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Educate Against Site-Neutral SNF, IRF Payments Before it is Too Late!

Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, January 23, 2015 Posted in: Inpatient Rehab

Blending Site Neutral Payment Ensures Blurred IRF Uniqueness

I left blog #3 in this series with this thought, “Applying site-neutral payment lacks real insight into regulatory realities that have placed IRF access and costs where they are today.” Why continue to support more SNF PAC beds in the matrix when regulations have forced most IRFs to be at 60-70 percent capacity or less?  

Patients deserving IRF level of care have payment possibilities in the PRESENT IRF PPS payment tool. These payments are less than both SNF and IRF experiences published in the June MedPAC report. I urge you to tell this story to your lawmakers!

Please know that I am not at all adverse to SNF access and care. I have long been an advocate of appropriate screening at acute care discharge so that each patient is referred according to their resource needs, both medically and functionally, when home is not the appropriate choice. There are far more patients that need SNF care than IRF care; but hindsight rules have not let patients slip through the crack. Instead, they are being PUSHED through the crack to an improper level of care, and it’s not always in their best interest to match acuity and oversight.

In the MedPAC meeting January 16th, the commissioners recommended site-neutral payment using SNF reimbursement. Yet in that same meeting they question SNF payment accurateness with another report.   That report states that SNF payment is inaccurate, and asks that these payments be reviewed and altered. How can MedPAC recommend site-neutral payment to an inadequate payment alternative per their OWN REPORT?

The fact that IRFs are not in 30 percent of Medicare beneficiaries’ markets has to do with suppressed IRF accessibility. IF regulations would have permitted full utilization of the IRF PPS payment methodology without reprisal, growth, rather than suppressed IRF locations, would have been more plausible. The issue that has made beds scarcer has been driven through policy.

Regulatory changes during the past eight years have forced most IRFs to be at 60-70 percent capacity or less! Protecting and restoring access specific to IRF criteria couldn’t be more important than now.

For those that have read the MedPAC study, you might say there is willingness to suspend IRF level physician oversight and the three-hour rule therapy, when site-neutral payment is adopted. Opening the door to site-neutral payment may increase census. To this I say, read on…

Presently, there is very specific classification criteria for a facility to be certified as an IRF. This can nullify that level of specialty more quickly than in all past regulatory mandates put together. If burden of care acuity payment and specialized IRF criteria are lifted, the uniqueness that sets IRF apart from SNF goes away. Are you willing to let this happen? Is this the path government may take to make post-acute care one melting pot of various levels with no real distinction to the IRF specialty? 

It can happen! IRFs should have full access to IRF PPS burden of care driven reimbursement possibilities for all patient types. Whether a tier is assigned or not, doesn’t mean the patient does not require physician and nursing oversight greater than a SNF level of care for their safe medical and functional rehabilitation.

If you recall, the present IRF PPS payment tool has burden of care payment with lesser level CMGs, including those with categories that state ‘no tier’ payment. That designation does not mean the patient is not complex. Tiers are assigned above and beyond the ‘inherent’ co-morbid conditions for a specific etiologic diagnosis. Therefore, a CVA with dysphagia, no matter what level, still needs acute dysphagia managed. And yet, it is never tiered because it’s EXCLUDED in all stroke patients. Therefore, the base CMI includes ‘potential’ acuity for stroke severity illnesses. That concept goes with an entire cohort of potentially complex medical management that may even cause death or near misses NOT recognized or tiered at the CMG level because the condition could be inherent in the etiologic diagnosis that leads to the impairment group code.

If your IRF facility accepts low level CMG patients without tiers, you will fall into an outlier status if admissions are at or above the 80th percentile for them. Why? PEPPER Reports are watching. You have already been forced into rationing rehabilitation level of care for fear of ‘improper use of IRF beds’.  No wonder IRFs can sit half empty!  

The fear that IRFs are already taking patients with ‘low medical necessity’ is watched carefully through PEPPER Reports, not only for joint replacement and other orthopedic low level CMGs, but several other conditions even when they are included in the 60% rule to defend IRF licensure. Below are 2 of 4 PEPPER target areas; the second discusses no tier low level CMG admissions. Monitoring PEPPER Reports helps determine if facilities are already in the target zone of being an ‘outlier’ for accepting potentially ‘improper’ patients.


Do not support Site-Neutral Payment when only a portion of the IRF journey and access story has been told.   

Dr. Bruce Gans, Chair, AMRPA Board of Directors, voiced concerns in a letter to MedPAC in December on this very issue.

Despite many testimonials directed to MedPAC, in January, they already recommended adoption of site-neutral to Congress. Your elected officials will, at some point, be asked to review, create policy and vote on that recommendation. PLEASE review all the rationale for why the study was done and the recommendations being made. This recommendation could be the nail that seals the coffin for a unique Inpatient Rehabilitation level of ACUTE care called IRF/U.   Most importantly how can this support the Three Part AIM where the PATIENT OUTCOME, Experience and costs are important.  Recall that in a previous blog I was able to show you IRF PPS payments for some beneficiaries that now access SNF for the recommended diagnoses can be cared for at a lesser payment level.


As the Director of Therapy Rehabilitation for a free standing IRF for 12 of 21 years there, the IRF was near capacity at the inception of IRF PPS  between 2002-2004.  In fact, with a waiting list and I operated 60 beds at the time.   In addition since this facility also had SNF beds those were appropriately filled as well.  Correctly guiding those patients that could tolerate and benefit from the intensity of an IRF was the ONLY consideration the medical director made. This was also done with the 75% rule using 10 key rehabilitation categories. Regulatory ‘rationing’ occurred with rule changes and IRFs were pushed to where you find them now.   

At this time, like NO OTHER, your voice needs to be heard in Washington DC. Educate your lawmakers to the regulatory demise IRFs have long suffered without sufficient argument. Protect patient access; protect a uniquely defined Inpatient Acute Rehabilitation level of care.   Most important, lets put the patient needs first!

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