Medicare’s Improvement Standard: The Saga Continues

Several years ago CMS entered into a settlement in litigation that has become known as the Jimmo case. CMS agreed that the improvement standard wasn’t in fact a standard for determining further Medicare therapy coverage and all was good, or so it seemed. Yet, now we learn it’s not, according to a recent story in Kaiser Health News. Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute explains

Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.

So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

The settlement was supposed to be the end of the matter, and instead of the improvement standard,  Medicare was to make the decision as follows, “not … on the ‘potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.’” So in August of last year, the judge ordered the parties to get together to “improve” Medicare’s educational initiative for those who deal with the claims and staff hotlines,  as well as the ALJs.   The parties reached an impasse, so it’s back to court.

Stay tuned.