Challenging the Improvement Standard: Jimmo v. Sebelius

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Challenging the Improvement Standard: Jimmo v. Sebelius

  1. 1. Challenging the ImprovementStandard: Jimmo v. SebeliusHARMONY UNIVERSITYThe Provider Unit ofHarmony Healthcare International, Inc. (HHI)Presented by:Barbara Patterson-PaulBSN, RN, CRRN, RAC-CTDirector of Operations
  2. 2. ObjectivesReview key points of the Jimmo v.SebeliusCMS ResponsePractical Application for Part A and BDocumentation to SupportHarmony Healthcare International, Inc. 2Copyright © 2013 All Rights Reserved
  3. 3. Key PointsJimmo v. SebeliusCMS Response
  4. 4. Jimmo v. SebeliusThe Jimmo v. Sebelius case challengedMedicares use of an "ImprovementStandard" to make coveragedeterminationsThe lawsuit was brought on behalf of:Six individuals representing a Nationwideclass of Medicare beneficiariesNational organizations representing peoplewith chronic conditionsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Individual Plaintiffs:Glenda JimmoCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5Paul O. Boisvert for New York Times
  6. 6. Individual PlaintiffsLead plaintiff, Glenda Jimmo, is a 76-year-oldMedicare beneficiary from Bristol, VermontBlind since birth and has had her right legamputated due to complications from diabetesRequires a wheelchair, and receives multiplehome health care visits per week for varioustreatments for her complex conditionMedicare denied coverage for these services,saying that she was unlikely to improveCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. Individual Plaintiffs:Rosalie J. BerkowitzCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7New York Times October 22, 2012
  8. 8. Individual PlaintiffsRosalie J. Berkowitz is an 81-year-oldMedicare beneficiary from Stamford,ConnecticutMultiple SclerosisMedicare denied coverage for home healthvisits and physical therapy on the groundsthat her condition was not improvingHer family said she would have to go into anursing home if Medicare did not cover theservicesCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. National OrganizationsNational Multiple Sclerosis SocietyParkinson’s  Action NetworkParalyzed Veterans of AmericaAlzheimer’s AssociationUnited Cerebral PalsyNational Committee to Preserve SocialSecurity and Medicare, an advocacygroupCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. Improvement StandardThe settlement addresses Medicareterminating or denying coverage tobeneficiaries who are not improving forMedicare Part A and Part BCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. Improvement StandardPlaintiffs alleged the “ImprovementStandard”:Is "a covert rule of thumb" that is notsupported by the Medicare statute orregulationsOperates as an additional condition ofeligibility which effectively deniesbeneficiaries coverage of certain skilledservicesCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Improvement StandardAccording to the Complaint, Medicare has :Failed to make assessments regarding abeneficiarys "unique condition andindividual needs"Does not rely on the Medicare statute,regulations and manuals, but relies on"more restrictive internal guidelines,policies, and Local CoverageDeterminations ("LCDs")Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. CMS SettlementAttorneys from the Center for MedicareAdvocacy, Vermont Legal Aid and theCenters for Medicare & Medicaid Services(CMS) have agreed to settle the"Improvement Standard" case, Jimmo v.SebeliusA proposed settlement agreement was filedin Federal District Court on October 16, 2012The Settlement was approved on January 24,2013Harmony Healthcare International, Inc. 13Copyright © 2013 All Rights Reserved
  14. 14. Jimmo v. SebeliusThe judgment indicates that as long as apatient requires skills of a therapist ora nurse, a patient would meet theskilled coverage criteria despite notmaking functional gainsDocumentation must support the needfor skilled therapy interventionCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. Skills of a Therapist or a NurseMust require the expertise, knowledge,clinical judgment, decision making andabilities of a therapist or a nurse thatqualified personnel, trained caretakersor the patient cannot provideindependentlyCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. Skills of a Therapist or a NurseThe patient’s medical complexity requirethe skills of a therapist or a nurseORThe services are of such complexity thatthe skills of a therapist or a nurse arerequired to perform the serviceCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Skills of a Therapist or a NurseDocumentation must support:Description of skilled treatmentChanges made to the plan of care dueto assessment of the patient’s needsMedical complexityWhy the clinical and critical thinkingof a therapist or a nurse are required(hands and/or brains)Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. Questions/AnswersHarmony Healthcare International(978) 887 - 8919www.Harmony-Healthcare.comConnect with Us!@Harmonyhlthcarefacebook.com/HarmonyHealthcareInternationalH linkedin.com/company/harmony-healthcare18Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  19. 19. What is a CHHRP-LTC?A Certified Harmony HealthcareRehabilitation Professional (CHHRP-LTC) is an InterdisciplinaryProfessional who has SuccessfullyCompleted an Intensive and Clinically-Founded Training Geared Specificallyto Patients in a Skilled Nursing Facility(SNF) SettingCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. What is a CHHRP-LTC?3-Day Certification Includes:CEUsMedicare Therapy Documentation ina SNF Medicare Coverage CriteriaRehabilitation Program DevelopmentMDS Coding for the TherapyProfessionalCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. 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 MedicalReview of Part B  Therapy2013 Multiple Procedure PaymentReduction (MPPR)Medicare Part A an B Denial TrendsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. What is a CHHRP-LTC?Upcoming CHHRP-LTC CertificationProgram: Watertown, NY, June 11-13,2013Host a CHHRP-LTC CertificationPrograms and earn free attendeeshttp://chhrp.eventbrite.com/#Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22

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