Happy Saturday. Thank you for being here and being the Hardy Group on Saturday evening for a discussion of peer-to-peer reviews. For those of you who I don't know, I'm Michael Lupinacci. I'm the CMO of U.S. Physiatry, and I co-chair the Academy's Leadership Institute. And I have the great distinction to be co-presenting with Dr. Michelle Gitler, who is the Med Director at Schwab Rehab, and also is the CMO of Post-Acute Care at Sinai Health System. And we're very, very happy to be here to discuss an increasingly complex process that we go through as rehabilitation physicians in the peer-to-peer review process. Our goal here is to give you some insights on how, when you have these discussions, that you can get to patient-oriented outcomes, advocacy outcomes, for the patients that we treat who are so vulnerable in this process and underrepresented. Dr. Gitler? Thank you. Next slide. Dr. Lupinacci, I've been waiting for this call for an hour. You were supposed to call me at 12 o'clock for this peer-to-peer. I have been waiting. I am trying to go to clinic. I am trying to take care of this patient. Obviously, you don't understand rehabilitation, and it's been so frustrating to speak with you and the people at the organization that you say you provide health care, and you don't. You don't care. Yes, I'm thinking we should have the discussion at another time. So please call me when you're under better self-control. You can call me. Thank you. Hi, Dr. Lupinacci. Thank you so much for giving me the opportunity to advocate on behalf of my patient, John Paul Jones. I know you have to tell me things about it being recorded and so forth. Do you need to say that right now? This session is recorded. Yes. Well, thank you. And again, it's Friday evening. We're all busy. And I'm going to take the next few minutes to tell you not just about this patient, but about why I know this patient would be best served at an inpatient level of care. So thank you. Right way and wrong way. And I think we've all probably felt like doing it the wrong way sometimes, but that doesn't help. Next slide. Dr. Lupinacci, you have asked for a peer-to-peer regarding your patient. I have to tell you that this is going to be recorded. And here's what I know about your patient. It's a 58-year-old diagnosed with COVID pneumonia, treated with Decadron, only one day of remdesivir. This patient was never intubated. Currently, the patient's on three to six liters of oxygen. And it looks like this patient is meniscus with all mobility and self-care. Given that, I believe this patient really could be best served at a lower level of care. I don't think they meet the acute rehab standard. Thank you for your opinion. I would like to clarify certain aspects of the case to help improve our understanding of where the patient is medically and why they would be better served in an inpatient setting in an acute rehab hospital. If anyone is not muted on the conference, if you could mute, that would be great. Thank you. Go ahead. A couple of things I want to emphasize is the patient was actually admitted on September 28th. That means she has been in an acute care hospital primarily at bed rest and also in the ICU for over six weeks. One of the issues I wanted to emphasize is that she had severe disease. She almost died in the process of dealing with COVID. And at this point in time, she has a number of medical issues ongoing. In addition, her CT scan shows significant pulmonary fibrosis as an after effect of her COVID pneumonia. She was previously healthy, so this has been a devastating medical stay for her. She has tachycardia, both resting, which worsens with exercise. So from our experience with COVID, it is likely she has an autonomic dysregulation due to COVID neuropathy. In addition, therapy-wise, she has been at minimum assistance, I agree, but that is in transfers only, brief episodes of standing only. She's been able to ambulate 10 feet with minimal assistance only. Her endurance is severely impaired. So let me ask you then, how do you know she'll be able to tolerate three hours? I mean, from what you're saying, she can't tolerate three hours of therapy. She will be able to tolerate three hours because we're going to be exercising her in very medically monitored ways. For instance, she will be started out on telemetry because she is at high risk for atrial arrhythmias given her history of COVID. She will need telemetry monitoring. Right now, she does need supplemental oxygen at rest, up to four liters, but she is able to tolerate some exercise to six liters. We have respiratory therapists on staff 24-7. She will have physician intervention each day to monitor her medications, monitor her labs. What do you mean by monitor her medications and labs? You could do that in a nursing home. Well, unfortunately, not on a daily basis and not by physicians on a daily basis, and she needs daily medical physician care, period. Anything short of that would be dangerous for her because you remember we're going to be exercising her in a very compromised status. I believe my opinion is she is able to tolerate exercise as long as we monitor her for adverse events as she continues to recover from a very severe COVID infection, which has affected multi-systems, which interplay with each other from a bodily function perspective. We have the most experience in getting these patients back home independently within a reasonably short length of stay. What I'd like to do then, I'm intrigued, I'm going to authorize this for seven days, and if she's not tolerating rehab, then do you agree she would go to a SNF? I'm very pleased to obtain seven days of rehab, and then we will regroup after that week. Thank you. Thank you. Appreciate that. Next slide. Next slide. These reviews primarily are coming from the managed Medicare side. We have Aetna, we have Savannah, we have Geisinger. There are a lot of managed Medicare programs that are enticing seniors to get into them for a number of reasons, mostly cost containment for the seniors. Unfortunately, one of the advertising schemes for the managed Medicare is not that you may not get into an acute rehabilitation hospital if you need it, but that's what is happening. The conversations with the insurance medical directors, I can say they range from very good to good to really bizarre. They range from being in the corporate office, their being in the corporate office setting, to them being at home in their kitchen. Not criticizing the insurance medical directors, we may have some on the video, it's just there's a great variation on how that interaction is going to go. A couple of things I want to do to distinguish it, preauthorization and physician to physician, a slight difference. Many times our admission staff can preauthorize an admission because that admission truly meets the criteria that the managed Medicare people have. It meets the criteria so they never have to get to me or to Dr. Gittler. It's the physician to physician review that we're going to be discussing here primarily, and that's where we get involved. That's where it's going to require your time, your advocacy, because you're not necessarily going to get reimbursed for this. In this case, I think Dr. Gittler and I agree, that doesn't matter. It's not about reimbursement. It's about getting the patient access and advocating for the care that we know we can give them in a superior fashion. Next slide. So we did a little demo, and this case that Dr. Gittler and I reviewed is a real case. Actually, I got this on my desk Friday, yesterday, and I have to talk to the medical director on Monday. So thank you for giving me a little practice about how I'm going to go through it. But this lady most definitely needs inpatient rehabilitation. So the one thing, a few things I want to emphasize, the art of medical storytelling is going to require some prethought. So obviously before we talked about this case, I sat down, I reviewed it, I highlighted the things that I thought were distinctive in their care, and then I told the story. And the story may be short or it may be long. But you are being recorded, and that will come up again. They don't always tell you, they rarely tell you you're being recorded, but you are. So the issues, again, we all agree that we really should be pleasant and respectful, because your emotional fuse for some of these cases is going to be really short. And I will give you an example of that upcoming. But you really need to have some restraint, no matter how ridiculous or good you're hearing from the other viewpoint. So definitely know the patient, know the records, pick out the things that are important and distinctive that will require someone to be at an IRF level of care, rather than a SNF level of care. If you can have the most recent progress notes, therapy notes, the admission H&P from the acute care hospital, that's not always possible. It's not always possible in my setting, but when we have a case that I know is going to be challenged, we try to get them a little bit more vigorously. Yeah, and I would add, knowing that case and knowing the medical issues off the top of your head, not just what you're going to monitor, but what you're going to manage, is really important, because that can swing it. Next, please. So again, create this narrative in your mind. I had some time to create this narrative. Remember, the reviewers aren't always going to know, particularly in, like, it's easy in a COVID case, because they don't know about autonomic dysregulation post-COVID. They don't know about post-COVID neuropathy. They don't know about post-COVID cognitive impairment in fog. So these are the things that are really important to highlight with any disease entity that you're talking about. And you don't know what specialty the reviewer is coming from, so their knowledge base may not even be at an internal medicine level. I mean, not that their knowledge base may be great, but in their subspecialty. So, you know, Dr. Gittler and I, we have two different views about how we would approach this. I like to ask the reviewer what information they have on a case, because then I can see the gaps they have. So I just listen respectively, and I know where I can come in with information they don't have, which is totally new. And I let them tell their narrative. And I like to tell the story, because too often they have huge gaps. And so what I say is, I don't know what you have. I assume you don't have everything I have, because this case was denied. So let me tell the story. And that's actually worked pretty well, especially if I've written the story as the consultant. Next, please. So again, when we talk about telling the story, and Dr. Gittler mentioned these issues, to combine the medical issues with the functional status pre and post event, and the environmental or home circumstances, and combine them into a complete story, a complete package story. We talked about clarifying gaps. There will be frequently gaps. Some of them are huge and some of them are small, but they're always there in their knowledge. Challenge them on any incorrect or incomplete information in a nice way, and clarify the information for them. And they express their opinions. Ask them for the basis of the opinions, particularly because most of those opinions are going to come more on the denial side. And ask them why they don't think they're a candidate for an IRF, as you're going to tell them why you do think they're a candidate for an IRF. And if they mention criteria, and we'll talk a little bit about the criteria the managed care companies are using, what criteria are they using? And see where they're coming from. And not all of the denials are for IRF stay. We'll be talking a little bit about denials for imaging studies, or maybe some other tests that you want to do. Remember, the initial denials are usually made by somebody who's not a physician, who's got a list of criteria in their checking boxes. They may or may not have much medical background. So our responsibility is to fill in the gaps and understand why they said no, and then create the narrative about how they need to get to yes. Next, please. So, again, emphasize your beliefs, why they're a candidate for inpatient rehab, and why you believe that they are. They can tolerate and benefit from three hours of therapy, as we did in the case study. Why do you feel they can tolerate three hours of therapy if they haven't been doing that much in an acute care hospital? They need medical and nursing care 24-7. What is that medical care that they need? What is that nursing care that they need? How will it make a difference? How often are you monitoring labs? Most companies like to see every other day, physician-wise. How often would you need to change medications? How often would you need to manage all those things that we manage when we mobilize people? Orthostatic hypotension, hypertension, insulin awareness, hypoglycemia, hyperglycemia, use of behavioral medications or not, IV therapies, rehydration. Have an idea of what those patients may need by the medications they have been on and what the acute care hospital physician have been doing with their medications over the course of their hospitalization if you can tell that from your documentation. Or if there's been a new start on a medication, they just started sentiment the day before they came over or some other medication that needs to be closely managed. But do recognize they all use proprietary algorithms for the decision-making process, and that happens frequently before, certainly well before even there is a physician peer-to-peer discussion, that the proprietary criteria virtually make the decision on level of care. I would add, I don't use the word monitor, and Mike and I have discussed this. I use the term manage and adjust. And some of the discussions that I've had that have worked in my favor include the management of pain medication, including weaning a patient off of opioid therapy and onto other appropriate pain management therapy including the use of modalities for pain management, has been really helpful, especially for patients that may not be medically complicated, trauma patients, patients with multiple fractures. I found that to be really useful. I think it's also important to be specific about the ongoing adjustment of medications for someone who's diabetic, moving away from insulin if they've never had that before and trialing maybe some of the oral agents. You have to be specific about what you're going to do. Next, please. So let's talk for a moment about the proprietary admission criteria. And so Michelle and I did a little bit of searching around for these criteria in preparation for this presentation, and what we found, much to our surprise, is that they're very hard to get access to. The organizations that we try, first of all, they're proprietary, so you have to pay to have them, and most organizations don't have them because of the... I'm not sure all the reasons, but it was a little surprising to us, but they don't. So fortunately, I was able to find one organization that did have the InterQOL, but whether it's InterQOL or NavarHealth, it's kind of a secret society of criteria. And there is some regional and company variation as to which criteria they use. And then the case interpretation in each of the admission criteria, proprietary criteria, is different. So I'm telling you this because I can't present the criteria because they are proprietary, but I did review the criteria, and I'll give you my impressions after having gone through InterQOL. That will be the next slide. So InterQOL, just to give you a brief history, the criteria actually started in the 70s, and they were met with a lot of antagonism from physicians, period, because doctors did not like anyone telling them what to do, especially in that age of medicine. But the criteria were basically nurse case management directed since inception, which is nothing wrong with that. We have amazing nurse case managers, and it's great that they took that initiative to try to standardize why people go to certain levels of care. And then the physician buy-in kind of slowly came along, and the input slowly came along over time within the InterQOL criteria. Next. So the criteria do cover all major rehab diagnoses, whether they're within the CMS-13 or outside the CMS-13. It covers major diagnoses like brain injury, stroke, deconditioning. But I will tell you, in reviewing the criteria, there are very complex decision trees as to who lands at what level of care. Let's just talk about the inpatient world now. There's really poor clinical relevancy, in my opinion. And as a physiatrist who's been around a while, I found them hard to interpret, and that really concerned me because I've been around the block on a lot of interpretations of criteria. And then, you know, fast forward, basically our patients are having non-physiatrists or non-physicians interpret the criteria and apply them to our patients. I honestly think they would find it nonsensical because it was hard enough for me as a physiatrist to come to a conclusion about a patient within the diagnosis at a certain level. Next slide. So, and I also found if you followed a patient, I could take one case study, and I followed it through the criteria, you could come to very dichotomous, you know, conclusions about their IRF candidacy. And, you know, I think if a reviewer cites a set of criteria to you, ask them specifically what the criteria are and what is it that doesn't match that patient for an IRF admission. And the other interesting thing is the interqual criteria, and I'm sure Nava Health and the others, they've referenced with the research that theoretically supports the particular line item in the criteria. But the research that's referenced is by far and away not definitively conclusive of any clear conclusion. So it's, it was an interesting hour and a half for me to go through that. I think it's really important to ask what the criteria are that the patient doesn't meet. I've had the experience recently of one of our Medicare-based clinic systems that's taking risk. They have one physician who's not a physiatrist, who's reviewing all requests for IRF care. And he was denying people that were absolutely appropriate IRF candidates. And when I asked why, he said, they didn't say they needed orthotics. I'm like, where did you get that? And I was telling Mike, I actually reported this guy to the insurance company, to UnitedHealthcare, because he was denying patients coming to rehabilitation if we didn't explicitly describe that they needed an orthosis. And that's a great story. I'll tell you more later. But he is no longer denying those patients because he was told by the insurance company that that's not an appropriate criteria. Next, please. So there's a lot of different ways to look at how to communicate the correct information. Obviously, you should communicate the correct information, what's happening with a patient. In general, it seems like from a functional perspective, sometimes if they're max assist, the argument would be, well, how are they going to tolerate and progress for max assistance? What can you do with them? And then the other end, if they're min assist to contact guard, it's like, well, they really could be managed as an outpatient. So mod assist tends to eliminate either of those arguments. But you can't determine that. The information is going to be what the information is going to be. Do you want to comment about high risk readmissions? Yeah. I think that we've kind of gotten caught between a rock and a hard place. Somebody had asked in the chat about, well, what about nursing homes no longer providing the high level of therapy services that they had before? Does that get you in? And I think what we've all found is if we cannot justify the medical necessity for them to be in an IRF, it doesn't matter if they're mod assist, min assist, max assist. If they're mod assist and they're completely medically stable, that could be tough. If they're min assist like our COVID patient and they have multiple medical issues that may result in them bouncing back into the ER, being readmitted, I think we have a higher likelihood of being able to make that IRF argument. And continuing, as Mike said, to make sure that they have the correct information. So often, the reviewer has the diagnosis. I'm like, where'd you get that diagnosis? No, that's not what we're talking about. And continuing to refocus and utilize the correct information. Next. So all the discussions are recorded. And I'll tell you a little vignette. So several years ago, I was on a peer-to-peer. It was a young woman who was in her early 20s who had a challenge of alcoholism. And she had a binge and basically shut down all of her oral organs and had a very tough time in ICU and post-ICU care and came in here cognitively impaired, physically impaired. So in any event, she recovered from all the medical things, did really well physically. And her parents were a professional couple. And we had the discussion. They said she cannot come home. She cannot be released to any place but inpatient alcohol rehabilitation because it will happen again in an instant. And so she was under managed care company. And they called for peer-to-peer because they were resistant to pay for inpatient care. And so in brief, I won't drag this out, but the medical director at that time told me he was denying her because alcoholism was a social issue and not a medical issue, not a medical disease. So being a little bit less experienced than I am now in peer-to-peer, I really led into that doctor saying, you know what? I'm not going to do this. Probably less aggressively than I felt it was. But it was much more aggressive for me than I would ever be usually. Because I was angry. I was just absolutely angry about an incorrect, the basics of medicine being incorrectly interpreted. And so he denied her at the end of the call. And so I went to the administrator of the carrier. It was a local carrier. And they said, Dr. Lupinacci, we had listened to the call. And our team thought, that's not the Dr. Lupinacci we know. And then she said, we apologize. It was reviewed by another one of our higher-level medical directors, and we've approved the inpatient admission. So she did inpatient rehab. Finished there. Went on. Completed her law degree. And is practicing law in the northeast here. And is drug and alcohol free. So anyway. Next, please. So there are a lot of different types of reviewers. And I know in the comments, in the chat section that people have mentioned, there are different types of doctors, too. And we agree with that. So we're all here to help make everybody better at that process. But there are some reviewers that are willing to discuss the case, will listen to your narrative, and they're willing to help you stack information in your favor. I've had a few of those, and they're just trying to make rational decisions. So there are those who don't seem to care and doesn't seem to listen. And maybe they do care and maybe they do listen. We'll give them the benefit of the doubt. But they don't really have a rationale for their decisions, and no just means no. So that happens occasionally. And then there's those that are willing to listen, and they'll try to make rational decisions, why they will still deny it, although the decisions aren't that strong. And then there's those that have their own thought process. It seems a little bit irrational, but it may not be rational. It just might be due to their inexperience in the field of rehabilitation or lack of knowledge thereof. I would add a couple of other reviewers. I've had reviewers that are willing to listen. They appreciate your thoughtfulness. They appreciate the other information. And they're like, yeah, you know, you're right. You're right. You're right. You have that information. And that's great. I've also had some reviewers that I have over and over again, interestingly, because of the managed Medicaid plans, where I get to know them. And so when they know it's me, they're like, oh, hey, yeah, I figured you probably, you know, you've always done the right thing before. So, okay. You know, it's like a ball. But I also think that there are the reviewers who are uncertain, and they think they're supposed to do something. And when you spend the time, whether it's confirming their right that this person's not appropriate for acute rehab anymore, and that sometimes happens, you know, you establish that credibility. Or the reviewer that, as Mike said, is new to this, and you go through what is important in acute rehabilitation and are willing to accept the responsibility. If I can't demonstrate that they're improving after, you know, seven days, if they're, I agree, they're not appropriate. But this is my best judgment. And I think that's important. They're human. They're humans, too. And most people want to do right by patients if we give them the chance. So, post-denial. So, let's say the conversation did not go the way you're hoping, there's a few things you can do. There's definitely, usually in our process here, I would contact the admissions office. I'd urge them to contact the family and to file a family appeal from the family's perspective. And that actually works more frequently than you would think, which is great. It's really great that they are listening to families when they're able to. And I asked them that they tell the family that a PM&R specialist reviewed it, I happen to be the medical director here, and strongly felt that the loved one would benefit from an IRF level of care, and certainly not a SNF level of care. And in a way, I let the staff know they should really suggest it. The family needs to be really a little bit pushy. I wouldn't say a full-blown meltdown, but they're welcome to have it if that's their inclination, but they need to be a little bit pushy about that they really want this to happen. However, pushy is defined within that family structure. Next slide, please. So, we're going to change the conversation a little bit here. We've been talking about up denials from managed care for IRF admission. So, as you all are aware, there also are retroactive Medicare denials from CMS. And so, there are denials by CMS's fiscal intermediary in that area. And what happens is they're denied from the beginning, and they're not paid until until there's some type of agreement and settlement with CMS. And we're going to show you that process. Next, please. So, basically, CMS has rulings 85-2, section 110. These are the criteria for inpatient rehabilitation Medicare coverage. You can go to the next slide because it's a little clearer than this. But again, this slide has the error of close medical supervision. I like it should be changed to management by a physician with specialized training or experience. They require 24-hour nursing care. They have need for relatively intense multidisciplinary therapy and with a multidisciplinary team approach with a coordinated program of care with practical improvement, documented realistic goals, and a realistic length of stay. I would add, the thing I would change, the multidisciplinary team, it should be interdisciplinary. And I would say that COVID taught us so much that our daily discussion or interaction with the therapists and the nursing staff regarding blood pressure management, diabetes management, heart rate management, management of orthostasis, you know, it's that interdisciplinary discussion. And many people don't know what that means. So, you have to be able to explain how you interact with the interdisciplinary team. Next, please. So, we're going to look at some claims data. And it is from 2007. Medicare is extraordinarily slow at getting this data out. And it's not data that they want to get out. So, that was, you know, that was quite some time ago, 14 years ago. Well, no, I'm sorry. It was seven. It was a long time ago. So, here's how we want to look at this slide. So, whenever the fiscal intermediary reviewed a patient's admission that had already taken place, and the patient completed their care, once the FI review is complete, 80% of those are denied retrospectively. And we'll go through the levels of appeal briefly. But once the level of appeal that physiatrists are involved in is over, 63% of those denials are overturned on appeal. So, we want to show you, there's a lot of money involved, which is withheld from rehab hospitals, which helps them improve their facilities, improve their staffing. And again, this is in 2007. So, you can multiply that 25 million multifold over the course of the past decade. Next slide. Next slide. Thanks. So, the claims appeal process has five levels. The one level that we see is when we're asked as physicians to do an administrative law judge hearing. So, basically, and I've done a lot of them, the administrative law judge has you do a testimony as to the narrative, the medical narrative of that patient, why they needed IRF level of care, why it could not have been done in a lesser level of care. So, you're telling them the story. But again, this is a different conversation because it's from you as a medical expert to them as a legal expert. So, it's really a lay narrative. Next slide. But I want to show you, don't look at this slide too long, but this is how complex for one patient who's admitted with general deconditioning, and I guarantee there will be COVID patients in here. It goes from the level one to the level two to the level three, which we're involved in as physicians. And if it's denied, it can go up to a level four and then a level five, which is a judicial review in a U.S. district court for that one patient. So, for each of those patients. So, anyways, no comment. I just wanted to show you the complexity of the process. Next slide. So, we're going to just describe a few case studies for you. We're not going to pretend to be the reviewer, though that's always fun. Just to give you a sense of the breadth and depth and scope of the denials and some of the wording, at least that I've used, to overturn those. Next slide. So, the first case is actually a 25-year-old with a C4 level spinal cord injury, secondary to a gunshot wound. Went from a trauma unit to an LTAC, from an LTAC to a nursing home. I saw this guy in the clinic, wanted to bring him in for rehab, and he was initially denied for rehab because he's not going to get any better. Like, he doesn't have functional use of his limbs. That's what they told me. And so, what I did, both in the document I created, that was my clinic visit, as well as my peer-to-peer discussion, I reviewed all, first of all, spinal cord injury should come for rehab. But what I had to do was discuss how this individual had to be independent, directing his care regarding transfers, bowel, bladders, spasticity, range, and on and on. And I just kept talking about every single secondary condition attendant to spinal cord injury, and I think I wore the person down. The guy actually ended up coming into rehab and went home with his family, which was terrific. The second one is someone I just admitted. It's a 40-year-old. She had supermorbid obesity, which as we know was a risk for COVID. She had respiratory failure, secondary to pneumonia. She was in a university hospital. And she was actually never referred for rehab because of her supermorbid obesity. She went to a nursing home for subacute rehab, where she has been in bed since May. This is now November, as you all know. And the initial review for the denial for rehab services pointed out that she was max assist to four or five people for mobilization. What I described is that, and she came to my clinic on, via ambulance, one of those rigs, they had two crews to get her to my clinic. We talked about the need for ceiling lift and specialized equipment to get her able to move from sit to stand. She's in rehab now, doing a little bit of standing, and our goals are household level mobility, and she's going to make that. But it was her morbid obesity, her supermorbid obesity, that was the initial trigger for the hospital to try to just get her to a sniff, which I don't understand. I saw a 70-year-old who had a managed Medicare plan. He was handling explosive devices. And if you know where I work, you'll understand this. He was trying to make bullets, but I'll tell you that story later. Anyway, it all blew up. He had burn injuries and partial amputations to both hands. He had a globe injury, and he was denied for acute rehab because he didn't have medical issues. And I pointed out that the wound care was medical. He had need for both therapies as well as rehab psychology services and pain management care. So he actually ended up coming to rehab. 40-year-old who had meningitis with multiple strokes, he had a peg placed. He was originally sent to a sniff because he was denied acute rehab by his managed care plan. So 40-year-old in the sniff, and he was not getting speech therapy. He was not getting out of bed. He had a managed Medicaid plan. For those of you that work with Medicaid, you know they don't get much therapy in the nursing facility. I spoke to his family, spoke to his wife. They were committed to getting him home. They just wanted him a little bit more mobile, like getting him up, able to get in and out of a wheelchair, which had not been happening. So I was able to convince the managed care plan that this guy was going to end up living in the nursing home or else we could get him home. He qualified for rehabilitation based on diagnoses, based on needing three therapies, and based on likelihood to improve. I had an outpatient who had a transhumeral amputation. You'll see there's like this theme for my outpatients with firework injuries. He was back to work, and we were trying to get him a microprocessor hand. It was denied because it was experimental. We ended up getting him a hybrid upper extremity prosthesis. We're still working on getting him the microprocessor hand. This guy's at work, takes care of his six-year-old daughter, you know buttons up her shirt and things. So I'm hoping we'll get that overturned, but that's going to have to go back for a medical director appeal. Next please. The next case is a patient of mine who had paraplegia, who had upper extremity weakness. So I wanted to order an MRI because I'm concerned that either he has a syrinx or had something going on in or near the plexus. I was told that this patient had to have therapy before they approve an imaging study. So this is clearly someone just checking the boxes that he hadn't had physical therapy. And I'm explaining that this guy's paraplegic, he's got to use his arms. As it turned out, he had a big juicy disc impinging on one of his roots. And finally, I think the thing we all struggle with is an extension for a patient who's making great progress. They're at MNCIST, and we're told that they have to go home. But we know if we can move them from MNCIST to supervision or contact guard, really decrease the physical burden of care, so their 70-year-old mother can provide supervision, that's going to enable them to go home. That's a challenge we have. And just Friday, and you all get this, right? Friday at three o'clock, we get a denial for a patient who we had asked. The original discharge date was next Wednesday. We're told they have to go home Saturday. It's not safe for them to go home because no equipment has been sent to the home. So I made the decision that we're keeping them until Monday so I can actually talk to someone. But I think all of us know what the right thing is to do in terms of advocacy for our patients. And our frustration is when we don't necessarily get that opportunity. And you take time, you lose money doing this because no one pays you to do it. And it takes time out of your day, but it's the right thing to do. Next, please. So this is Mike's gift to me, what makes me crazy. What makes me the craziest is when patients with stroke are denied inpatient rehab. A reviewer tells me that their needs can be met at a skilled level of care. And what I found is that there are many reviewers who believe they know what happens in a nursing home. They think that all nursing homes provide up to two and a half hours of therapy, three kinds of therapy that they're gonna get the nursing care and the medical care they need. And what I say is, listen, I don't know where you are. I'll tell you where I am. Because where I am, people with managed Medicaid plans don't have that level of therapy. And some people get that at some places in and around the Chicagoland area. And some reviewers tell me they don't believe it. And over and over again, when they tell me that, I've reached back out to the plan. I've been able to speak to the medical director of the plan who's confirmed to the reviewers that what is available for Medicaid or managed Medicaid is not always the same thing as what's available for persons with managed Medicare. So you just have to educate, educate, educate. And the kind of skilled therapy somebody will get, occupational therapy, speech, and physical therapy, and that integrated therapy in the IRF is not what they're gonna get in the SNF. So, boy, that's me, but with blue eyes. Next, please. So, boy, the chat's been really busy. Thank you all. I know all of you have been tremendous advocates for your patient. I think that I'm gonna just respond to Dexanne's comment about nursing homes. There are many people who are sent to SNFs who don't know that they are aware of getting to IRFs. We've been talking with case managers at the SNFs, and it's a process, but word starts getting around. And when families reach out saying they want their family member moved, you have the tools to do it, but it takes time. So let's go over a few other really great questions in the chat room. They're all great questions or comments, I have to say that. It's obviously a topic we all struggle with from time to time. Spencer asks, are there tips and tricks to preventing a peer-to-peer in the first place in terms of optimizing documentation? Michelle, do you wanna go first on that? Yeah, I would say overall, when I look at what we do in documentation, we're doing a lot of things we have to do for Medicare, but what we're not doing well is we're not putting in our documentation what we're going to do in rehabilitation in terms of optimizing their glycemic control, optimizing their blood pressure management, that we're going to, together with the pharmacy, winnow their medications so that it's something they're going to be able to administer at home. We have these rote phrases we use, and we don't take the time to be specific about what's important for this patient. And I think when you start talking about bowel and bladder management, which is something we and our rehab nurses are uniquely qualified to do, not just the management, but teaching the patients, and putting that in the note, that's really helpful. It's kind of like you wanna anticipate all of the questions ahead of time. Yeah, I think if you have the advantage of being the consultant in acute care, that's a tremendous opportunity because you have direct access to the progress notes of the day-to-day actions. And I think we're in a unique position to pick up problems that the hospitalists don't quite grasp that are going to be significant in the patient's recovery. And again, COVID is a prime example of that issue. Who knew that post-COVID recovery patients would certainly be at high risk for recurrence of bronchopneumonia during the rehab stay? Well, they are, it happens all the time. Who knew that we would have problems with orthostatic hypertension much beyond what we would normally expect because of the autonomic dysregulation? So there's a lot of things, if you have the ability to be in the acute care hospitals, those are things you can pull out that are only gonna help in that decision-making process of birth versus SNF. You know, I also think that even if you're not in the acute care hospital, sometimes we get referrals. And again, the diagnoses that come over aren't quite jiving with what we're seeing in the rehab part. And how many times have you had a case where a patient presents with a stroke-like syndrome and they're hemiparetic, but they call it a TIA? Well, it's not a TIA. I'm sorry, what your imaging studies showed or didn't show. So, but things like that, we live in the environment where we can pick those things up very, very easily. And someone commented on chat, effective documentation is only gonna help in that initial decision-making process. Yeah, I would also say, don't underestimate the therapist's notes. We also get referrals from hospitals all around the Chicagoland area. So I don't have the luxury of being the consultant for all of them. Reading the notes, the cut and paste of the physician notes, you know, everybody's strength is normal. And then when you read the therapist's notes documenting proximal greater than distal weakness, or, you know, whatever it is they document, then I'm more able to describe this as a critical illness myopathy, or, you know, whatever it is I'm looking at when I look at the speech language pathologist notes documenting their cognitive dysfunction. I think that it's really hard to know what notes go to the insurance company. The insurance company is denying it because if I read that trauma note, I'd deny rehab too until I recognize that, oh, the patient has a spinal cord injury. Don't just have an L2 fracture, they actually have a mixed conus cauda lesion. And that wasn't even documented in their progress note because that's not their level of expertise. So look at those therapy notes. Yeah. It was also a comment on having the insurers be more consistent with their scheduling of peer-to-peers. Some of our audience, Stephen, has had difficulty with them being inconsistent. They requesting a specific time, you might be in clinic, it's in the middle of a very busy day, and there's a lack of coordination of when the physician is most available and has had time to review the records. So I haven't personally had difficulty with that, but I'm honestly thinking that you're going to need the hospital's support in communicating with those carriers that do that. Yeah, I agree. You need to get the name of that carrier and report it to whichever department in your hospital or your clinic is responsible for working with managed care because there are criteria that they have signed a contract to abide by. And if what they've said is that we're giving you 20 minutes for a peer-to-peer and we signed off on that in the contract, shame on us, but very often they're making stuff up. Nonetheless, if you know something's been denied, my recommendation, and you feel strongly about it, you have to feel strongly, is that you just kind of review it and keep it in an index card in your pocket if you guys still use index cards. I guess some of you would just put it on your phone. So from Susan, a great comment here, is the change in subacute reimbursement associated decrease in therapy services an opportunity to point out the need for IRF? Well, my opinion, it is a great opportunity. My experience has been the medical directors don't listen to that or acknowledge it as happening. I am not even sure that they know that it is happening, but from a physiatric perspective, it is absolutely a reason why IRF is even more superior than SNF, particularly with their reduction in therapy services, which has been dramatic across the country. Yeah. Let's see. Great comments, everyone. From John, there's often a need to educate Medicare Advantage medical directors that they're legally responsible to follow Medicare criteria and then review with them what those criteria are. Have had episodes where the medical director acknowledged and admitted that the patient was appropriate by Medicare criteria, but still denied the patient, so. Yeah, yeah, that's, I would say that's not uncommon and you need to report that. Again, I gave that example early on about someone, a group that was assuming risk for Medicare Advantage. So this wasn't actually the Medicare Advantage medical director. It was another physician, but they, you know, and when you ask why, you know, this patient clearly meets criteria. They, they're just cranky sometimes. And Maria has an example related to that point of that she's discussed management of a number of medical issues that would be more appropriate in an IRF to get IRF coverage. And then she was told that the patient is likely not medically stable yet to leave the hospital if they need that much medical care. But then when they were medically stable in the hospital, they would be more appropriate for a SNF. So it's the, as she points out, the double-edged sword. I think that's, that might be part of their schooling of one way to get out of a sticky bucket. Well, let me say that is sticky. I think the way around that is instead of saying we need to manage this and we need to manage that, it's as they start therapy, we anticipate fluctuation in their blood pressure, in their glycemic control because of the energy expenditure, you know, which is going to change dramatically from being at bedrest. And the, so that's where it can be managed, that they're medically stable to move to the next level of care with that physician intervention. But, you know, sometimes all they're looking for is a reason to deny. Yeah, and Dr. Watson just chimed in that it's in our favor if the peer-to-peer call is recorded. So when the patients appeal and it's clear that the patient has met criteria that we have more than one leg to stand on. Thank you. And I think we'll end, Dexanne, appreciate your comment on the fact that it's very, very true that most people who are sent to SNPs, they're unaware of any possibility of getting an IRF care later in their trajectory. And I think that's absolutely true. So we have to continue to get that word out for first chance or second chance rehabilitation. It's, and it's happening, it's going to be happening more and more capacity. So we're at the end of our session. Thanks everyone for the engagement in the chat. We appreciate it. Michelle and I don't have all the answers, but we're hoping to help together to give everyone direction on this. Really, it's a difficult, it's a difficult topic. No question, but thank you all. Thank you very much. Have a great rest of your Saturday evening. Good night. Yeah.

peer-to-peer reviews

rehabilitation physicians

patient-oriented outcomes

advocacy

functional status

insurance reviewers

compelling narrative

proprietary admission criteria

retroactive Medicare denials

documentation