- CMS is seeking to reduce the administrative burden for inpatient rehabilitation facilities on top of a proposed $75 million Medicare payments increase in the 2019 fiscal year.
The federal agency released several proposed rules for post-acute care providers in late April 2018, including the proposed Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS) rule. The proposal contained standard Medicare reimbursement rate updates, including an estimated 1.35 percent increase factor and an approximate 0.4 percent decrease due to the updated outlier threshold.
In total, the proposed Medicare payments rate update would increase overall inpatient rehab reimbursement by 0.9 percent, or $75 million, compared to reimbursement in the 2018 fiscal year.
On top of the Medicare reimbursement bump, CMS is aiming to significantly decrease the administrative and regulatory burden felt by inpatient rehabilitation facilities. The FY2019 IRF IPPS proposed rule would modify coverage requirements and ease documentation rules. Key changes to inpatient rehab coverage and document requirements included:
• Permitting the post-admission physician evaluation to count as a face-to-face physician visit
• Allowing the rehabilitation physician to lead the interdisciplinary team meeting remotely without adding documentation requirements
• Eliminating the admission over documentation requirement
“CMS believes that the rehabilitation physician should have the flexibility to assess the patient and conduct the post-admission physician evaluation during one of the three face-to-face physician visits required in the first week of the IRF admission,” the federal agency wrote.
If finalized, the coverage criteria changes would go into effect in the 2019 fiscal year, meaning all inpatient rehab discharges on or after Oct. 1, 2018, would be impacted by the proposed modifications.
In addition to coverage criteria changes, CMS is considering reducing the burden of face-to-face visit requirements to decrease physician burden in inpatient rehabs.
Since 2010, rehabilitation physicians must conduct face-to-face visits with patients at least three times a week throughout the patient’s stay.
However, stakeholders expressed concerns to CMS in a 2018 Request for Information (RFI) that the face-to-face visit requirements increased burdens for inpatient rehab doctors, arguing a “decrease in visits would not only assist with reducing the documentation burden on rehabilitation physicians, but it would also afford the rehabilitation physician more time to focus on higher-acuity, more complex patients resulting in improved outcomes and lower readmission rates.”
While CMS proposed several coverage criteria changes that would address face-to-face visit burdens, the federal agency is willing to go further after receiving more information.
“To maintain the hospital level of care that IRF patients require, we would continue to expect that the majority of IRF physician visits would continue to be performed face-to-face,” the proposed rule stated. “However, we are interested in feedback from stakeholders on whether we should allow a limited number of visits to be conducted remotely.”
The federal agency is calling on stakeholders to comment on whether the rehabilitation physician can determine if a patient needs to be assessed face-to-face and when an assessment can be made remotely or via another communication channel, such as video or telephone conferencing.
Nurse practitioners, physician assistants, and other non-physician providers could also help to reduce the burden of face-to-face visits, CMS considered.
Generally, a rehabilitation physician must visit each patient admitted to an inpatient rehabilitation facility and perform an assessment. The physician must also conduct a post-admission evaluation within 24 hours of an admission to an inpatient rehabilitation facility.
Stakeholders mentioned in the 2018 RFI that “expanding the use of non-physician practitioners in meeting some of the IRF requirements would ease the documentation burden on rehabilitation physicians.”
To expand on this suggestion, CMS is looking for additional stakeholder comments on the use of nurse practitioners and physician assistants to fulfill some requirements of rehabilitation physicians. Specifically, the federal agency is wondering if non-physician providers have the training to assess patients, how the provider’s credentials can be documented and monitored, and if the providers can fulfill Medicare inpatient rehab requirements.
“In exploring this issue, we have questions about whether non-physician practitioners have the specialized training in inpatient rehabilitation that would enable them to adequately assess the interaction between patients’ medical and functional care needs in an IRF,” the proposed rule stated. “Another concern that has been raised regarding this issue, is whether IRF patients will continue to receive the hospital level and quality of care that is necessary to treat such complex conditions.
CMS also intends to reduce the administrative burden for inpatient rehabilitation facilities by removing the Functional Independence Measure (FIM) Instrument and associated function modifiers from the IRF-Patient Assessment Instrument.
While inpatient rehabilitation facilities could see a lot of administrative changes in 2019, many other post-acute care providers may also see their documentation burdens significantly fall by next year, too.
CMS also released proposed rules for skilled nursing facilities and hospices alongside the 2019 IRF PPS proposed rule. The other proposed rules each contained specific ways that the federal agency aims to reduce administrative burdens on providers.
For skilled nursing facilities, a proposed Patient-Driven Payment Model would transform how the facilities are paid and reduce reporting burden by $2 billion over ten years.
In addition, hospices could see “more efficient use of Hospice Compare data by no longer directly displaying the seven component measures from which a composite measure is calculated on Hospice Compare, once the composite measure is displayed,” the proposed update to hospice Medicare payments stated.
In all the proposed rules, the federal agency highlighted its commitment to reducing administrative burdens on these post-acute care providers.
“In the proposed rules announced today, the agency is also responding to comments from stakeholders and seeking to incorporate its Patients over Paperwork Initiative through avenues that reduce unnecessary burden on providers by easing documentation requirements and offering more flexibility,” CMS Administrator Seema Verma stated.
As stakeholders approach CMS with various strategies for streamlining care, CMS could propose additional changes to Medicare payment systems to reduce administrative burdens.