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Three-Hour Rule NOT Defined: How To Interpret Regulations When Black-and-white Guidelines Do Not Exist

Three-Hour Rule NOT Defined: How to interpret regulations when black-and-white guidelines do not exist

I was recently asked whether there was evidence somewhere to support that patients discharged on day seven do not have to receive three hours of therapy for at least five days of the week. I immediately went to my trusty Medicare Benefit Policy Manual – Chapter 1, which I assumed would provide me a concrete answer for this scenario. Well, I was mistaken and started wondering how to respond to this question.

Having just finished watching the final episode in season seven of Game of Thrones, the following interaction between Lord Baelish (a.k.a. Littlefinger) and Sansa Stark came to mind:

Sometimes when I try to understand a person’s motives, I play a little game. I assume the worst. What’s the worst reason they could possibly have for saying what they say and doing what they do? Then I ask myself:  How well does that reason explain what they say and what they do?

What does this quote have to do with the three-hour rule?

Do I really think that CMS regulations are the “worst” or that the organization has “bad” motives?  Absolutely not. However, if you take the essence of this quote, it can be used to assist in figuring out the intent of a regulation when there isn’t a concrete, black-and-white answer. The three-hour rule interpretation is a great example.

Per the Medicare Benefit Policy Manual, the three-hour rule is the “generally accepted standard by which the intensity of services is typically demonstrated in IRFs.” It also states that the “… patient’s IRF medical record must document that the required therapy treatments began within 36 hours from midnight of the day of admission to the IRF.” You might be thinking that because therapy doesn’t have to start until day three, I don’t have to worry about meeting the three-hour rule until day four. Is this the justification that a patient with a stay less than seven days doesn’t have to meet the three-hour rule?  Before you answer, let’s play the little “game.”

Why would CMS determine a stay less than seven days was not an appropriate IRF admission?

In all the documentation related to the justification of a patient stay in an IRF, CMS repeatedly mentions that the “… patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs.” In other words, if a patient is admitted to an IRF, the patient must require AND participate in intensive therapy services that are unique to an IRF. If a patient is not participating in this unique level of service, then CMS will question whether the patient could have received rehabilitation at a lesser level of intensity (such as a skilled nursing or home health).

If, during this stay of six midnights, the patient only received three or four days of three hours of therapy, does this meet the intensity of rehab if the patient had the potential to have at least five days of three hours of therapy? Does the reason for requiring intensive rehabilitation explain why CMS might say that this particular stay was not appropriate?

Granted, there may have been extenuating circumstances in the scenario, but if you look at the reasons why a patient’s stay might be denied, you must look past the black-and-white rules to understand the intent of the regulation.

In today’s world, it isn’t enough to be able to just check off the boxes that I did this or did that; instead, it is necessary to really dig into the documentation to be sure that each patient meets all criteria for IRF admission.

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Success Story: Aspirus Wausau Hospital Inpatient Rehab

Success Story: Aspirus Wausau Hospital Inpatient Rehab

With MediLinks, clinical processes are streamlined to increase efficiency and revenue.

At Aspirus Wausau Hospital’s inpatient rehab facility (IRF), clinicians used a manual scheduling system to track patient care. This “whiteboard method” and paper documentation made it difficult to track three-hour-rule compliance during audits and led to inconsistencies in important patient scheduling processes. In addition, clinicians rated patients with subjective FIM scores, which led to lower reimbursement rates.

Since adding MediLinks into to its Wisconsin facility and integrating it with the facilitywide electronic medical record (EMR) system, Aspirus Wausau Hospital’s IRF can now:

  • Track three-hour-rule compliance automatically
  • Report standardized, objective FIM scores to ensure maximum reimbursement
  • Monitor clinicians and patient scheduling in real time with new digital processes

“If we had to manually track what MediLinks can do, we’d need to hire another full-time person.”

Nicole Trempe, Manager of Rehabilitation

Automatic three-hour compliance

Prior to MediLinks, Aspirus clinicians identified that the hospital’s EMR had a shortfall—the lack of three-hour tracking and reporting tools. Manually tracking each patient’s scheduled and delivered care wasted valuable time and increased the risk for reimbursement inconsistencies. “The biggest thing we needed was three-hour tracking and reporting. Alone, our EMR can’t do what MediLinks does,” Nicole Trempe, manager of rehabilitation, said. Now, as Aspirus clinicians enter patients’ treatment data, MediLinks automatically monitors their progress toward the three hours required for reimbursement from CMS. When audits arise, clinicians aren’t left digging through folders of paper. Evidence of proper patient care is easily accessed electronically within minutes. “When we recently got audited by CMS, we were quickly able to pull 40 three-hour reports,” Trempe said. “Before MediLinks, we tracked on paper charts, and that would have taken hours upon hours to pull what we needed.”

Consistent FIM scores

Aspirus IRF aimed to maximize reimbursements by standardizing the collection of FIM scores. Because subjectivity in FIM scoring decreased the interrater reliability of the FIM tool, the IRF wasn’t always receiving the maximum reimbursement for each patient. With MediLinks’ objective FIM scoring tools, the IRF clinicians at Aspirus provide consistent, accurate scores for every patient. Early on, the new system translated directly into increased revenue. “During our trial of MediLinks, we were able to increase payment by $800 for every stroke diagnosis,” stated Kim Krohn-Rick, supervisor of therapy.

Smooth scheduling

Before the IRF integrated MediLinks with its hospital wide EMR, clinicians relied on three white boards in three different rooms to track patient scheduling. Because of the dynamic clinical environment, changes made on one white board often wouldn’t make it to the other two. Manual scheduling created confusion for patients and clinicians alike. “It was inefficient,” Krohn-Rick explained. “Manual scheduling would cause issues for families and patients because we wouldn’t have the correct treatment times listed for them.” Today, clinicians can track and update patient scheduling in real time at monitors throughout the unit. This way, last-minute changes are immediately known to patients, families, and care providers. Aspirus Wausau Hospital IRF boosted efficiency with MediLinks’ standardized FIM scoring, automatic three-hour compliance, and seamless scheduling processes. The software has become so critical to the facility’s operations that, according to Trempe, it simply couldn’t function as efficiently without it.


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Webinar: What You Need to Know About the 2018 IRF PPS Final Rule

CMS released the 2018 IRF PPS Final Rule in July, and after last year’s changes, inpatient rehab providers can relax since there are only a few minor changes required for this year. However, big changes are expected for FY 2019. Our clinical team is ready to help, prepare, and train your staff so that you can stay ahead of upcoming CMS regulatory changes.

To help you navigate the changes, Mediware’s Clinical Consultant, Virginia Littlepage, M.S., CCC-SLP, has prepared a review of the information included in the final rule, specific to IRF-PAI and payment changes.

Here are a few things you will learn during this webinar:

  • Review of all changes presented in the final rule
  • Understand the changes from the proposed rule to the final rule
  • Receive recommendations on how to prepare for FY 2019 changes

About the speaker:

Virginia Littlepage has been a Clinical Consultant at Mediware for the past seven years. Before Mediware, she spent more than 16 years working in inpatient rehabilitation facilities, skilled nursing units, long term acute care facilities and outpatient hospital settings, in clinical, supervisory and management roles. She received her Master of Science in Communication Disorders from the University of Oklahoma.

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4 Productivity Lessons From IRFPAI 2017

4 Productivity Lessons from IRFPAI 2017

Lessons learned last year can help IRFs prepare for the next change cycle.

CMS’ annual updates to the IRFPAI drive significant challenges to IRFs who want to remain compliant and not suffer across-the-board penalties.  From time spent planning and preparing, to workflow changes and provider training, it’s not unreasonable for an IRF to invest 500 to 750 hours of non-productivity time.  Considering that there is no advantage to the IRF for this investment (beyond continuing to get paid), that’s a significant hit to the bottom line with no relief.

After the extensive changes that went live on October 1, 2016, Mediware conducted a survey of more than 2,000 IRF providers to assess how they dealt with the change cycle.  This survey yielded several insights about how preparation impacted the results and the level of productivity that was lost.

The first finding related to the impact of management engagement on attaining a self-reported “good outcome”.  The survey data indicated that 78% of the surveyed IRFs reported a good outcome.  However, when considering the amount of time the management team invested in preparation, we can see that there is a wider range of outcomes.

Those organizations whose management team invested 20 or fewer hours of preparation under-performed the group.  As expected, the more investment that was made by the management team, the higher the likelihood of a reported good outcome.  We were slightly surprised to see the relatively small incremental improvement between the 20-40 hour category and the 40+ hours category.  This suggests that either both groups were very closely grouped around the 40 hour metric or that the organizations which dramatically exceeded the 40 hour mark were not effective in using that time to improve their outcomes.

Overall, it is encouraging to see the 70% success rate for even the lower category of management time investment.  However a 10% swing in good outcome likelihood does seem like a fairly  wide swing given the impact on practitioners and patients alike.

The second finding related to the relationship between therapist and nursing training and outcomes.  Again, the sample generated a 78% likelihood of good outcomes.   We are pleased to see this high level of positive outcome.   However the organizations which invested 2—5 hours per therapist/nurse reported the lowest likelihood of positive outcomes.

It is remarkable that every one of the 6-10 hour training responses reported a good result.  However this category was a minority of the overall sample.  The clear majority answer, 2-5 hours, under-performed the sample.  Our conclusion suggest that the organizations who invested the extra time did so in a more effective fashion than the lower or higher category.

As with the management results, more is not always better.  The highest level of training, 10+ hours, did not significantly out-perform the lowest level (77% vs 73%).  The data does not offer a clear reason, but we suspect that the “overwhelming training” of 10+ hours lacked focus or timing needed to have the maximum impact on the staff.

A final observation from the data looks at the relationship between clinical staff training and the amount of extra workload that was experienced by the organization.  74% of therapists reported a meaningful increase in extra work and 49% of nurses reported the same.

With therapists we noted an unexpected inverse relationship between training and extra work load.  Those organizations who reported lower levels of therapist training had a lower likelihood of experiencing additional work.  However that favorable result was not far removed from the results experienced by the organizations who invested the most training.  We believe that the nature of the IRFPAI changes had a greater effect on the amount of therapist extra work than did the amount of training provided those practitioners.

With nurses the result seemed a little different.  While nurses experienced lower levels of extra work than therapists, training seemed to have a positive impact with the 6-10 hours of training experiencing a marked reduction of extra work compared to the lower or higher levels.

We believe that the distribution of impact was shifted toward the therapist community as opposed to the nursing community because of the natural workflow of completing the new QRP data elements.  The data supports this conclusion given the overall difference in extra work impact.

Looking ahead to October 1, 2017, it  appears that CMS has chosen to give IRFs a year of respite.  The change load that we can expect (based upon the current proposed rule) is negligible compared to last year’s IRFPAI.  However extending the vision to 2019, CMS will pick up the pace of change to at least the same level as 2017.

Given this one year reprieve, we believe that prudent IRFs will take advantage of the time to implement systems and workflows that can be leveraged to drive change and reduce the impact that is expected in 2019.  Preparation over the course of a year will have less operational impact on organizations that a crunch-based plan implemented in a year.  It will also allow for a more thoughtful set of changes to be planned and executed.


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