Somehow, although certainly not from a clear reading of the Medicare statute, there was long a perceived rule that Medicare would only cover certain services if the patient was making measurable improvement. This created the perverse circumstance that a provider was discouraged from delivering services that would maintain a patient’s current health level even if the absence of those services would result in the patient declining and then needing even greater services.
Through the hard work and perseverance of six named individual plaintiffs, led by Glenda Jimmo of Vermont, and seven advocacy organizations, the perceived “improvement rule” has been struck down. (For information on the settlement of the case and the legal ramifications, see information available through the Center for Medicare Advocacy. That’s the good news given the importance of keeping certain patients from getting worse, the bad news is that the settlement of the Jimmo case is not widely enough known.
Reports suggest that claims for skilled maintenance services are still being denied, or, in many instances, providers do not even offer these services to patients based on the assumption that reimbursement will be withheld. As a result of the Settlement, CMS agreed to embark on an education campaign around this ruling. That educational effort will need to be redoubled to get the message out, especially given the reality that many service providers themselves think only in terms of patient improvement and not maintenance, as improvement has long been the primary measure of their effectiveness.
Earlier this week, the Center for Medicare Advocacy convened a group of providers and patient advocates to identify barriers to implementing the Jimmo decision and how to circumvent them. Stay tuned for more!