challenging the improvement standard: jimmo v. sebelius
TRANSCRIPT
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
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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
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Individual Plaintiffs: Glenda Jimmo
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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
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Individual Plaintiffs:Rosalie J. Berkowitz
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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
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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
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Improvement Standard
The settlement addresses Medicare terminating or denying coverage to beneficiaries who are not improving for Medicare Part A and Part B
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Improvement Standard
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
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Improvement Standard
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")
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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
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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
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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
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Skills of a Therapist or a Nurse
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
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Skills of a Therapist or a Nurse
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)
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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
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What is a CHHRP-LTC?
3-Day Certification Includes:CEUsMedicare Therapy Documentation in a SNF Medicare Coverage CriteriaRehabilitation Program DevelopmentMDS Coding for the Therapy Professional
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What is a CHHRP-LTC?
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
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What is a CHHRP-LTC?
Upcoming CHHRP-LTC Certification Program: Watertown, NY, June 11-13, 2013Host a CHHRP-LTC Certification Programs and earn free attendees
http://chhrp.eventbrite.com/#
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