicare Advantage providers. And they're kind of wanting to talk with the physician prior to doing the initial appeal or making the initial decision. So, our consulting teams, primarily trauma and neurology, have loved having us on board, because part of our marketing is we've said, we'll do your appeals for you. And they've been glad to give up all of their appeals, and we're actually having tremendous success doing appeals. Nobody documents in the acute care record like a physiatrist, and we're winning almost every one of those. But this new kind of preemptive request by the payer to talk with us is something new that we've been seeing in our area. Expedited appeals has been mentioned. This is a patient right. We've talked about it in principle, but this is a 72-hour kind of fast-track secret weapon to getting patients in the IRF. Basically, what happens is after a patient has been in the acute care, they've made the request to an IRF, the Medicare Advantage patient denies their request to go to an IRF. And the patient now has a right to complete what's called an appointment of representative form. It's an AOR form. Basically, they can select a representative for the appeal, a family member, an attorney, a physician, whoever they want. They can have them sign it, and there are three places you sign on the form. Basically, accepting the role and waiving any payment for the service, and then you're off to the races, and you can start your appeal process. So our process at Siskin is that we have nurse liaisons in the acute care hospitals, and they notify our admissions office of an appeal, of a denial, and the patient's request for an appeal. They send a clinical summary to the medical director for review, and we kind of decide if the case is, you know, quote, worthy of an appeal. This is part of our medical director contract where we do some of these appeals on behalf of the hospital. And basically, what I do, I do pretty much all of these for our facility. I do a one-page summary, an explanation of why the patient's appropriate for IRF. I'm going to go through in a minute what that looks like, and literally, word for word, just what one of my one-page summaries look like. And basically, you end up waiting about 72 hours. We saw that statistic that said we wait 2.5 days. That's pretty accurate. If it's on a Thursday, you know they're going to have it in by Friday afternoon, because they're not going to do it on a Sunday. But if you do it on a Friday, they're always going to wait until Monday. So there's an art to this. We've had an 80% success rate. I'm relatively proud of that. It's better than the 28% or 23% that was shown just a minute ago. But what I can say is that the 20% that are losers, they're no different than the winners. I cannot see any difference, because I have a selection bias, because I've chosen the ones I want to fight for, and I see no difference between the winners and losers. So this is just my format. I'll just go through this real quick, and that'll be my last thing. But this is what I do. I title it IRF Expedited Appeal, put their name and date of birth, and then this catchphrase here. Their health and recovery will be adversely affected if they're required to wait the standard timeframe, and inpatient rehab is further delayed. And then I go on to the summary of the patient. I do a brief summary. So the case I chose is an 82-year-old female. Seems like stroke is a theme here. She has aphasia and dysarthria and ADL impairments. She has new medical problems. She's got new CHF. She's in exacerbation. She's getting IV diuretic. She's on new anticoagulation because of a thrombus. They're adjusting her blood pressure medication. She's got aspiration pneumonia. Her diabetes is uncontrolled, sugars are terrible, and she's got some renal impairment in her history. Then the next paragraph I put in is why do they need to see a rehab physician visit? In my experience as well, this is the biggest reason why appeals are denied, because they don't need to see a rehab physician is what they tell us. So I put in there why. Medical management of CHF diuretics in the context of their renal impairment, assessing their CHF risk factor reduction to prevent the reason they're there in the first place. Their new aspiration pneumonia, their dysphagia needs, their anticoagulation management and education. Coordinating all of this rehab care in this complicated patient with new neurologic and medical diagnoses. Next slide. I talk about what are their functional needs and requirements. I believe they can tolerate three hours of therapy a day. They have new assistance required for ADLs and mobility. Actually, this patient, I just kind of left it off on purpose. They didn't require moderate to max. They were fairly high level for their ADLs and mobility, so I just said they required assistance, which they did. But this lady in particular had a lot of needs for speech therapy due to her aphasia. And then I did, as Dr. Dawson recommended, I put in their PT, OT, and speech all recommend inpatient rehab. This patient needs to be independent. This is going to give her the best chance of going home in her situation. Next slide. And then I wrote, why do we need interdisciplinary care? This is really, why do you need an IRF and not a SNF? Because the rehab MD is going to coordinate with PT and OT to monitor their neurostability and their CHF status and their sugars and their medication tolerance. I don't know about you guys, but every patient I see that comes on GDMT ends up orthostatic or with renal failure. So it keeps the nephrologist, keeps the physiatrist busy. Rehab coordination with speech therapy and dietician for their new dysphagia, nutritional and aspiration risk. Speech therapy coordinating with neuropsychology to coordinate for their cognitive language evaluation and to determine the feasibility of safe return home. It's a very complex thing that we're doing. I'm just trying to put it in words that a reviewer can understand. Next slide. And so then this is where I lay it on thick after careful review and consideration. I'm board certified. I believe they meet CMS criteria for IRF care. Oh, by the way, the AHA, ASA guidelines indicate that eligible stroke survivors should receive care in an IRF in preference to a SNF. And then from a medical standpoint, they're far too complex for safe care at the SNF and to offer anything less than an IRF to this patient would be providing below standard of care rehabilitation services. So I do lay it on pretty thick. Next slide. Thank you. So that's pretty much how I do it. And like I said, we've won about 80% and every case is put on one page and very similar. Thank you so much for sharing. I actually love the language you use and we may borrow some of that. Go for it. All right. Thank you. Our next speaker is Dr. Jameson Haake, who is chief resident of Mary Free Bed Lansing Sparrow Hospital, the Michigan State University program. And I asked him specifically to speak about how his program actually uses residents in the peer to peer process because I don't know that all of us do, those of us in academic practice, and I was kind of interested as to how they incorporated them. So he'll be sharing what their program's policy has been. Dr. Haake. Thanks, Dr. Shapiro. And thank you for allowing me to speak on this and giving me some guidance through this process. And then thank you, Dr. Ryder, for sharing that great case and going through some of the phrasing of how you pose these cases. I think that's really important for us to review and everything. And I have a little bit on that. But me, I'm from Lansing, Michigan. I'm a current Sparrow resident. And you can get some details about the size of our hospital. I'm in my fourth year, and I've been lucky enough to sign with Michigan State, who is the supervising group over the Sparrow PM&R residents. So we're an academic PM&R group, and we service inpatient outpatient PM&R needs of the greater Lansing area. This summer, I'm hoping to, or I will be helping McLaren Hospital, their smaller, the smaller hospital in our area with consults, acute care follow ups, inpatient outpatient EMGs. So what do the residents do at our program? We do nearly all of the peer-to-peers. And so this kind of originated back when the peer-to-peer volume started to increase, and there was just not enough attending time to manage all the peer-to-peers. My attending was telling me actually today that he had a needle in someone's back doing an EMG. He was getting a call, and he just decided that this was now fell to the residents. So we do about 90% of the peer-to-peers, and we, when there's a denial, we get the case, put it on our desk from the admissions coordinators. We decide whether to pursue the peer-to-peer, or to delegate to a junior resident that may have seen the patient might be more familiar with the case and might save the senior some time to review the case. And then we complete the peer-to-peer on the phone and then following the denial, we decide whether we're gonna do the FAST appeal or not with the admissions coordinator. And so I pulled some data from the last few months here. And so us residents, there was 71 peer-to-peers done in total over the last three months and 68 were done by residents. So averaging about one a day or so. And we won about 35% of them on peer-to-peer. So some of them were won afterwards by FAST appeal. I didn't get that data but this is more focused on peer-to-peer. We won about 35% of those on peer-to-peer. And when I kind of toss an informal poll around the residents and the attendings, kind of trying to gauge, what percentage of peer-to-peers are the attendings winning versus residents, thought that we were winning about 20 to 40%, which seems pretty accurate with the most recent numbers. And the attendings listed as high as 50%, but as low as 20% for their peer-to-peer. So maybe some differences, maybe not in that regard. And then, so this is a smart phrase that I have made on my own that our residents will use sometimes after peer-to-peer. There's specifically been cases that have had traumatic brain injuries or strokes that we've had denied that I've made, wanted to make sure are documented very well in the chart that this patient in case could potentially be reviewed. And then we submit this along with the FAST appeal. And so I won't bore everyone with the phrasing of it all, but it's here for your reference. And so more recently our admissions in Mary Free Bed Lansing, we are starting to adopt a process for Mary Free Bed Grand Rapids where we're starting to skip the peer-to-peer like Dr. Ryder was talking about. So this is very similar. So essentially we are using this appointment of representative as soon as we get that denial, or if we anticipate a denial, we start this process and then we go directly to the insurers. And we have a lot to learn about this because this is like a couple of weeks old. So we've had eight patients that have been put through this process and it looks like we're right in the queue of that 70 or 80% got approved through this process. So we'll see how this kind of works at our institution. So why should residents be involved in the peer-to-peer process? So sometimes we have some more time that's more flexible. So we're more readily available to attend as opposed to the attendings. And some of the cases are unlike to be overturned on appeal. Kind of like those 20% cases that Dr. Ryder was scratching his head about, just some of them are gonna be denied and maybe the residents are just gonna be the brunt of that. And so also I think that I've gotten a lot of practice with peer-to-peers. It's certainly launched me into my consulting career that I'm gonna start as an attending soon. And it's led me to be a part of this community and be a part of this talk. And so I'm very thankful that I've had that practice. So what are the pros and cons? So it offloads some time-consuming work from the attending physicians, gives us certainly some more volume to work with by having the residents do it. It might help us with our advocacy skills and it prepares us for practice, which I think that it has helped prepare me. But on the con side of things, I think that we are getting a lot of denials and that may be worse than the attendings, but that could be studied. And then of course there's potential for resident burnout, which I think is why a lot of us are here is that this is a burning out process when you're dealing with this large system that we're dealing with. So thank you everyone for your time. Thank you so much. That was really interesting. We need to consider whether we implement something like that here because I think our attendings are a little overwhelmed with the peer-to-peer volumes at times. Our next speaker is Dr. Vishwa Raj, who is clinical professor in the Department of Orthopedic Surgery and Rehab at Wake Forest, Chief of the Section of Rehab at the Levine Cancer Institute, Medical Director at Carolinas Rehab and Vice Chair for Clinical Operations in the Department of Human R at Carolinas Medical Center. All right, thanks Lauren. So I promised Lauren I would behave during this presentation. So we're gonna see how well I can keep my promise. I have 24 slides, but I'm gonna do them in 10 minutes. And I think most of those slides will be references for the folks in the audience if they need it. So if we go to the next slide, just as a disclosure, many of these slides are taken from a talk that Brian Moore, our CMO for Physician Advisor Services here at Atrium Health and I did for the AMRPA in 2019, specifically talking about expedited appeals. And so we're gonna go over to some background rationale and then explanation. Hopefully this will give you more context in the idea of expedited appeals to support some of the talks that I've already had. We move to the next slide. So just quick case study. The study is not so important. I think it's a general concept. We had a patient with cancer, brain tumor, several functional deficits, several medical deficits. And interesting, when Dr. Dawson was talking a little bit about what they, or what he perceives medical necessity to be versus true medical needs, I think it would be hard to argue that if you had a cancer patient with a brain tumor who's getting radiation and chemo and has hyperglycemia from steroid dosing and multiple other medical comorbidities associated with the tumor, very hard to argue that that medical necessity doesn't justify our rehab mission that requires 24-hour nursing physician supervision. So I just leave you with that. Now, next slide. So when we look at patient access and we go to the next slide, I just wanna, not that you have to memorize this, but I just wanna make sure everybody understands when you look at Medicare requirements in terms of what are the services provided and what are the requirements, skilled nursing versus inpatient rehabilitation facilities, they're not as concrete as people might present. So this slide just goes over the basic services that have to be provided at skilled nursing facility. And if you go to the next slide, these are the basic requirements for admission to IRF. And for the previous talks, those five bullet points are actually the key components to what we use to justify admissions. We often see this in HMPs, we see this in our documentation, we see this in our pre-admission screens. And so when you look through this very carefully, some of the interpretations that we heard earlier about what helps justify a rehab admission is not explicitly stated in this. So I think when you're looking at the Medicare regulations, you have to really look at these and try to decide for yourself when you're making the case for a patient, can you justify based on what you see that the patient requires these five standards for admission? Next slide. One important thing about HMOs, and this is super important. Medicare Advantage plans, Medicare HMOs, are authorized by the federal government to distribute Medicare benefits to patients. Those Medicare benefits have to be the same as those benefits that are offered to patients with Medicare A and B. So there's no difference. Medicare HMO has to abide by those rules. In the next few slides, we'll talk about that a little bit. But in the end, when we're looking at the criteria for admission, they are not two different standards of admission criteria. So what you may hear is that certain privatized plans may have different justifications for admission, whether it's using the 60% rule. Sometimes they have other tools, like a Milliman criteria and other things like that to try to say that this is a patient's appropriate for rehab and other patients are not. But I want to make sure it's very clear that the standards for Medicare A and B have to be applied for Medicare HMOs. Next slide. Okay, now in the end, why are we talking about this? Because it always comes down to cost. So if we go to the next slide, when you look at the total cost of post-acute care overall, it's about $60 billion on the Medicare budget. And if you look at where that money's going, majority of it is going to home health and skilled nursing. Inpatient rehab is actually a much smaller portion of that Medicare budget. And when we go to the next slide and we look at how many facilities are, the money follows the settings, right? So when you look very carefully at how many facilities exist in the US, when you look at skilled nursing compared to inpatient rehab, you can see there's substantially more skilled nursing facilities, but why? And if you look at the next slide, I realize I'm going kind of quick, but if you look at the next slide and you look at the actual cost per day of a skilled nursing facility on average, it's about $500 a day, give or take. And so when you look at inpatient rehab, which is the next slide, the cost averages out to about $1,800 a day, probably a little bit more than that. So unfortunately to the untrained eye, when somebody looks at cost of rehab, you look at a metric like that, somebody might say, well, gosh, skilled nursing is just cheaper than inpatient rehab. And if rehab to rehab, send them to SNF. And that sometimes is how the decisions unfortunately are being made when it's privatized. It's not so much a clear cut objective measure to say, this patient does meet criteria, does not. Sometimes the explanation is as simple as patient doesn't have medical necessity or require a higher level of care. But really, when you look very carefully, you have to make sure you can justify why you need a higher level of care. It's not just about cost. It's not the same level of service that's delivered at both. It's not that SNFs aren't important. They are, and IRFs are important, but you have to be able to justify why a higher complexity patient needs an IRF. Next slide. Okay, so in our experience with the Niles Management Expedited Appeals, if you go to the next slide, we can talk a little bit about why we had to move forward with expedited appeals. And this was back in 2018. Basically, we were given rationales for denial by payers that said, patient didn't meet medical necessity criteria, patient's needs could be met at a lower level of care, things of that nature. And at that time, we accepted those explanations, said, well, I guess there's nothing much we can do. And as we delved a little deeper into the HMO rules and the Medicare rules, what we found was we didn't agree with that interpretation of the rules. As a matter of fact, we found that many of the decisions were being made and they weren't following the Medicare regulations as we interpreted them or as we would apply to Medicare A and B. Then we had attending physicians who were trying to do peer-to-peers, and we weren't getting very far because when we talked to the medical directors at the HMOs, we were given those same explanations and nothing more substantial than that. Then while this was happening, the HMOs were taking more time to make decisions. Length of stay started increasing in acute care and acute care started saying, well, gosh, if you're gonna take this long to go to an inpatient rehab, we're gonna send them to skilled nursing or somewhere else because the cost is just becoming too expensive to keep a patient in the acute care setting. So it started becoming a very dismal picture. And we said, we have to do something different. As we operationalize things, we realized there was an opportunity to try to make things more efficient and also hold the HMOs accountable for their decision-making process. Next slide. So probably the impetus for this was the Office of Inspector General, federal government that first started examining challenges with Medicare advanced denials in 2018. And what they noticed was that back then, only 1% of the denials were sent for first level of appeal. And then what they found was that when you did go through appeals, you were getting a significant amount of overturn. And one of the conclusions was, perhaps the reason why this was happening was not because there was objective review of the data that was being presented. Rather, there was insufficient denial letters, there was incomplete clinical information or incorrect decisions being made based on the information presented and not shared with those submitting. And there might be a case that medical care is being denied for profit. Next slide. But the real impetus was back in 2020, 2021, when the Office of the Inspector General released another study that actually showed that 13% of denials actually met Medicare coverage rules and HMOs are actually denying this patient, 13%. It's a very substantial number. And then a lot of the reasons for denials were because the HMO team were saying that there was not enough documentation to support approval, whereas independent reviewers found that there was. Once this study came out, now that there was a greater deal of scrutiny over the HMOs, what we're finding is that some of the decision trees are changing regarding approvals for IRF. So next slide. One other thing to consider when you do an expedited appeal is that patients have rights. So these four areas are the main areas that help substantiate an expedited appeal. Patients have the right to file a grievance. They have a right to appeal a decision. They have a right to an expedited decision tree on their appeal. Next slide. Okay, so just very quickly, what's the difference of expedited versus standard? If you do a standard process, it could take up to 14 days in acute to make the decision. If you do an expedited, they are required by law to make a decision within 72 hours, as was mentioned earlier. And the first level of appeal is 72 hours. The second level of appeal, which is another 72 hours. If you're not in agreement, you can push it to an ALJ level. But the point is that you're forcing an HMO plan to make a decision in a much quicker fashion. And the justification for the expedited appeal is that by not doing so, it actually has the potential of causing medical harm for a patient. So you're basically saying that if they stay in acute care, the risk for comorbidities, hospital-acquired conditions, things of that nature are more harmful, and you have to be able to consider that to make the decision quicker so the patient can move on. Next slide. I'm almost done. All right, so as was mentioned earlier, to do the expedited appeal, an enrollee can actually designate the provider or rehab hospital or anyone to represent them on their behalf and submit that. So it takes the responsibility off the patient. And then if you have the appropriate process, you can go ahead and submit those expedited appeals. And if you go to the next slide, we found that we had great success, like mentioned earlier. Now, as the years have gone on, that success rate has gone down because I think Advantage plans have figured out counter-arguments to try to not justify the HMO, sorry, not justify the approval for rehab from an HMO. So you just have to be mindful that whatever technique you have, it might work really well at one point, but as the medical environment changes, then the decision trees might change and the approval rates might change. Next slide. And so in the end, for this patient, we did submit, we went through the expedited appeal, we did it our way, and we got it approved. So the patient who was not necessarily a compliant diagnosis on the surface, even though you can call it a non-traumatic brain injury, did get approval, the justification for the medical worked, and we were able to get the patient to care. And that, I think next slide is the conclusion. So that concludes my side, and thank you for the time. Great, thank you very much. I know there are some questions that have popped up and we will get to those at the end of tonight's session. Our next speaker is Dr. Adriana Balboina, who is the chair of the inpatient consultants member community. She's also my colleague here at the University of Miami in the office right next door. And she serves as the medical director of our consult service. And I specifically asked her to walk us through a case where she assisted a patient perform their own appeal for authorization for her. So, Dr. Balboina, take it away. Thank you, Dr. Shapiro. Thank you for the opportunity. So just, I'm gonna start giving some background. Dr. Shapiro and I work on a huge hospital system. It's a county and a private hospital. We are 1,500 beds at Jackson Memorial Trauma Center and University of Miami is 500 beds. We get a lot of cancer referrals, and we go with a lot of challenges with this peer-to-peers. I started the consult service about eight years ago before it was a rotating service. So consults went from four consults a day to now having close to 20. Now we have another faculty join. So offering to do the peer-to-peer, it's very challenging on these cases because we were getting more and more and more on each, I mean, 20 on one side and 10 or 15 in the other side. So my, and I don't know if this happens to you before, but we had some issues with some of the insurance saying that physiatrists, when the patient was on the acute side, the peer-to-peer didn't need to be done by the acute team. The physiatry have conflict of interest. So in view of all these difficulties, I start doing some in-service to the acute side, to the nurse practitioner, and some of the residents and the trauma, to how to conduct a peer-to-peer, what was the vocabulary they needed to say. And we have a successful rate on getting overturned on some of the cases, they don't respond the peer-to-peer in the timeframe, the team, the insurance requests. So another education part that we have in, and this is what I'm presenting this case, it's educating the family. There have been some challenges on the acute side. As you know, all this is gonna increase the lens of state on the patient, on the acute side. So in this case, this is what's a kind of different case. This is a patient with a prior history of a spinal cord injury, an incomplete C67, and she was modified independent in all her activities, and she sustained a fall while doing the transfer from her wheelchair to the car. She sustained a fracture, it was treated surgically, and she was put in with a precaution of no way varying on the left lower extremity. Her hospital core has multiple issues, she had a COVID-19 infection, she was not requiring ventilator, the pain on the leg, she also had autonomic dysreflexia with multiple UTIs, she ended up having to, she was completely independent on the bowel management and bladder management prior to this admission, and now she had to, she had to have a super acute tooth placement by urology due to she was having a lot of difficulty with self-catheting while in the hospital. Next slide, please. As I mentioned, prior level of function, she was living by herself, being modified independent, she was working, her house and her car was accessible for her, but her plan, after discussing what are gonna be the goals, functional goals on her, she was agreeable to be the shark with her mother, but now her mother needed to be trained because she always was, before the injury, she was able to do everything herself. Next slide. So she was pretty much needing a mod to max assist, anything that inverted the lower body, she was needing max assist, and she was also needing with basic ADLs. The goals were for her to be, being assist with transfer, something that would help the family to manage easier than max assist, and she was able to, the plan was to her to achieve modify independent on some of the ADLs and bed mobility. So PMNR was consulted and was in agreement with the recommendation of physical therapy that the patient will benefit from acute inpatient rehab. Next slide, please. So we had started the process of the insurance, and it's as I train, I do my in-service with acute side, it's hard to find this sweet spot where when to send the referral. The insurance will get back to you and say the patient is too low level, or the patient is too high level, or the patient is not medically ready for admission when you try to just get ahead of your game and try to minimize the time on the acute side. So this is an example of how long it took for the patient to get admitted. It was eight days from the initial insurance authorization, it got denied, the answer came four days later saying deny. Then the peer-to-peer was also denied, insurance stated the patient was too low level and should go to a skilled nursing facility. Patient completely refused about skilled nursing facility. So the rehab team, the liaison helped the family and the patient with the process of the appeal, getting all the documents. So we're now doing a package on all these appeal process where we're sending the physical rehab, the inpatient consult, PM&R consult, the PT and OT, and the PAS signed by the meeting that, you know, who is ever gonna be that meeting attending. So the family was able to overturn, but it took two days to get the final approval and the patient was admitted after eight days of the initial plan. And a patient was able to be discharged home with family training. So that's just a summary of, you know, challenging cases, challenging situations we do. This is kind of an example of the letter that the administration, the rehab administration team, coach how to, you know, what to write, how to write it. And it was sent to the insurance with the family appeal. So that's another way to help and advocate a patient's educating family and empowering family about their rights. Of course, the acute side, it's usually not happy about this process, but we need to do what is the best for the patient. Thank you. All right, thank you very much. And our final speaker tonight is Dr. David Steinberg, who in addition to serving as vice chair of the inpatient rehab member community, he also serves as the chair in the department of PM&R at the University of Utah and the executive medical director at the Craig H. Nielsen Rehabilitation Hospital. Thank you, Dr. Shapiro. And I first want to give a big shout out to my colleagues who joined us on this call, really amazing information. I've been like soaking it all up, great templates for using for authorization letters and appeal letters and really working that expedited process. And I've looked through the chats and I totally agree needing to be proactive is really important. I'm worried a little bit about Medicare Advantage, admitting those patients and then doing appeals after the fact, but we'll talk about that in just a moment. I'm going to take seven minutes and go really quickly through this. I'm now an academic physician. I'm the chair of the PM&R department here at the University of Utah. But prior to this, prior to 2018, I was in Ann Arbor at St. Joseph Mercy Hospital, a Trinity Health Hospital. I was in a private group. I served as a medical director there for an acute inpatient rehab unit for 17 years. And then came here, jumped over to the academic side where I joined the department and now run a 75-bed acute care academic medical center, inpatient hospital connected by a skybridge to an amazing quaternary care center. So much like many other centers around the country, we are very much involved in very, very complex cases, far above the 60% rule, but we get regional referrals from across the Mountain West, 10% of the United States landmass, very complex cases, but more and more we're running into these challenges with denials of prior authorizations, et cetera, et cetera. So this is the kind of setting that we're in right now. We're dealing with the same thing. We have increasing case mix index, a high complexity of cases. Patients are staying on average almost three weeks and quite a range. Our biggest problems with the prior authorizations tend to be those patients with medical complexity, with debility and deconditioning, and it's an increasing challenge. Next slide, please. So we have an appeals process very much like those that are described, and I'm gonna start using our residents more and more. I love the Mary Free Bed model. Let's let our residents learn and throw them to the wolves. I mean, give them a chance to learn. And the other examples from Carolinas, it's just amazing, it's great. So we have a very strong access coordinator who works in lockstep with their inpatient medical director who runs the consult service. So very much like we're doing at Miami, we're very proactive, advocating for patients, trying to avoid the peer-to-peer if we can, but if it is denied, we will try to do that expedited appeal process. I'm not sure why insurance companies can insert themselves and require you to do a peer-to-peer. It seems to me that the expedited process is one that is designed to do just that, is expedited. So that should be challenged by a legal counsel and try to get in front of that as much as you can. So we try to do case by case, and we have our attendings do those reviews right now and the peer-to-peer. Next slide. So why is this a big problem? Because more and more complexity, medical complexity, that's a little bit more difficult to verbalize and to create a narrative to explain the medical complexity. And what's really important is to see that across the country, CMI is increasing with a lot of post-COVID patients and a lot of other complications that are triggering issues. And just like our colleagues in other areas, our acute care hospitals are jammed packed. We know that the stress on acute care hospitals is increasing with challenges with staffing and problems with labor shortages across the country. So we are also getting major pressure from the acute care colleagues to bring patients sooner, and they get so frustrated when there's a delay in care. Back at St. Joe, they were counting, they were literally counting our delay days, the delay days that rehab was causing because of insurance denials. And we must have really effective cases or resources to make sure that we're bringing those patients quickly and early on. Next slide, please. So I just want to tell a quick case. This is really back when I was at St. Joe. It was not a Medicare Advantage case, which creates additional complexity where you must get prior authorization. This was a standard Medicare case, and the denial came much after the fact. It was a retrospective denial during an audit from CMS. And so we had to go through multiple layers of appeal, ultimately, to an administrative law judge. But it was a 68-year-old woman with standard Medicare who was in the hospital for nearly a month after a complicated admission with sepsis, pneumonia. I think she had a chest tube. She had a trach and a peg, very debilitated, a lot of sarcopenia. And because of her complexity, initially, her ability to participate in three hours a day was very marginal. And so she actually went with our initial blessing to an extended care center for SNF or subacute rehab from the rehab hospital stay. And it went downhill from there. So at the SNF, she developed a DVT and a PE. She was readmitted to the acute care hospital where we saw her once again. She was stabilized and placed on full-dose anticoagulation and participated in acute therapies. And again, her ability to manage that three hours a day was very much on the margin. And I saw her on the consult service, so very much like our colleagues in Miami, is at the bedside. And I kind of explained to her that she was not a stellar rehab candidate and that we thought she might need it to go back to skilled nursing. And when I told her that I thought she would need to go back to skilled nursing facility, her face went pale. She started to shake. She was tachycardic. She literally had a panic attack. She said, don't send me back. She held my hand. She said, if you send me back to skilled nursing, I'm going to die. Don't do it. In fact, she said, I'm not gonna go. So I was at the bedside and I said, you know what? If you were my mother, I wouldn't hesitate. I'll bring you to the rehab unit. But I said, I think we're gonna have some challenges, but we did bring her to rehab. And over 16 days, she made remarkable progress and she was discharged home. Next slide. The bottom line is that her case was retrospectively or retroactively denied. And so I had to go through a very arduous process of appealing that process. So next slide, please. Initial appeal to the FI was denied. Qualified independent contractor denied. I finally got in front of administrative law judge. I explained that it was in my medical opinion that as the rehab physician, that this patient's needs would be best met at that level of care. And the administrative law judge agreed with me and overturned the denial. We know that denials are overturned frequently when it gets to an ALG level, ALJ level. I urge all of you to do what you think is best for the patients. Be your patient's advocate, get out in front of this, bring patients to rehab. If in your medical opinion, that's the best place for them. Next slide. So denial overturned. Next slide. Okay, so the bottom line is that the 110 manual does say that most of the decisions should be based on the functional needs of the patient. Medical necessity is important just as it's been reviewed here, but always make sure that you are focusing on the medical necessity of that team-based, intensive rehab with good goals and a practical, reasonable chance of getting home or to a better functional outcome. Next slide. So we know that understanding these policies are critical to us as rehab physicians, as we advocate for our patients. I urge all of you to learn the qualifications and build these dot phrases and have these letters ready to go so that you can be proactive in advocating for our patients. Next slide. So including the bullet points as was described earlier, I think is really critical. Being explicit on why rehab physician management is necessary for face-to-face visits throughout the week. Being able to, you're able to document that coordination of care is important. I couldn't do any better than my colleagues have already stated it. So just make sure that you're emphasizing that in the medical record as well as in your appeal documentation. Next slide. Don't forget to emphasize why rehab nursing is necessary because that's critically important as a differentiator, not only on the medical side, but on the nursing side, what's different about a skilled nursing facility versus inpatient rehab. Do not accept a denial without appealing. And so I think it's really important. And just like Mary Freebet is doing, get out in front of the process, get an expedited process going. Next slide, please. So here's just a little bit of data. It's a little bit aged. This is from 2007, that this retrospective review found that 63% of denials were overturned on appeal. So we know that if you go through this process, you should be successful. If you have good structured documentation and you have good rationale, the physicians generally on the other side of the phone will listen to you if you're respectful, keep your voice calm, understand that they're doing a job as well, try to get on the same page with them and understand, I thought the explanation of medical necessity, when you can describe the rationale, not just related to the preexisting or the reason that they're in the acute care hospital, but tied into their new disability and why there's complexity, I think is more successful. Next slide. So again, this is just a reminder of all the criteria under 110. If you don't know these things, you should really have them on a card. I have all of our consulting physicians and residents hold this in their pocket in their rehab as they do their consults, so they can show it to the acute care teams, they can show it to patients and families, they can remind themselves when they're doing their documentation as part of their workflow all the time. Next slide. So policy coverage determinations and the appeal process can be complicated, but it's well worth it. Having a medical director with enough time and experience is critically important. So our systems throughout the country should make sure that we're supporting and training people adequately to be able to articulate well why we should have these local coverage determinations overturned. Next slide. If we're getting close on our time, these five level appeals are pretty straightforward and standard. I had to go through multiple times to get to level five in an administrative law judge, and I'd urge each of you to feel comfortable doing that, just like learning how to do a deposition with an attorney as part of being a rehab doctor these days. Next slide. So, and if you follow through these things, hopefully it won't take too long, but retrospectively it takes often up to 24 months to get these appeals overturned. The fact that that case that you described in Miami of having that amazing delay, obviously is a stone in the shoe of all of our acute care colleagues, but be ready for the long haul if you're gonna be doing these retroactive appeals. So I'd be very cautious about just charging ahead with taking people who you know don't meet criteria because it's gonna be a hassle later on. I think that's probably my last slide, Lauren. It's a tough haul, but take some risks. Okay, thanks. All right. Thank you very much. I will invite all of our speakers to participate in the Q&A at this point. It looks like a few things have come in through the chat. Also, if anyone would like to ask a question on camera, you can raise your hand and Devin will hopefully be able to help me with that. I did see a question that I wanted to make sure we address about from Paul saying, anyone try admitting patients to IRF before formal insurance approval has been granted? And I think that's a question a lot of us have asked. At our facility, we sometimes do, but we look very carefully at the case as well as the insurer. So there are some plans for which we will not consider it no matter how busy the hospital is. And those are largely ones that we have to appeal through NaviHealth because our success rate is quite low and it's very time consuming. But if someone has like straight Cigna or Blue Cross Blue Shield, and it's a pretty slam dunk case, we will sometimes do that. Dr. Raj, what is your practice? So it's interesting you bring that up. About two months ago, we started that practice as well and we've done it on about a hundred patients and only HMOs actually. So we're not even doing private insurance, we're doing HMOs. And when we did this, Brian, my counterpart was super enthusiastic and he's like, look, there's rules and regulations they have to follow. They're not following them. He believed that if we brought them to rehab and we used our documentation rehab to appeal a patient that had been denied by an HMO, that we could get overturned. I was skeptical, but I'll tell you, he was right. So 80 out of a hundred have been overturned. And of the 20 that haven't, it's one payer specifically and we're ready to go fight that through the ALJ. And these again are very specific patients where you believe they meet criteria. This is not like one where you just throw caution to the wind and just bring them in. These are patients that if they have Medicare A and B, it wouldn't even be a second thought. You would bring them in, they meet medical necessity and functional criteria. So, but if you're gonna do that, I would just warn you, don't just say, hey, we're gonna try this. You have to have a very strategic plan and a very good understanding of the rules and regulations and very good advocates, either in your hospital or healthcare system that can help you through that process. It's not a small thing to do, but I think it's showing us that there's opportunity. Dr. Ryder, are you guys admitting without authorization? No, it's been discussed several times. I like the plans I'm hearing from both places, but I'll be bringing the topic up again. And Dr. Steinberg, do you wanna chime in? Prior to being in Utah, back in Ann Arbor, we had an agreement with Blue Cross that if we were running into a holiday, long holiday weekend, or there was a delay in response, but we felt confident. So it was an agreement we had with the medical director who was doing the appeals. And I have very positive collegial relationship with them. And they actually told us to bring patients before we were able to get approval because they trusted us. So having that kind of partnership, I thought was very positive. We don't have that same type of relationship now. So we've been very reluctant to bring patients before we have authorizations. We will not take a patient when we've had an actual denial, but I do push our case managers and admitting people to take people if we're sure they meet criteria. If we're confident that we'll get an approval after admission, then we'll go ahead and take the risk. Great, thank you. So another question came in from Cheryl, and she was saying that one of the most significant issues she battles is with the medical necessity component, as many of their peer-to-peers focus on the medical necessity. The peer-to-peer reviewer will argue either not enough medical necessity or too much medical necessity, so needs a higher level of care. What do you think is the best way to approach this? Would anyone like to chime in? Well, first off, I would just say that in terms of what you can manage on the inpatient rehab medical necessity is a decision by your system. That's not an external reviewer. If you have the resources and the setting that's safe and appropriate for patients to be stable, actually being in a hospital level of care is a lot safer than being in a skilled nursing facility, that patients can benefit from that setting. That's exactly why we have supervision. We have other resources available so we can monitor patients more closely and respond to their needs. So it's a challenging splitting the difference there. They're either too stable to come to rehab or too unstable to come to rehab. So I would argue that we are optimally designed to manage patients who are unstable and have higher risk. I think I wanna mention, when I'm with a medical director, besides the medical part, I usually use the word stable. I just need close monitoring. And it works sometimes when I, and specific on the lens of state that I foresee the patient is gonna be in the rehab. And I said, like the patient is currently in this, I estimate the patient will achieve this in seven to 10 days or in 12 days. And I should be able to successfully send the patient home. Sometimes they are a little resistant. I say, well, you know, this patient is very likely gonna come back to the ER and come to the, especially it's a transplant and it's been gonna be more money for you. So it sometimes works just staying stable, just need close monitoring. And I just anticipate the patient is gonna be X number of days here to achieve this level of care. This level of assistance. Vanessa asks, in our area, insurance companies don't usually allow physicians or families or expedited appeals unless a peer-to-peer has been done. Any way around this? Yeah, hey, it's Fish. So yeah, there is, I mean, actually, so you can decline the peer-to-peer and there's no reason you have to actually do it. And once it's documented as declined, you can move forward with an expedited appeal. So, you know, I think one of the challenges is when you're, again, this goes back to understanding the rules. When somebody says that you have to do a peer-to-peer, first reaction is, okay, I guess I have to do a peer-to-peer. You can decline it. And then if you decline the peer-to-peer, that forces the insurance company to make a decision quicker. And once they make that decision, then you can move forward with a different appeal process. At least that's been our experience. Another question was, what can we do when an expedited appeal does not get back to us in 72 hours? I don't know if anyone wants to handle that. I would just call them and complain, but I don't know if anyone else has a good solution. I can tell you. So in our experience, what you do is, depending on how aggressive you are and who you have backing you up, what you do is you file a grievance with Medicare. Once you file a grievance with Medicare, let's assume it's an HMO, that gets reported as a formal complaint against the HMO. Once it's reported as a formal complaint that's documented, the HMO has to address it. And the HMO also has this on their record over a fiscal year to say that they received these formal complaints and they are or are not in compliance with Medicare regulations. So again, this goes back to knowing the rules, but if you know how to file that grievance, you'll find that once you do file a grievance or two, all of a sudden the decisions become very much by the regulations within 72 hours moving forward. Dr. Karim asked, with changes to the final rule for 2024, do you foresee any changes in Medicare Advantage in the coming year? I hope so for the better, but I don't know. I think we're still looking over the language in great detail to figure out what the impact will be. I don't know if anyone else has anything to add on that. Only thing I can say is that, there's been a lot more NaviHealth usage with some of our payers and they just keep punting, I guess NaviHealth's like the assassin, they're just paid to do a job, they're like the bad guy. We've had a lot of luck with NaviHealth in the acute care setting, getting patients into IRF. However, trying to get patients from IRF to SNF is virtually impossible with NaviHealth. We can, I mean, I'm like running at 0%. It doesn't matter what I do. Well, on the topic of NaviHealth, there's another question. Many medical, this one is for Michael. Many medical directors, non-physiatrists with NaviHealth and Evacor, tell me that a patient should be stable and then go to SNF. Even though I explained we can manage medical issues at IRF and do intensive therapies so patient can leave acute care sooner. Any way to better explain this? I don't know if anyone wants to tackle that. I think at this point, I don't take it personal. I used to take it personal. I used to, I actually would call Lauren and been so upset and frustrated about this peer-to-peers process. There are gonna be times, no matter what you said, they had their mindset. So it is, it will be just going to the next step. So we just swallow and move to the next step. The family have a lot of powers. I've seen a lot of overturn from families. So I tend to start the process early to avoid the lens of state complaint from the acute side. When I see the patient's diagnosis, I'm not gonna be successful. And the insurance, we give in some numbers to see if we find a trend and a specific insurance that always deny. So we start to start early, get the peer-to-peer process done and go to the appeal process with the family. We think we'll have better chance in certain insurance than others. Yeah, I agree. One thing that we're being pressed by our acute care hospital cause they're jammed full and they have access challenges. So we have some access capacity in the rehab hospital and we are connected by a SkyBridge. So we're in the process right now of decertifying some of our acute beds or our rehab beds to become acute care. So some of these cases that are in kind of extended denial limbo, I think we can bring over into the rehab hospital, but in an acute care bed and get them used to the milieu and kind of decompress the acute care hospital area so that we're not getting them so angry because there are delay days that this process will get them very angry. It's gonna be a lot different if you're a freestanding IRF and you don't have acute care beds or if you have a partner that's coming in from other areas. So there's been a lot of conversation in the chat but we're just about out of time. Unfortunately, I know there's a lot of additional questions that people may have. I will set up a discussion in the FIS forum and I will ask that my panelists tonight help me answer them in the days to come. So please check out either the inpatient rehab or inpatient consultants member community. And again, if anyone has any ideas for any additional education sessions, any directions you'd like to go for our member communities, if anyone is interested in assuming a leadership position with the next election, please get in touch with us. They will be posting on FIS forum, call for nominations later this month. But if you have questions, please reach out. And again, thank you to all the panelists. Thank you all for participating. We will work to getting, I will ask the panelists if they'll share their slides and we can potentially just post that on FIS forum for everyone. I know I wanna steal some of the language in Dr. Ryder's appeal and some of the others as well. And I hope to see you all in New Orleans. Thank you so much. And thank you, Devin, for your assistance tonight. I appreciate it. Thank you all. Have a good night.

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