Dec 182012

For years, physicians and insurers have applied the so-called “improvement standard” for care rendered to Medicare beneficiaires, insisting that if the patient was not improving, he or she was ineligible for benefits. Taking on what she calls that “intractable myth”, Judith Stein, Executive Director of the Center for Medicare Advocacy, led a team that filed a class-action suit, whose plaintiffs included 5 individuals and 6 organizations. For years, Stein said, the Center had responded to individual requests for help appealing such decisions, but had been unsuccessful in its efforts to negotiate the issue with represenatives from the Centers for Medicare and Medicaid Services (CMS). The group concluded that the only way to achieve “systemic change” was to take the issue to court. On October 16, 2012, a settlement in principle was reached. According to the Center’s Litigation Director, Gil Deford, the government claimed that there was no such thing as the improvement standard and, had there been, it would not have been enforced.

The settlement is designed to ensure that denials based on the improvement standard will end. Beneficiaries can receive skilled, covered services, even if they have “plateaued” or if the services are for “maintenance only.”

To make this information more widely known and understood, CMS will revise its Medicare Beneficiary Policy Manual for skilled nursing, home health, and outpatient therapies. The current version is ambiguous, says Deford. Attorneys for the plaintiffs will review CMS’ proposed revisions, and a final version will be released. Deford estimates that this process will take about six months. CMS will then launch an educational campaign that will include updates on its website, national phone calls with stakeholders, open door forums, and materials and training.

In the meantime, any claims dating from 1-18-11 that have been denied because of the improvement standard can request a review of that denial. The Center for Medicare Advocacy has developed self-help packets that can be downloaded from its website at Margaret Murhphy, associate director of the Center, told participants in a webinar last week that if claims are denied because of the improvement standard, they should, “appeal, appeal, appeal!” There are strict time limits in which appeals must be made–but the appeals process is launched with just a phone call.  The Center is trying to spread the word: Jimmo can help people now. And it applies to anyone who needs skilled care.


key words:  Jimmo, improvement standard, Medicare beneficiaries, Center for Medicare Advocacy