The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule highlighting intentions to regulate Medicare Advantage (MA) plans from using internal, propriety guidelines to inform coverage determinations for its patients.
CMS also recently released a final rule detailing changes to Medicare Physician Fee Schedules (PFS) and its impact on outpatient (OP) therapy services.
Benefits of the proposed rule
Enacting the proposed rule would allow inpatient rehabilitation settings to more effectively admit patients that meet the criteria for intensive rehabilitation therapy and therefore improve patient care and outcomes.
Lifepoint Rehabilitation is an active member of the American Medical Rehabilitation Providers Association (AMRPA). To express our support for CMS’ proposed rule, AMRPA submitted a response detailing concerns around the current abilities of MA plans and expressed urgency to enact with the proposed rule.
What you need to know: highlights of 4 key responses
- Reduce MA’s ability to divert patients to other care settings
Currently, MA plans can deny coverage of inpatient care if they feel a patient could potentially seek care in another setting. These denials often contradict the guidance and medical expertise of the referring physician and can have profound impacts on long-term patient outcomes.
AMRPA states in their response that by setting limitations on MA plans (i.e., allowing for coverage decisions to be made based on clinical outcomes rather than cost), patients can begin receiving care in a setting best fit to address their needs – therefore generating improved outcomes and lower readmission risk.
- Require MA plans to provide individualized patient assessments for coverage decisions
Under CMS’ ruling, for a patient to be accepted or denied coverage an individual assessment must first be conducted. This includes providing an overview of medical history, physician recommendations and clinical notes. However, MA plans often use a single sentence to deny coverage, or simply state that the patient does not meet the medical necessity criteria. This places the burden solely on providers during the first round of review.
In their response, AMRPA recommends that CMS standardize the language MA plans use in their denial explanations, including specific reasons for denial and demonstrate that the MA plan has considered the required factors in reaching its decision.
- Ensure continuity of care protections
Transitions of care are critical for patient outcomes and overall safety. Yet, MA plans currently limit access to inpatient rehabilitation facility (IRF) care by keeping their IRF provider network narrow. Since there are no network adequacy requirements for MA plans, many patients are unable to transition to the appropriate care setting – placing strains on quality and access to care.
AMRPA highlights their support for the need to improve network adequacy standards within the IRF setting – something they have previously done for behavioral health.
- Optimize MA plan response time for rehabilitation admissions
Delaying rehabilitation care can have dramatic and negative effects on a patient’s recovery. In their response, AMRPA urges CMS to reduce the required response time of MA plans for rehabilitation admission to 24 hours, as opposed to the current 72-hour timeline.
Additionally, MA plans are not currently required to respond to requests over the weekend, forcing hospitals to either delay a patients care or push them to seek care in another care setting that may not be equipped to address their unique needs.
By closing the response window to 24 hours with the addition of weekend responses, patients in need of post-acute care can receive it in a prompt and effective manner.
CMS 2023 Medicare Physician Fee Schedule Final Rule: What does this mean for OP?
In November 2022, CMS issued a final rule that included updates and policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023. Key changes of this rule that will impact outpatient (OP) services include:
- A reduced conversion factor by 4.7% compared to 2022 for Medicare PFS.
- The Consolidated Appropriations Act of 2023: This Act was passed in December 2022, which provided additional funding to CMS offsetting the Medicare PFS reduction by 2.5%.
- For 2023, the conversion factor will be reduced by 2.08% compared to 2022 levels.
- The annual therapy threshold has been increased from $2,150 to $2,230 for PT/ST and OT services with the targeted manual review threshold remaining at $3,000.