The Centers for Medicare and Medicaid Services (CMS) released a proposed rule in April 2020 that would allow non-physician providers (NPPs) to provide services that are currently performed solely by physicians in accordance with the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). This ruling was immediately met with opposition from more than 120 health care organizations, including the American Medical Association (AMA). The opposition to the proposed rule was a factor in the CMS’ decision to ultimately not finalize the proposal and instead publish a final version of the rule with limited expansion to the scope of NPP capabilities.

The proposed rule, titled CMS-1729-P, indicated that, if implemented, NPPs would have the ability to provide “any of the IRF coverage service and documentation duties that are currently required to be performed by a rehabilitation physician, provided that the duties are within the non-physician practitioner’s scope of practice under applicable state law.”1

The American Association of Nurse Practitioners (AANP) supported the proposed rule as written, and submitted comments to the CMS. “Nurse practitioners are providing high-quality, cost-effective health care across the country. Enabling NPs to practice to the full extent of their education and clinical training will improve our nation’s health care delivery,” Sophia L. Thomas, AANP President, told the Clinical Advisor.

In June 2020, the AMA expressed its opposition to the proposed rule.2 In letter to Seema Verma, the administrator of the CMS, the organization stated, “While we understand and concur with CMS’ desire to increase access to post-acute care services in rural areas, we do not believe services led by NPPs will rise to the level of services that IRFs are designed and paid to provide. To the contrary, in cases where NPPs are allowed to independently complete IRF coverage requirements currently completed by rehabilitation physicians, we believe there could be meaningful risk that patients would not be receiving IRF-level care.”


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The American Academy of Physician Assistants (AAPA) disagreed with this sentiment. AAPA Vice President of Reimbursement & Professional Advocacy Michael Powe told the Clinical Advisor that “authorizing qualified PAs to perform all IRF physician visits would have ensured a robust rehabilitation work force providing patients with timely access to medically necessary rehab services.”

The AMA’s letter was co-signed by more than 100 medical organizations, including the American Academy of Physical Medicine and Rehabilitation. The basis of their concerns regarding a potential decline in quality of care for IRF patients included the fewer required years of education and clinical training hours that NPPs complete compared with physicians. In its opposition to CMS-1729-P, the AMA also resurfaced their concerns about section 5 of a 2019 presidential executive order that reduced Medicare supervision regulations for NPPs.3

The final version of the CMS rule, which will go into effect on October 1, 2020, allows NPPs who are determined by the IRF to have enough specialized training and experience to perform 1 of the 3 required face-to-face visits with a patient per week.4 NPPs are allowed to conduct these visits in lieu of a physician during or after the second week of a patient’s IRF stay, as long as this responsibility is within the NPP’s scope of practice under state law.

Mr. Powe expressed disappointment in the final rule’s limited capacity but acknowledged that the policy change would provide some new opportunities to NPPs like PAs. “AAPA appreciates CMS’ policy change in the IRF final rule authorizing PAs to perform 1 of the 3 weekly IRF visits beginning with the patient’s second week of care,” Mr. Powe said. “However, we were disappointed the agency did not maintain the language contained in the proposed IRF rule that would have authorized PAs to perform all required physician visits in an IRF.”

References

1. Centers for Medicare & Medicaid Services. Fiscal Year (FY) 2021 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) (CMS-1729-P). CMS website. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2021-inpatient-rehabilitation-facilities-irf-prospective-payment-system-pps-cms-1729#:~:text=In%20the%20FY%202021%20IRF,non%2Dphysician%20practitioner’s%20scope%20of. Published April 16, 2020. Accessed September 23, 2020.

2. O’Reilly KB. How CMS move may undermine doctor supervision across medicine. American Medical Association.. https://www.ama-assn.org/practice-management/payment-delivery-models/how-cms-move-may-undermine-doctor-supervision-across. Published June 18, 2020. Accessed September 23, 2020.

3. Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors. Whitehouse.gov. https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/. Published October 2, 2019. Accessed September 23, 2020.

4. Centers for Medicare & Medicaid Services. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2021: Final Rule. CMS website. https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-17209.pdf. Published August 10, 2020. Accessed September 23, 2020.