If your outpatient therapy, home health or skilled nursing claims are still being denied because of a Medicare “improvement standard,” it might be time to enlighten your Medicare contractor about the impact of the Jan. 24, 2013 class action settlement, Jimmo v. Sebelius.
 
You can get more details about this and other events impacting therapy and orthopedic practices in upcoming issues of the Orthopedic Coder’s Pink Sheet, but for here’s what you need to know now:
 
The case, brought by the Center for Medicare Advocacy (CMA), effectively bars CMS and its contractors from denying payment for skilled services – including therapy provided in the home, skilled nursing facility or therapy office – just because the patient’s condition is not improving.
 
Instead, under the settlement, CMS must update its Medicare manuals with new language stating that Medicare coverage “to perform a maintenance program does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.” The change took effect immediately on Jan. 24, the date the settlement was finalized.
 
The CMA brought the case on behalf of patients – many with chronic conditions and disabilities – who were not expected to improve during treatment, but whose conditions would decline without the skilled treatment.
 
Prior to the settlement, such beneficiaries had to fight for Medicare coverage for maintenance therapy in the face of the improvement standard included in Medicare’s manuals. For example, the Medicare Benefit Policy Manual currently states that therapy “documentation should establish through objective measurements that the patient is making progress toward goals.”
 
In the months since the decision, CMS issued a two-page fact sheet clarifying its coverage policy under the settlement, and laying out its plan for updating manuals and launching an educational campaign. But the agency is still formulating those policies, a spokesperson told Kaiser Health News recently.
 
And claims for these services are still getting denied, says CMA. The center has assembled a kit for patients and their providers to use to pursue payment, including a copy of the settlement agreement, a copy of the CMS letter to Medicare Advantage organizations and other documents.