Wednesday, October 29, 2014

Medicare “Improvement Standard” Returns to Courts

Dan Ciolek and Dianne De La Mare

In a landmark court agreement in 2012, the Centers for Medicare and Medicaid Services agreed to settle a class-action lawsuit filed by Glenda Jimmo, a 78 year old woman from Vermont who was denied Medicare coverage due to a “lack of improvement”. In the settlement agreement, and in subsequent updates to Medicare policy manuals, CMS agreed that beneficiaries cannot be denied coverage based solely on the lack of improvement in health or function. Coverage instead is based upon the need for skilled care, and that the care can only be safely and effectively be performed by qualified nursing or therapy professionals.

In the settlement agreement, beneficiaries that were previously denied care due to the improper “improvement standard” were offered an opportunity to appeal claims denied only due to lack of improvement. In April 2014, Ms. Jimmo received a decision from the Medicare Appeals Council (the 4th level of appeal) which upheld the earlier denials agreeing with the original medical review decision that her condition was not improving. As reported in Kaiser Health News, Ms. Jimmo with the support of the Center for Medicare Advocacy (CMA) have filed a lawsuit (Jimmo v. Burwell) seeking a reversal of Medicare’s decision to deny coverage.

AHCA continues to monitor this situation. For more information, contact Dan Ciolek or Dianne De La Mare       

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