Challenging the Improvement Standard: Jimmo v. Sebelius

Challenging the Improvement Standard: Jimmo v. Sebelius

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Barbara Patterson-Paul BSN, RN, CRRN, RAC-CT

Director of Operations

Objectives

Review key points of the Jimmo v. SebeliusCMS ResponsePractical Application for Part A and BDocumentation to Support

Harmony Healthcare International, Inc. 2Copyright © 2013 All Rights Reserved

Key Points Jimmo v. Sebelius

CMS Response

Jimmo v. Sebelius

The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations The lawsuit was brought on behalf of:

Six individuals representing a Nationwide class of Medicare beneficiaries

National organizations representing people with chronic conditions

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4

Individual Plaintiffs: Glenda Jimmo


Paul O. Boisvert for New York Times

Individual Plaintiffs

Lead plaintiff, Glenda Jimmo, is a 76-year-old Medicare beneficiary from Bristol, VermontBlind since birth and has had her right leg amputated due to complications from diabetesRequires a wheelchair, and receives multiple home health care visits per week for various treatments for her complex conditionMedicare denied coverage for these services, saying that she was unlikely to improve


Individual Plaintiffs:Rosalie J. Berkowitz


New York Times October 22, 2012

Individual Plaintiffs

Rosalie J. Berkowitz is an 81-year-old Medicare beneficiary from Stamford, ConnecticutMultiple SclerosisMedicare denied coverage for home health visits and physical therapy on the grounds that her condition was not improvingHer family said she would have to go into a nursing home if Medicare did not cover the services


National Organizations

National Multiple Sclerosis SocietyParkinson’s Action NetworkParalyzed Veterans of AmericaAlzheimer’s AssociationUnited Cerebral PalsyNational Committee to Preserve Social Security and Medicare, an advocacy group


Improvement Standard

The settlement addresses Medicare terminating or denying coverage to beneficiaries who are not improving for Medicare Part A and Part B



Plaintiffs alleged the “Improvement Standard”:

Is "a covert rule of thumb" that is not supported by the Medicare statute or regulationsOperates as an additional condition of eligibility which effectively denies beneficiaries coverage of certain skilled services



According to the Complaint, Medicare has :

Failed to make assessments regarding a beneficiary's "unique condition and individual needs" Does not rely on the Medicare statute, regulations and manuals, but relies on "more restrictive internal guidelines, policies, and Local Coverage Determinations ("LCDs")


CMS Settlement

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius

A proposed settlement agreement was filed in Federal District Court on October 16, 2012The Settlement was approved on January 24, 2013

Harmony Healthcare International, Inc. 13Copyright © 2013 All Rights Reserved

Jimmo v. Sebelius

The judgment indicates that as long as a patient requires skills of a therapist or a nurse, a patient would meet the skilled coverage criteria despite not making functional gainsDocumentation must support the need for skilled therapy intervention


Skills of a Therapist or a Nurse

Must require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently



The patient’s medical complexity require the skills of a therapist or a nurse

OR

The services are of such complexity that the skills of a therapist or a nurse are required to perform the service



Documentation must support:Description of skilled treatment Changes made to the plan of care due to assessment of the patient’s needsMedical complexityWhy the clinical and critical thinking of a therapist or a nurse are required (hands and/or brains)


Questions/AnswersHarmony Healthcare International(978) 887 - 8919www.Harmony-Healthcare.com Connect with Us!

@Harmonyhlthcare

facebook.com/HarmonyHealthcareInternational

H linkedin.com/company/harmony-healthcare

18Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

http://www.harmony-healthcare.com/

https://twitter.com/Harmonyhlthcare

What is a CHHRP-LTC?

A Certified Harmony Healthcare Rehabilitation Professional (CHHRP-LTC) is an Interdisciplinary Professional who has Successfully Completed an Intensive and Clinically-Founded Training Geared Specifically to Patients in a Skilled Nursing Facility (SNF) Setting



3-Day Certification Includes:CEUsMedicare Therapy Documentation in a SNF Medicare Coverage CriteriaRehabilitation Program DevelopmentMDS Coding for the Therapy Professional



Hot Topics Discussed:Office of Inspector General (OIG) ReportFunctional Reporting of G-CodesThe Jimmo Settlement AgreementUpdated 2013 Process for Manual Medical Review of Part B Therapy2013 Multiple Procedure Payment Reduction (MPPR)Medicare Part A an B Denial Trends



Upcoming CHHRP-LTC Certification Program: Watertown, NY, June 11-13, 2013Host a CHHRP-LTC Certification Programs and earn free attendees

http://chhrp.eventbrite.com/#


http://chhrp.eventbrite.com/

Date post:	07-May-2015
Category:	Documents
Upload:	harmony-healthcare-international
View:	562 times
Download:	1 times

Challenging the Improvement Standard: Jimmo v. Sebelius

Documents