In 2013, the Centers for Medicare and Medicaid Services (CMS) settled a class action lawsuit (Jimmo Vs. Sebelius). The lawsuit was filed regarding denials of therapy claims that were based on goals of maintaining patients function or conditions that were not improving.
The Transmittal #: R179BP with an implementation date of 1/7/2014 stated: “Coverage of skilled nursing and skilled therapy services (OT, PT and SLP)…. Does not turn on the presence of absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”
Although it has been four years since this modification to coverage criteria was issued, some therapy providers and beneficiaries continue to be denied payment. “Many seniors have only been able to get coverage once their condition worsened and once it improved, treatment would stop.” Coverage would not begin again until the patient got worse.
It is important to remember that the Jimmo settlement does not depend of the “potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.” Although the revised guidelines were distributed to Medicare contractors, not all have implemented the guidelines when reviewing therapy claims.
Jaffe, Susan. Medicare Coverage of Therapy Services Again is in Center of Court Dispute. Downloaded from Kaiser Health News. January 30, 2017
MLN Matters #MM8458. Department of Health and Human Services, Centers for Medicare and Medicaid Services.