Maintenance Therapy and Medicare Reimbursement

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care. Subsequently, revisions were made to several portions of the Medicare Benefit Policy Manual, Chapter 8 & 15, as a result of the settlement agreement. Key among them was an emphasis that an “improvement standard” may not be applied as a basis for denial of maintenance claims for which skilled care is required in the skilled nursing facility, home health and outpatient settings. The primary addition to the Manual provides that:

• Coverage for skilled care does not turn on the presence or absence of an individual patient’s potential for improvement
• Coverage is based on the patient’s need for skilled care to improve or maintain the patient’s  current condition or to prevent/slow further deterioration

So, now it is up to us as skilled therapy and nursing professionals to ensure that we are appropriately and actively identifying those residents with skilled therapy needs and providing treatment accordingly. Not only must we ensure that the need for medical necessity is met through skilled service, but we must also provide documentation that supports that skill to ensure payment.

The healthcare industry now has support through the positive results of this lawsuit to care for long term residents with progressive disease processes, conditions, or debilitating co-morbidities to ensure that they maintain the highest level of independent function possible and prevent unnecessary decline through skilled therapy services. As our healthcare system ebbs and flows with multiple legislative changes and methods for reimbursing care, it is important to remember that we must ultimately be responsible for our clinical decision making in regards to deciding when, why and how we will provide therapy treatment to residents in need.