AMRPA Calls on All Members to Participate in Tracking Project During July-August 2024

As AMRPA continues to advocate for reforms to the prior authorization practices used by Medicare Advantage (MA) plans, we are once again launching a field-wide effort to collect standardized data from inpatient rehabilitation hospitals on prior authorization denials and the burdens they impose on patient access. Our past 2021 survey was a major driver behind new prior authorization policy changes and general MA scrutiny, and this new effort is designed to build on those reforms and deliver more meaningful changes in the coming years. 

To accomplish this, AMRPA is asking all of our member hospitals to track certain prior authorization metrics in a standardized format for the months of July & August 2024. 

AMRPA held a short informational webinar on June 27 to walk through the survey and answer questions. The recording of the webinar is available here. The presentation slidedeck is available here. 

**ACTION REQUESTED** If you are planning to participate in our Prior Authorization survey (and we strongly urge all member hospitals to do so), please complete the short pre-registration survey here to let us know you will be participating. We appreciate all responses by Friday, June 28. 

Additional Information:

 

Who: All AMRPA member hospitals. In order to best leverage our data to impact MA policy, we need robust participation from all hospitals – large and small, freestanding and units, for-profit and non-profit, system and independent. We are also working with other national post-acute care (PAC) organizations to collect similar information from other settings, such as Skilled Nursing Facilities (SNFs), Long-Term Care Hospitals (LTCHs), and Home Health.

What: We will be collecting information on Medicare Advantage prior authorization for IRF admissions. We are asking all hospitals to report information on a monthly basis, separated by MA plan, so we can understand both the total burden of prior authorization as well as any patterns or trends with different plans. The data elements we are collecting include:

• Medicare Advantage Plan Name (e.g., United Healthcare, Aetna, Humana, etc.)
• Network Status (whether the reporting hospital is “in-network” with the plan)
• Referrals Requesting Prior Authorization (the total number of prior authorization requests for IRF admission submitted to a plan for month)
• Referrals Initially Denied (the total number of initial requests denied by the MA plan)
• Average Days to Decision (how long, on average, it took to receive an initial decision from each MA plan – e.g., 2.4 days)
• Level 1 Appeals (how many denials were submitted for reconsideration by the MA plan)
• Level 1 Denials (how many requests were submitted for reconsideration and then denied by the MA plan)
• Admissions (how many MA patients were actually admitted to the IRF in the month)
• Top Reason for Denial (the most common denial reason provided by the MA plan)

We are asking for each hospital to report this information on the facility level, meaning that if you are part of a larger system, we would still like to collect information by each hospital, rather than the entire system’s data for the month.

When: AMRPA is collecting data across two months, July & August 2024. We will ask participating hospitals to make two reports: one in early August, covering admissions & requests from July 1 – 31, and a second report in early September, covering admissions & requests from August 1 – 31. We recognize there may be some hiccups as hospitals prepare to track & submit this information through a new process, so we are viewing July as a “test run” (but we still look to collect robust data reported in that month).  

How: AMRPA and our PAC partners have developed a data collection tool (available for download here) in a spreadsheet format to collect information from hospitals. This will allow hospitals to report the necessary information by MA plan, whether they have a few or a large number of plans serving their patient population.

Step 1. Hospitals intending to participate in the data tracking process will fill out a short survey to let us know you are participating.

Step 2. Hospitals will track each relevant data element in the way that is most convenient for them. AMRPA has included an optional “Claim Log” tracking tool for hospitals’ use, if a facility prefers to track each admission through the form to collect the aggregate monthly data, but hospitals will not be asked to submit this form to AMRPA and we will not be seeking any individually identifiable protected health information (PHI).

Step 3. At the end of each month, hospitals will calculate the aggregate data for the month, separated by MA plan, and report it in the appropriate worksheet in the tracking tool.

Step 4. Each hospital will send back the monthly tracking tool (i.e., “July 2024” in early August and “August 2024” in early September, etc.) to AMRPA staff for analysis. AMRPA will not report any information that is attributable to your individual hospital, and we will only report out information aggregated across the IRF field or on a state-by-state basis. All individual data will remain confidential for AMRPA staff’s eyes only.  

Why: Having a up-to-date, data-driven review of the burden prior authorization presents for IRF patients is critical to AMRPA’s advocacy efforts. In 2021, our data represented a total of 475 freestanding IRFs and IRF units, approximately 40% of the entire IRF field. Our final 2021 report was extremely well-received by policymakers (both in Congress and at CMS and other agencies) and was a major driver in advancing some of the crucial recent reforms we have seen to prior authorization. Now, we need to ensure that policymakers are aware of the continuing burden that prior authorization still presents, especially as some MA plans reportedly continue to delay and deny medically necessary care even under the new 2024 MA regulations.

Frequently Asked Questions (FAQs)

Administrative Questions

1. Will my hospital be identified in the survey results? How is this information kept confidential?
   All information submitted to AMRPA through the survey process will be kept confidential, and results will only be published at an aggregate level. AMRPA will not identify any specific hospital or health system in discussing the survey or publishing results. If you wish to execute a confidentiality agreement further outlining this approach, please contact Joe Nahra ([email protected]) or Kate Beller ([email protected]).
    
2. Can I/we provide information at a system level?
   When possible, we encourage members to submit information at the individual hospital/facility level to allow for greater understanding of any geographic variation or trends in prior authorization. However, if necessary, we will accept system-wide information, and ask that the submitter identify 1) how many facilities are represented in the system numbers and 2) how many IRF beds are collectively represented.
    
3. How do I submit survey results to AMRPA?
   Once you have completed the summary statistics for a given month, please send the information in the July 2024 or August 2024 spreadsheet as an attachment to Joe Nahra ([email protected]). The deadline for submitting July 2024 data is August 12, 2024, and the deadline for submitting August 2024 data is September 10, 2024. Please reach out to our team as soon as possible if you anticipate any issues with meeting these deadlines.
    
4. How will the data be utilized – at the national level only or at the state level?
   Once AMRPA staff has collected all information and analyzed the data, we will publish the results in the most meaningful presentation possible, depending on the robustness of the response. We expect to report aggregated data on the national level and, if possible, broken out by state and/or region to highlight any geographic trends, but no individual hospitals or systems will be identified in any published results. We expect this report to be finalized in Fall 2024.

Substantive Data Questions

1. How are Peer-to-Peer conversations handled in this survey?
   For purposes of the 2024 Summer Prior Authorization Survey, we are not collecting any specific information on Peer-to-Peer conversations with an MA plan physician or other clinical representative. If your hospital conducts a Peer-to-Peer call with an MA plan as part of the initial decision phase (i.e., the hospital or the plan requests a Peer-to-Peer prior to the plan returning an initial decision on the request for authorization), any time associated with the call should be included into the calculation for the “Average Days to Decision” column. This column should report the average time between the submission of the initial request for authorization and the plan’s initial decision (approval or denial), regardless of whether there is a Peer-to-Peer call in between. In those cases where a plan denies the initial request but offers a Peer-to-Peer call to potentially overturn that denial before proceeding to an official plan reconsideration request (Level 1 appeal), that time should still be incorporated into the “Average Days to Decision” column.
   
   If a there is a Peer-to-Peer call during or after the plan reconsideration (Level 1 appeal) stage, we are not collecting specific data on the time associated with those calls. Any reversal after a Peer-to-Peer call in this case should be counted as a “Denial Overturned on Level 1 Appeal.” If you experience any especially concerning plan behavior regarding the peer-to-peer conversation or other details you would like to relay beyond the summary statistics, please include these in the “Notes” column or send information directly to [email protected].
    
2. Should I submit information on Independent Review Entity (IRE) or Administrative Law Judge (ALJ) appeals?
   For the 2024 Summer Prior Authorization Survey, we are only collecting information on initial prior authorization requests and Level 1 appeals (plan reconsideration requests). If you have any notable experiences with Level 2 or higher appeals to share, please contact Joe Nahra, [email protected].
    
3. For the column “Average Days to Decision,” what days are we tracking?
   For this column, we are asking hospitals to track the time elapsed between the submission of an initial request for prior authorization and the plan returning an initial decision, whether this is an approval or a denial. This should include weekends and holidays, as we know that hospitals operate on a 24/7 basis even if plans and claims processors do not.
    
4. How should we handle interactions with third parties (such as NaviHealth) contracted by the MA plan(s) to oversee their initial prior authorization processes?
   If the reporting hospital knows which plan the third party is operating on behalf of, we ask that any third-party data be reported as part of the overarching umbrella of that MA plan (e.g., UnitedHealth, Humana, Aetna, etc.) If there is anything especially notable you would like to report regarding patterns of behavior with specific third parties, you can communicate that separately to AMRPA staff as necessary.
    
5. How should we break out the MA plans?
   As much as possible, hospitals should report data broken out by each individual insurer (e.g., UnitedHealth, Humana, Aetna, etc.) When one insurer offers multiple plans, such as HMO, PPO, etc., these should be categorized together under the umbrella of the main insurer. If there is any confusion as to whether a given plan falls under one insurer or another, please feel free to report the information broken out and AMRPA staff can work to provide any necessary clarifications on the backend.
    
6. What if my hospital tracks authorizations differently, or if I want to collect more detailed information than what AMRPA is requesting?
   The 2024 Summer Prior Authorization Survey was designed to allow for the collection of standardized information by the maximum number of hospitals. We ask that, if necessary, you modify your tracking for the months of July and August to ensure you can submit data in the format laid out in the survey tool. If you are tracking additional data or anecdotal information about prior authorization and wish to share with AMRPA, we would be happy to receive it separately, but only as a supplement to the data requested in the survey tool. Please note that we cannot accept any patient-identifiable information that may be collected through additional data tracking.
    
7. Should data be reported on the IRF level of care only, or include LTCH and SNF beds as well?
   For purposes of the AMRPA Summer 2024 Prior Authorization Survey, please only submit information on requests made for IRF-level care. However, we are partnering with other organizations representing other settings of post-acute care and we encourage member hospitals to submit information to other associations through their survey process for those other settings as appropriate.
    
8. What if some information is missing in our records (such as the reason for denial, if that was only communicated to the referring hospital)?
   We ask that members report the requested data as comprehensively as they can with the information they have. For the Summer 2024 Prior Authorization Survey, we are not requesting that members report any specific information on individual claims, only the monthly summary statistics broken out by MA plan and the most common denial reasons by plan. If the hospital is missing certain information on a given claim(s), we ask that the summary data be reported based on those claims for which you do have the appropriate data available.

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Additional Questions? Please contact Joe Nahra, AMRPA Prior Authorization/Medicare Advantage staff lead, with any questions. We are here to help and to make sure that every AMRPA member hospital is ready to provide robust data on these critical issues.