Written by Marjorie Mantione, Clinical Consulting Manager, McBee

Medicare Advantage (MA) IRF (Inpatient Rehabilitation Facility) admissions have been a challenging aspect of healthcare administration. The industry grapples with hurdles like attaining pre-authorization for IRF services, conducting successful peer-to-peer reviews and battling post-care denials. These struggles can often seem impossible to overcome. However, recent developments in regulatory guidelines and rules offer some hope.

The Growing Influence of Medicare Advantage

Medicare Advantage plans have seen significant growth. In 2022, MA plans captured 48% of the market, growing to 51% in 2023. Projections indicate that by 2024, enrollment will increase to 54%, and by 2030, it’s expected to reach 60%. This growth is driven by several factors:

  1. Additional Benefits: MA plans often offer benefits beyond traditional Medicare, such as dental coverage and gym memberships.
  2. Financial Protections: With rising premiums for Part D prescription drug coverage, many are attracted to the financial protections offered by MA plans, including an annual out-of-pocket limit.
  3. Convenience and Simplicity: The streamlined approach of MA plans appeals to many beneficiaries.
  4. Aggressive Marketing: Insurers heavily market these plans, further driving enrollment.

Regulatory Resources and Education

UDS has focused on educating providers about the regulatory resources available for navigating MA authorizations and appeals. Key resources include:

  • Social Security Act, Section 1852
  • Code of Federal Regulations
  • Medicare Managed Care Manual

These resources provide crucial information and verbiage to help overcome challenges in pre-authorization processes, initial determinations and denial appeals.

Pre-Admission Screening and Medical Necessity

Even when a specific MA plan doesn’t require a pre-admission screen, it’s recommended to perform one. The thorough completion of a pre-admission screen provides a strong foundation for IRF admissions. There should be a focus on demonstrating medical necessity, including the need for multiple therapy disciplines and the management by rehab physicians.

Peer-to-Peer Reviews

Peer-to-peer reviews are important when it comes to advocating for IRF admissions. While some plans may insist on reviews by acute care physicians, it’s essential to involve rehab physicians. Educate referring physicians on regulatory resources and new MA rulings to use as tools in these reviews. Request that peers from the plan side have expertise in inpatient rehabilitation.

Understanding Appeals and Grievances

Distinguishing between appeals and grievances is vital. An appeal’s aim is to overturn denied care decisions, while a grievance is a complaint about not receiving entitled services. Complaints can significantly impact a plan’s ratings, especially in a competitive market. Providers and patients should be proactive in filing grievances with CMS to ensure timely resolution.

Challenges and the Path Forward

The IRF Review Choice Demonstration (RCD) has highlighted common issues in non-affirmed decisions, such as compliance issues, lack of support for rehab physician management and delayed therapy initiation. Recent findings indicate that stability and participation expectations are now primary concerns. These focus areas can overflow to MA Plan reviews.

MA plans also often scrutinize IRF-PAI section GG and may allege inaccuracies in self-care and mobility evaluations.

Regulatory Relief and Compliance

Recent OIG reports and the 2024 MA final rule bring significant relief. Key elements include:

  • Pre-authorization adhering to traditional Medicare guidelines
  • Ensuring medical necessity denials are issued by experienced professionals
  • Prohibiting limited authorizations and extending stays only after further review

The electronic prior authorization rule emphasizes turnaround times, reporting metrics, and accessibility through APIs. These changes aim to streamline data access and support smoother authorization and appeal processes.

Advocacy and Continuous Improvement

To ensure compliance with these new guidelines, it’s crucial to document and track all interactions with MA plans. Bring these trends to the attention of the plans and, if necessary, escalate issues to CMS. Sharing information with UDSMR, part of McBee, allows us to advocate on your behalf, leveraging our communication channels with CMS.

Equipping yourself with regulatory knowledge and staying informed about recent rulings will enhance your ability to advocate for IRF admissions and overturn denials. By actively engaging in this evolving landscape, we can ensure that MA plans adhere to guidelines and provide the necessary care for our patients.

Click here to listen to our recent IRF Industry Insights webisode on Medicare Advantage

About the Author

Marjorie Mantione, Manager of Clinical Consulting

Marjorie Mantione is a Clinical Consulting Manager in the Education, Training, and Consultation (ETC) Department at McBee. She has over 20 years of experience in rehabilitation audits, including 14 years in management roles. Marjorie oversees McBee’s IRF coding and clinical chart audit services and manages ETC’s Clinical Consulting Supervisors and Coders in this service line. She is versed in Medicare and Medicare Advantage IRF compliance regulations. In addition, Marjorie presents webinars and workshops related to IRF regulatory compliance and documentation education.

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