All right, so thank you, thanks Dr. Scholten. And we are actually gonna have a little bit of a schedule change due to just some schedule changes with our speakers, same speakers, but we're just changing the order a little bit. Next we are going to have Dr. Mark Durden, who is board certified in four areas, including PM&R. His subspecialties include spinal cord injury, independent medical examinations, and disability analysis. He has worked with the physician group at Rehabilitation Associates of Indiana for 20 years, and he's currently working for a Medicare contractor, National Government Services, to develop and educate the application of Medicare policies for patients in the U.S., and he continues to practice part-time in clinical medicine. He's served on several boards of trustees, boards of directors, committees, and commissions over the years, so thank you, Dr. Durden. Thank you. Thank you, sir. OK, so my name is Mark Durden. And like I said, for the first 20 years of my life, I dealt with just a general practice. I also was on clinical faculty at the Indiana University School of Medicine. When I got out of residency, Randy Bradham was starting up the PM&R program here at Indiana. And he gave me an opportunity to kind of get started in the field. And I stayed there for a couple of years. And then I was later asked to join National Government Services. And I really didn't know much about Medicare. But it has turned out to be the best job that I've ever had. And I'm not really into superlatives, but it really is. This is a fantastic job. And let me just tell, and as I go through this, I'm going to tell you a little bit about it and how I could open up perhaps some of the doors for you if this is something that you find interesting in the near future. So what I'm going to look for today is just give you a little bit overview of what Medicare is like. I'm a Medicare Part A, Part B director. For the first five years of doing this, I actually did DME, medical director. And now I'm doing the AB work. And then I'm going to describe a kind of a typical day of what the perfect job is like. And the key thing I think about this is that I get to accomplish everything now in an eight-hour day, which when I was in clinical practice, that was unheard of. I mean, my typical day was 12 to 15 hours. And so this has provided me, as I've gotten grayer, the opportunity to do a lot of fun work, but not kill myself anymore. I'm going to give you some discussion about what is it? Is there concerns about having to work for an insurance company? And then I'll help you on some ideas of what you can do if you'd like to be interested in it. Out in the marketplace, there are tons of insurance companies. And there's lots of opportunities, particularly for PM&R physicians, to get involved in this. Because the PM&R physicians are truly like hen's teeth out there in the Medicare world. In Anthem, where I work, let me go through that. So in any of these kind of things, I actually work for Anthem, formerly WellPoint. But the big five is what you may want to really kind of focus in on. All little insurance companies are there, and they need PM&R docs. They just don't realize they need PM&R docs. But the big five know they need PM&R docs, and they can't find them. And so the opportunities out there for PM&R is significant. In Anthem, where I work, and I'll show you how it kind of breaks out, there are currently, of the hundreds of physicians employed by Anthem, there are five PM&R doctors. And we all know each other, because despite Benton working in California, and me working for the federal government, and all those kind of things, we actually need each other, and we actually have to collaborate with each other on this development of policy. And I'm going to talk about how we did that. In the corporation I work for, I actually work for Anthem. The subsidiary of Anthem that does the Medicare contracting. And here is, so remember the Wizard of Oz, when they came into the wizard's court, and it was this big, fiery thing, and you had to pull back the curtain, and you find the wizard there? Well, in the fiery world of Medicare and the federal government, if you pulled back the curtain, you'll see me standing there. Because I'm just this gray-haired old guy that's enjoying what I do, and it has this appearance of being this big, fiery thing. And it's not. So the Medicare system, I actually work in the government side, so we have a Medicare contractor, Medicaid contractor, that is done by these insurance companies. I was completely unaware of that when I got into this business. I didn't realize how much contracting work the federal government does. And in fact, in all things, the federal government just simply contracts out. And so there are tons of contractors out there that need the PM&R doctors. You can also work on the commercial side. The other four PM&R docs in Anthem work on the commercial side. But there are so many branches of the commercial side that they're simply, they can't do all the work that needs to be done, particularly, for example, DME. So Kim works in Colorado, and she is the national DME person for Anthem. So if someone gets a prosthesis, and you want to look on a microprocessor knee in your prosthetic leg, is that person needing that C-leg for that microprocessor knee? Or can they get by with a multiaxis knee or something else? And so again, people don't know that they need you, because if the companies have somebody with your expertise to sit there and say, this is what is reasonable and necessary, that gets me on one parenthetical thought that I wanted to give you today. If you want to get into this market, you've got to learn the language. The language of this is like learning the language of medicine. Remember, we went the first couple of years of medical school, you had to learn all that Latin-based words. And here, this is just acronym-based words. So there's lots of things out there. But let's think of it in this way. What is reasonable and necessary? Most clinical physicians would have a very difficult time defining reasonable and necessary. But think of it in these terms. Necessary is that you have an injury or illness that's needing treatment. So that makes it necessary. So if someone doesn't have an amputated limb, they don't need therapy to be an amputee. Necessary. That's the easy one. Reasonable. In your world, you're going to get denials from either commercial or Medicare because it's not considered reasonable. And so when I was a clinician and someone told me that it was not reasonable, I said, hell with you. You don't know what. You're not seeing this patient. I know what is reasonable for this person. That's because we don't know the definition of what is reasonable. In the Medicare world of reasonable, it first comes down to safe and effective. So did it get passed by the FDA? The FDA only determines if something is safe and effective. That's the first hurdle or the first bar to get over. So once you get FDA clearance, and then there's a couple of forms of FDA clearance, but let's not go into that nuances. Then the next hurdle up is the reasonable one. So is something that you're giving reasonable? And that comes down to, is it appropriate in intensity, duration, frequency, whatever? So if someone's getting rehabilitation, do they need it on a daily basis? Do they need it on a weekly basis? Again, appropriate. Frequency, intention, duration. Then is it experimental? Has it been proven? Is it evidence-based medicine? If you can understand that that's how things are determined, then you can get a much better view of how these entities view what you are writing on your prescriptions. Because is it going to be reasonable to them? Is it FDA approved? Does it have that first hurdle? Sorry, the first hurdle. Then the second hurdle is appropriate in frequency, intensity, and duration. And the last hurdle is, is it experimental or evidence-based? When I first thought about going to an insurance company or working for an insurance company, this is actually what I thought I was going to do. My job was to deny things that come through on my desk. That is not true. Doctors that work insurance companies are not just the denial source, but they work on reasonable and necessary. When I work as a medical insurance person, I think of these things as the things that I have to do in a typical day or things that I have to have experience with. I have to understand how medical policy is developed. And Joel just gave us the lecture just before that talked about how things are developed. And this is the same in Medicare as well. In Medicare, you first have the laws, the statutes, that are developed. And they're usually pretty vague. Then the federal government develops what is called regulations or how they determine what they read in that statute. And it comes out as the CFR, Code of Federal Regulations. And those are the regulatory guidelines. Then the next step after developing a regulation is the development of a policy. And so the policy that I have to work on and develop is how do we follow that statute that is then developed into the regulation, which is now developing into a policy that Medicare is going to require you to follow. Another thing I do is do medical review. So medical review nurses, insurance companies hire lots of medical review nurses. Things get screened all the time. I'm going to pull back the curtain on Medicare and give you a secret of Medicare. What do you think your risk is for getting audited by Medicare or an insurance company? Low, high, medium? Medium? The answer is 1%. In the Medicare world, there are so many claims that get paid by Medicare. If it's 1%, you're lucky. And most of the time, they're not looking at physicians. They're looking at bigger entities, hospital systems, DME companies, that kind of thing. The likelihood of a physician being reviewed, medical review, is really very low. And that's only if you hit outside of a particular metric. And I'm going to explain it a little bit more. But just basically understand that there's a comparative billing report that Medicare will sometimes send you. If you get a CBR, that comparative billing report, pay attention to it. That means you hit outside of some metric for that company at that time. And that means that you're on a list, probably the top 10 or 20 list, that are going to get reviewed. So then that's where you need to take a look at it. For example, when I was in clinical practice, I got a CBR one time that says you're billing pretty high on level 4 and 5 E&M codes. Now, can I prove that my E&M codes, certainly at 4, were always very reasonable? And in the 5s, I could actually justify as well. But I took a long time with my patients. And so based on time and my documentation, I could prove I was a level 4 or 5. But I also recognized that I was hitting that radar. And that's something you want to look for. In the insurance company, also, your job is to look at utilization review. Fortunately, I don't really enjoy utilization review. And I don't have to do any utilization review. But utilization review, is it reasonable and necessary for this person to get this equipment or this inpatient rehabilitation stay or something like that? And then you get a one-to-one with the doc. Then there's appeals. Appeal system in Medicare is, again, another big curtain. Nobody knows really how it exists. Let me give you an idea of how this exists. In Medicare, you get a denial. And if you get denied by Medicare or an insurance company, you have the option to appeal. The first level of appeal is actually to the same company. And then that usually has a system. And every insurance company has it. So the utilization reviewer nurse reviews something. The utilization physician may review something. And then if they deny it, you have the right of appeal. The appeal then goes to somebody else in that company. So usually, it's another medical director in that company that takes a look at that same information and decides if it's reasonable and necessary. If it gets appealed, the first level of appeal is usually going outside of the company. And then that goes to another medical director. And that usually is another medical director for another company that's doing these appeal work. And there's lots of them out there doing the commercial. And in the Medicare world, they're called a Qualified Independent Contractor, or the QIC. And the QIC then determines if something is reasonable and necessary. If it's not reasonable and necessary on the second level of appeal, then the third level of appeal is when you go before the administrative law judge. And then you argue your case there. And I will explain that a little bit more in detail later. Finally, the other thing that you do as a medical director in an insurance company is you work in provider education. So recently, I've been on provider education calls, typically with physical therapy programs. Because my jurisdiction includes New York City, there seems to be a lot of New York City therapy programs. And they're doing things that would not be necessarily considered rehabilitative. They're considered conditioning. And that's not rehabilitative. Rehabilitative is to show that you're going to make a reasonable improvement within a reasonable period of time, or a significant improvement within a reasonable period of time. So those are the kind of things you do as a medical director at an insurance company. Now, in my typical day, I first am looking at review of medical policy. So if a medical review nurse comes by and they say, what about this chemotherapeutic drug? Is this reasonable for this patient? I mean, I'm a PM&R doc. So those kind of things still come to your table. And I look at the thing. I look at what the policies are. I look at what the regulatory guidelines are. And after you do this for a couple of years, it's not like it's de novo work every day. These are things that I've seen before. And I look back over it again. Then I can make a decision on coverage. And remember, Medicare is the great way to describe Medicare is not that it's an insurance company, because it's really not an insurance company. Medicare is the defined benefit that is being provided to the beneficiaries. Defined benefit means that it's defined by the statute, the regulations, and the policy. And if it doesn't hit within any of those three, then it's not reasonable and necessary. So that's what I do. Look at medical policy and interpret it. Second is to write LCDs, or local coverage determinations. Local coverage determinations are for your jurisdiction. And I'll explain jurisdictions in a little bit. But I don't want to get too far in the weeds away. When you have a policy, then your job is to determine that it's how do you define in the words what is reasonable and necessary. Describe first the injury or illness so you can describe what is necessary, and then you describe what is reasonable and you base the policy wording on that type of thing. And let me give you an example. Right now I'm working on a cognitive rehabilitation policy. This cognitive rehabilitation policy is getting a lot of political kickback. I have lots of conversations with CMS about it. So the question that they're asking me as a PM&R doc is how do you differentiate cognitive rehabilitation from cognitive training to cognitive stimulation to reminiscence therapy? Reminiscence is that you're just reminiscing on something. You show a picture. This is Johnny. Do you remember Johnny? Johnny is Johnny. And then what is stimulation? It's doing things that are stimulatory to the reading or your processing type of things. So you have to be able to define all of those kind of things and then narrow it down to what is cognitive rehabilitation. So that's the kind of the policy that I've been working on and that's the kind of things that you do in this job. Also with the administrative law judge hearings is what I do. So my job is to represent Medicare at an administrative law judge hearing. My job is to first understand that I'm there to protect what is called the trust fund, the Medicare trust fund. And the way you protect the Medicare trust fund is that whatever is getting paid has to be paid based on regulation, statute, or is it the policy? That becomes critical at an ALJ level because at the ALJ level is the judges are mandated to follow the strict statutory letter of the law and the regulatory letter of the law, but they're given discretion on how they interpret the policy. So my job as the ALJ representative for Medicare is to explain if I don't have a good regulatory guideline or a statutory guideline for something, and there usually is not, usually when you're getting down into that granularity, you're usually talking policy. Now I have to talk about policy and how is this reasonable and necessary for this beneficiary at this period of time based on that documentation that is in the chart. And it's all a documentation review. So that's what I do during the days as well. I get on the hearings with the judges and we argue with whoever it is. And today at 1 o'clock I have one that's actually with a beneficiary. In Medicare, as you know, Medicare doesn't pay for hearing aids. Medicare doesn't pay for teeth. And this beneficiary had lost some teeth and now wants Medicare to pay for it. So I have to go to the administrative law judge hearing today and explain that teeth is not part of the defined Medicare benefit policy, therefore it's not reimbursable by the Medicare program. Also you have tertiary review and medical data analytics that you have to look at. And this is kind of where that comparative billing report stuff comes out of. So I sit down with a group, a medical policy group, medical review group, data analytics groups. We do this on a weekly basis. We actually sit for an hour or an hour and a half reviewing the data of something. So let's say CMS comes out and says we need you to look at this policy or we want you to review for this. Then we look at our data and find out if there's any outliers, if you are outlying of the system. So if you're in that outlier group, then the is there a reasonable explanation to say that this person is doing X. I'll just give you an example. Let's say if you had spinal cord injury medicine. I used to do spinal cord medicine. And so if I was billing a lot for power mobility devices, and as a PM&R doc I would be ordering a large number of group 2 wheelchairs, then I would probably fall out the normal metric of what would be the normal bell shaped curve for a doc providing those wheelchairs. And so that would be a reasonable explanation to be outside of the metric. Why do these companies need PM&R docs? They need us because we understand inpatient rehabilitation. And I will tell you that the pendulum is coming as far as it comes to inpatient rehabilitation services. You're going to see some push in the next couple of years over IRFs and proving that that patient needs that specific inpatient rehabilitation for that. We saw that initially with the PPS system when it hit us, and I went through that whole process in the clinical world. Now I'm kind of dealing with it on a different level, and the IRFs are coming up in Medicare. DME, same thing. You have intricate knowledge of DME that nobody else has, and this is expensive stuff. I mean if you buy, say there's a group 2 power wheelchair that comes across your desk, are you really looking to see if it has two actuators or three actuators in it, and then have your doing whatever else for the equipments that it needs, the chances are that you're not getting into that granularity. But they expect you to know that as a PM&R doc, and generally you would. You would probably read a couple of articles real quick. You'd get caught up really quickly on the issues of a group 2 power wheelchair and the headrest, and do you need a toggle device versus a bar device for the hand, that kind of stuff. So you have that knowledge. Also for chronic care needs, chronic congestive heart failure, COPD, are these programs reasonable and necessary? And you, because of your rehab, know that you're obviously not going to make your lungs better with COPD, but you can improve the oxygenation level or that oxygen transfer at the tissue level, so maybe you can show how that would be reasonable in the management of that chronic care patient, and working out those kind of details and policy. And you also know the language of rehab. When I'm talking to physical therapy and occupational therapy or speech providers across the country or even their national associations, when we're talking about policy, I understand their language, and that is something that, again, primary care in general, and there's a lot of primary care docs that do insurance medicine, internists and family practice, just because there's more of them, that they need PM&R docs to be sitting in there because we do understand things. What concerns do I have as it regards to working for an insurance company? The answer was nothing. My ethics are still where I think they are, and I'm not going to deny something just because I'm here to save a dollar for somebody else, the insurance company, but I will follow the policy to the letter, and I don't see this as any conflict other than what I would do as a PM&R doc in the normal world. I also do independent medical examinations. So when I do an IME, and I still do them now, when I do an IME, I look at what is reasonable and appropriate. What injury or illness occurred as a result of this motor vehicle accident or as a result of this traumatic event, and what treatment was reasonable and appropriate, and what's not reasonable and appropriate. That would be the same thing that you would be doing at this kind of job, is that you look at the policies and you look at the things of how that they're going to be interpreted for that individual at that individual time. So there's really not a conflict really for a PM&R doc because you do this all the time with IMEs, or if you do IMEs, but you'd be surprised how much in your own clinical practice you do this review of something and say, okay, that's not reasonable anymore because you really don't need a swimming pool to treat your arthritic knees. That's not reasonable and necessary. Medicare is a defined benefit policy program. You've got to understand that it's based on the policy as well as statutes and regs like we talked about, and it is the biggest payer out there. And so it is very important for you to get in touch with the wording of Medicare because what Medicare does, typically insurance will follow. Let me give you an example of that. A couple of years ago we were going to work on the lower limb prosthesis article for Medicare, and at that time there was this hue and cry from the O&P community that Medicare should not change their policy. The reason is that everyone that came to that hearing was to, they were talking about you're going to deny me my leg for my prosthesis. And none of them were Medicare beneficiaries, none. They were insurance, they were military, they were other payer sources. But they clearly recognized that if Medicare changed something, that has the potential to impact how other people review their policies as well. So you can have a big impact on determining how policy is reviewed and also on how things are interpreted versus fraud, waste, and abuse. Those are three key words in the Medicare program, fraud, waste, and abuse. Because remember, everybody thinks that when you're doing something wrong, it's that you're abusing the system. Well, there are people that do abuse the system, but that's like malingerers. There are not very many of them, right? But there are symptom magnifiers with chronic pain, and that's the bigger chunk of people as opposed to the malingerers. In Medicare, the same analogy would apply. There's not a lot of abusers of the system, but there is a lot of, sorry, fraud in the system. But in other people, there's just wasting money. Ordering extra tests, doing those other kind of things are not really reasonable and necessary. So as a reviewer, then I'm really looking really for the people that are wasting money in the system. But they're not truly, it's not true outright fraud. So how would you get involved in the first steps of getting into this? Well, the first thing I think that's critical is that you have a good, strong clinical base. Most people that are looking into this usually have at least five years. I think that's the critical litmus test for that. I'll give you an example of where I think I got into something too early. I came out of academics. I was started in academics. Within three years, I was put on the RRC, the Residency Review Committee, and I was the young guy on there. I mean, they're all chairman of these departments, and I was the AMA representative. The reason I got to be put on that is that I showed up and I spoke up when it came to opportunities. But getting on the RRC at three years was probably too early. I was really very young. I was still speaking like a resident, and I hadn't really changed that tenure that seasons you a little bit. Same kind of thing as this. You need a little seasoning in your clinical years to do this. Then you've got to learn the language of Medicare. So if you understand what fraud, waste, and abuse is, if you understand what's reasonable and necessary, then you're kind of getting into what you're doing. And you also need to start to learn the acronyms because there are just a ton of the acronyms, and it is reasonable for you to start learning that language. You know the PM&R language. You know the medicine language. If you learn this other language, you're going to be in much better shape. Then one of the things that I did probably about ten years in my first year of ten years of practice, I didn't realize this was going to be beneficial for me. Someone came up and they asked me, they said, would it be reasonable for you to be a tertiary reviewer for an insurance program? And the answer was, oh, sure, I'll do that. You know, they pay you $100 to review a chart. And, you know, it may be, you know, big charts. And so it really wasn't worth my time. But I thought, you know, this would be a good experience to understand how things are done. And so I got to doing this as a tertiary reviewer. Remember, I talked about the appeal system. In every system, there's an appeal system when there's a denial given. In that, they, in that appeal system is where they need PM&R doctors to be able to look at the cases. And what you just need to do is put your name out there, and people will start picking up on your name. And if you do good reviews, that does not mean you deny everything that comes across your desk. That is not a good review. Just like IMEs, they don't want every IME doctor to say, well, everything was due to that motor vehicle accident. Everything from this point on was due to the motor vehicle accident. If every report comes out that says that same thing, you are not a good IME doc. Same way if you said, if I was an IME doc and nothing is ever related to that traumatic injury or that traumatic event, then you're not a good IME doc because you're too narrow. You're too predictable of what you're going to say. What they really want to know from you is, what do you think? And give me the rationale and the basis for what you think. So if you look at it as a tertiary reviewer for an insurance company, and you'll say, yeah, in this case, it doesn't have the documentation to support whatever they need, but it would support them needing this. So the example would be in power mobility devices, you say, well, they got a prescription for a group two power wheelchair, but this person could use a scooter, a POV. And so they could still have a mobility device, but they'd be more under the quality of the POV. Therefore that would be what is reasonable and necessary. So again, your job isn't to say yes, no. Your job is to determine what you think is reasonable and necessary. And a tertiary reviewer of a Medicare or of an insurance program is a great way to start. Another way to start, and this is going to change a little bit in 2019, because the federal government's changing a healthcare system dramatically every year. This is the Carrier Advisory Committee, the CAC. This is something that you want to get involved in. They need PM&R doctors in this because they need it for your pain. They need it for your management of inpatient rehabilitation facilities. They need it for your experience in DME, prosthetics. They need it for all sorts of areas, you know, epidural injections. How many is reasonable? How often should you do them? And the Carrier Advisory Committee is actually the committee that advises the medical directors of the Medicare program. So I'll give, in the example, I went to Wisconsin last week, and we sat down, and there were cardiologists, oncologists, and all specialties sitting there, and we were looking at various policies. And then we would get advice from those specialists on how to implement those policies and how to do those reviews for our jurisdiction in Medicare. And that's where you can really get your name out there because it's an unpaid position, but it takes one meeting every quarter, and it is a good way for you to get your name out there. Then as you know in everything in government, like I said at the beginning, is that all things are done by contracts. So even in Medicaid, it is contracted out. So as you know in Medicaid, it's a federal government system, but it's administered by the states. And the states then administer it by hiring contractors. And those contractors need medical directors to do this. So in Indiana, for example, there are the four big managed care programs that do the administrative work for the Medicaid system. And that's, again, where they need to have PM&R docs. There also is break-offs of the pure Medicaid. Now that you have actually Seema Verma, she actually ended up at CMS. She actually helped develop this HIP program, Healthy Indiana Plan. So what put her kind of on the radar for the feds was is that she came up with this innovative way of administering the Medicaid program in Indiana, where people pay a premium to the state to join that Medicaid system, as opposed to no premium under the other, you know, just your, you meet certain financial levels. This one, you could have higher financial income coming in, but still be eligible for Medicaid, but now you pay into the system. But all of that needed to be managed by people like you to get out there and to participate and to say what is reasonable and necessary. And I remember when I was, again, starting this and doing Medicaid is, in Medicaid in many of the state programs when it's administered, again it goes back to the wheelchairs, I didn't know much about power wheelchairs when I first came out of residency. But I got pretty good at it because I started working for the Indiana Medicaid, and in order to get a wheelchair approved in Indiana Medicaid, that medical director would have to send it out to a clinician in the field, and that same stuff happens in every one of your states. So there are things that are specific to your state Medicaid program that needs to have PM and R physician input, and they need to have people in the field doing it. Now you are not going to make a lot of money doing this, but it gives you experience. It gives you knowledge and understanding of how to work through these complex bureaucracies, and it gives you a good way to get started if you want to change your career path later on. This is just a map of the jurisdictions for the Medicare administrative contractors for Medicare. Medicare has, I actually work in Jurisdiction K, which is the northeast states up there, and Jurisdiction 6, which are those three Midwestern brown states. So I look at those. These maps are on the CMS website. If you want to get in touch with, you can actually look at each of the companies that are administering these contracts and put your name out to those contract medical directors. Every one of these programs has two, maybe three medical directors. So Novitas has two or three medical directors, not just for Novitas, but they have it for the JH and the JL programs, Jurisdiction L, Jurisdiction H. So they need to have these medical directors for every one of these programs and every one of these systems. The nice thing is, you don't have to live in that particular state to work in this environment as well. I have lived in Indiana. I did my residency at Northwestern, and then I started in Indiana, and I just ended up in Indiana. I stayed in Indiana. Now that I'm not clinically practicing full-time, I practice part-time in Indiana, my full-time work is Medicare, but I get to go and do whatever I can, and it's all via computer now anyway. So you're not limited by the locations of these things, because they'll take you wherever you are. Same thing for the DEMIPAS, the DME, prosthetic orthotic services that are provided under Medicare. There's a contractor specifically for that, and there's really two of them now. They've consolidated at CMSS. They've gone down to CGS and Meridian. Those are the two ones that manage all four of those contracts. Now you have heard about the RAC, and the RAC has usually been viewed as this hot red poker that comes after clinicians and usually comes from behind them and sticks them, right? The RAC is simply just another Medicare contractor. They look at things that CMS tells them to look at. So if they want to go after, for example, the two midnight, well, there's the two midnight rule for a hospital stay, or it used to be the overnight stay versus an observation stay in the hospital. So if the federal government wanted to look at what is reasonable for you to be in the hospital, and it used to be 24-hour rule, and then it's moved to the two-hour rule, but you would then look at the cases as a RAC contractor in determining if that hospital met Medicare coverage criteria for having that person in the hospital as an inpatient versus the observation level of care. And again, that's something you just get trained at learning and doing and how to do it. Plus, there's a Medicare Advantage programs. So remember, Medicare has two big buckets. The first bucket of Medicare is fee-for-service Medicare, the traditional Medicare. That's the stuff that's administered by the Medicare contractors. Then there's the Medicare Advantage programs. The Medicare Advantage programs is, and you see the ads all the time for these things, is sign up for Medicare here, and we're Humana, and we're the best in providing your Medicare, and so join us. What's critical is is that all of these programs need medical directors as well. They need PM&R medical directors, and they have to follow Medicare guidelines. So for this, the Medicare Advantage programs, they can administer their Medicare program however they want with the caveat that they cannot provide anything less than what Medicare says. Now that sounds like a pretty good hard line, a good, nice red line that they can't cross. But remember when I said at the very beginning is that there's statute, there's regulation, and there's policy. So statute and regulation are monitored to the letter of the law. Policy is interpretational, and that's where people usually start getting problems with Medicare Advantage programs because they'll say their interpretation of reasonable and necessary wasn't that what it would meet for the Medicare program. So therefore, it's not going to be covered. The key for you as a clinician, and if you really want to get into this, this would be an excellent way for you to start using your clinical skills now in the application of understanding Medicare Advantage. Let me give you an example. Every Medicare system usually has a local coverage determination, you know, made up by those different MAC areas that were on that map. Or they have national coverage determinations, something that has to go through the entire United States. Now there's some debate in the Medicare world of whether we should turn the LCDs, the local coverage determinations, and instead of calling them national coverage determinations, we're going to call them centralized LCDs. Centralized LCDs mean that all the jurisdictions follow the same policy guidelines for the LCD, but we're not going to call it an NCD because it's a different policy development way of doing things. So Medicare is moving, you should learn what your local coverage determination policies are for rehabilitative services. There's probably three or four. There's an OTPT one, usually a speech one, and then there's, of course, the DEMIPAS ones. But look into those LCDs, find out what they say, because when and if you get a denial, particularly from a Medicare Advantage program, because they're ministered much tighter than the fee-for-service programs, you should know the language of Medicare to be able to counter and say, well, my understanding is that the only thing I have to show is significant improvement within a reasonable period of time to be rehabilitative. And I know it's not conditioning because it's not going to improve within a reasonable period of time. And again, if you understand the word reasonable again, intensity, frequency, duration, not experimental, safe and effective, et cetera, then you can use those words in your appeal process and you become a much better advocate for your current patients now and for your future development should you want to ever get into something where you're starting to learn about working for an insurance company or working for a Medicare program or a Medicaid program. Finally, in Medicare, as all things in the federal government, again, we're pulling back the big curtain from the Wizard of Oz, and you'll see that there are lots of administrative contractors out there for the Medicare program. There are supplemental review Medicare contractors that are reviewing different things than the Medicare contractors are reviewing, so they call it an SMRC. And then they have the QICs, which actually do all the appeal work for things that are getting denied and whether it was reasonable and necessary. You have Railroad Retirement Board, which is a whole different set of the federal government, and they have their own sets of statute, regulation, policy. And that is a completely different beast and a completely different language. Then you have the zone program integrity contractors. Those are the ones that are actually out there looking for fraud. The Medicare review contractors are looking out really for mostly waste, maybe abuse of the system, but the ZPICs are the ones that are looking for fraud, and they're the ones that work with the OIG and DOJ and those kind of things. And if you like giving testimony, I even got pulled into—it's called a 30B6 witness as a—I had to go to the DOJ in Washington, D.C., and they give me this grilling of how we interpreted something in the Medicare program because one of the nursing homes was getting sued by the federal government. That I wouldn't express that as a pleasant experience because you have some really good lawyers there in D.C. There's some opportunities, again, for you to have learning in how to look at things based on fraud. Then you have the drug integrity contractors. You know, how much is the use of a chemotherapeutic drug, and if you're giving X amount of that drug into the thing, what do you do with the waste? And if you—thank you. So you have to be able to determine that as a Medicare reviewer if that is going to be something that's reasonable and necessary. So you have this—the independent contractors that they need PM&R docs to get into doing for all of these different contracts out there. Now these—and I hope you have my slides as well. You can look all this up on the CMS website, and they actually have contacts for the contractors. Here's how I would recommend that you get into that. Then you want—if you're interested in something, first is you can reach out to me, and I will kind of help guide you to a place. We did something last year, I think, at the academy—sorry, with the association. In that, we—there was a couple of people that wanted to get some—get in touch with other medical directors. Well, I know other medical directors, so please feel free to reach out and get in contact with me. I have that Anthem email address that you can contact. Then I can tell you what's out there in the world, and if I can't tell you a specific job opening that's currently there for something that you're interested in, at least I'll know where and how to get a hold of the medical director or the director of the contract. Those are the two main people you want to be able to contact. The medical director of the Medicare or Medicaid contractors is a good point of contact to get and find out if there's job opportunities. Same with the insurance company. The medical directors over the insurance companies, each of those have people that usually start in utilization review if you're going to start with a commercial program. That's a way to get started, to get your name put there. Of course, in anything else that's out there, and the whole hodgepodge of the Medicare program and all the different contractors that are out there, you can get a hold of either the director of that contract or the medical director of that contract. Those are the two key people in those contracts. I'll be happy to answer any questions. Yes, sir. Sorry, I've got a bunch of questions. So, this interpretation, it's kind of like religious text interpretation. Oh, yes. So, I work with IRF. In the past four months, I've gone from maybe four peer-to-peers a month to five peer-to-peers a week. And we're all interpreting 1987 IRF rules as reasonable and necessary. And I've had some great medical directors in these peer-to-peers say, sorry, all strokes and humane are going to SNF. It doesn't matter what you say. It doesn't light up on my computer screen. Right. And the same thing with well-repaired Medicaid. They're extremely strict as well. Even for head injuries, subdural, and brain anatomy, all go on to SNF, which has become frustrating because it's the same rules from 1987. Right. So, that's my question. Okay, let me hit that one real quick. The answer to that is understanding your PM&R literature and your ability to define what is a brain injury. So, that's a Medicare Advantage program, it sounds like, because it's a commercial insurance that's managing the Medicare program. Under the Medicare program, remember, in PM&R, we have acquired brain injuries, and then you have different types of other things like the traumatic brain injuries, open, closed, et cetera. What they typically view as a brain injury is that it's traumatic or non-traumatic or closed injuries and such, not acquired. So, what you'll need to do is learn to get the verbiage of what is acquired and describing how that acquired brain injury is similar to the traumatic brain injury. And then, if you can get that language in your discussion, first of all, to shift, you will find a much better answer that meets the needs of your patients. Let me break in just a second here, just in the interest of time. We have just about a minute here before our official break, and I don't want to get into that too much. So, on some of these questions, I think you might want to ask Dr. Durden. Yeah, I'll be here for a moment. Okay, if he'll be here during the break, you can ask him some of those. I want to get your questions here to the career-oriented questions instead of sort of the practice-oriented, which, like I said, I'm sure he's happy to answer. But for our purposes of the conference time, let's just keep them to career questions, and let's just take maybe one or two, and then we'll go to a break. I don't have a question, though. Okay, one second. And then I also just want to comment, because I know that Dr. Durden is going to be leaving. I'm also a medical director for insurance, and so I think for the breakout session, since there were a lot of questions from me yesterday about what I do, I think I may step in there for the breakout and have a table for this topic, and I'll be Dr. Durden for that session. Probably not as well-prepared, but I actually also work for Anthem, so there's a little bit of what we'll have there. But anyway, so you'll have a chance there as well. We'll include that in the breakout session, so I'll be the one doing that. So, did you have another question on career-oriented? If you can provide a process of, as a medical director, your job performance review, and as a medical director, how is your performance reviewed as a good medical director or a bad medical director, and maybe give us some of that kind of career insight there. So, the way I get reviewed is, how do I conduct enough, whatever enough is, and it's usually a minimal number of ALJ hearings, and do I conduct enough policy reviews? And so the answer is, those are relatively easy metrics to make. There are no denial metrics that are ever used. The thing that we look for is, how are you using your clinical skills in the application of this policy interpretation? So, if we have medical reviewers that have questions, are you able to address those? And do your peers, your other medical director peers, also feel like you are a good resource to be able to go to to come up with the answers of how to do it? So, it's really not based on numbers or metrics, at least certainly for me in the Medicare program. They're looking at, how do I play well in the sandbox with everybody else? And, am I a good resource? Am I somebody that people will come to when they need to have an answer? And if I don't have the answer, am I good at being able to get them to the right people to get the answer? That hard. Okay, why don't we take a break now? We will be back, we will resume at 10.30. Thank you.

Medicare

insurance companies

medical director

defined benefit program

medical policies

acronyms

PM&R physicians

inpatient rehabilitation

patient advocacy