A family member just went into rehab for a fall after hospitalization. The facility informed me that if there was no improvement in her physical capability, say being able to walk again, that she would be discharged since that is the medicare requirement. There has to be continual improvement. But the way I understand it, there is no progress standard. That standard was applied for years incorrectly. If you look at the actual law that governs Medicare, it clearly states that the criteria is to prevent further deterioration, not improvement. Due to the Jimmo lawsuit settlement, Medicare agreed to inform people of this fact. Right in the revised Medicare manual, it says.
"No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care."
Here's the underlying law.
"(c) The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities."
Does anyone have any insight into this? What the SNF is telling me seems to be at odds with what Medicare says. How should I handle this? Should I ask them for clarification now or should I wait until, or if, they try to discharge due to no improvement?
The Center encourages Medicare beneficiaries and their families to appeal unfair “Improvement Standard” denials, even though Medicare patients "and their families should not be in a position of having to educate providers, contractors, and adjudicators about Medicare policy."
They advise patients "and their families to continue citing to the Jimmo Settlement and related materials when challenging denials."
But the most effective way to avoid the need to fight a Medicare appeals (which is not likely to succeed) is to engage the physicians and caseworkers before the time they must make a decision to terminate their Medicare billing.
A Geriatric Care Manager or Advocate who understands the patient's needs, the medical providers, and their billing practices, gives you the best chance to gather the facts needed to continue care paid by Medicare. Hire the advocate as soon as the patient is in the hospital, before being discharged to a facility, and you give yourself the best chance to better results.
These professional Advocates are privately paid by the patient. But the cost is worth the benefit of having an objective advocate working alongside you and your family.
https://www.medicareadvocacy.org/jimmo-implementation-update-where-is-cms/
https://www.rd.com/health/conditions/save-money-fighting-hidden-hospital-policy/
My family received notice from my moms rehab / SNF that they are releasing her before they have completed the therapy as prescribed by her orthopedist . They were initially verbally telling us it was because she had plateaued and was not showing improvement . We appealed and their QIQ declined the appeal . Their stated reason is there is no longer a need for skilled nursing care and she could move to a lower level of care.
Our mother is 88 and was living independently until she had a fall and broke both ankles. The doc did surgery and put in plates and screws . He prescribed intense PT and OT , but non weight bearing . Since the last visit , he added range of motion to begin working to resolve her plantar flexion in both feet . This therapy was to continue daily at least until next doc appt .
Given the docs orders and my mother’s current state, we don’t understand how any rational person can suddenly declare she no longer has a need for this therapy. Jimmo clearly says that “need” is the main criteria for continued coverage , so they have now moved away from arguing that she has plateaued and now saying she no longer needs it, so they shifted their game to hit on the correct term. But the fact remains that she very much does need it, especially now . Otherwise she will regress and be relegated to a state of total dependency .
Your advice and tips in this situation would be appreciated .
Thank You
Looking at the Jimmo settlement, progress is not the criteria. In the update to the CMS manual, they clearly state that it's not. The bottom line criteria is to prevent deterioration in function. That's not even due to the Jimmo settlement. That's been the law for over 25 years. The Jimmo settlement was that Medicare needs to enforce that law instead of letting people get discharged for "no improvement".
I spoke to Medicare and they said I should appeal if there's a "no progress" discharge. Which I think now is the way to go. It could not be an issue. Why make it an issue now? I also spoke to our supplemental insurance company and they said there is no policy for "no progress" discharges during recuperation.
this will get kicked up to Medicare. If Medicare again refuses, then either she must pay herself, or she must move to a long term facility or home.
"Q7: Can a patient change from an improvement course of care to a maintenance course of care, and vice versa?
A7: Yes."
"Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program."
https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html