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  • Jimmo Advocates Back in Court, Alleging CMS Hasn't Lived Up to its Agreement to Educate Stakeholders

    Three years after a settlement was reached, the Jimmo v Sibelius battle has returned to court—this time, to address allegations that the US Centers for Medicare and Medicaid Services (CMS) has not kept its promise to adequately educate Medicare providers, contractors, and adjudicators on why they can't use the "improvement standard" as a basis to deny claims for skilled maintenance therapy.

    According to the Center for Medicare Advocacy (CMA), which has joined with Vermont Legal Aid to represent 7 individual plaintiffs and 7 organizations, CMS has "clearly failed to educate key components of the provider community and Medicare decision-making system" about the fallacy of the assumption that a patient must demonstrate improvement in order to receive coverage. In February, CMA issued a statement essentially warning CMS of CMA's dissatisfaction with the education efforts; on March 1, it filed a Motion for Resolution of Non-Compliance.

    APTA agreed with CMA's take on the situation and submitted a declaration of support earlier this year, writing that the information provided by CMS is "introductory in nature and [has] not been sufficient in educating our members."

    In a recent article in the Barre Montpelier, Vermont Times-Argus—a newspaper from the home state of Glenda Jimmo—APTA President Sharon L. Dunn, PT, PhD, OCS, acknowledges that the association continues to receive questions about the settlement. "We have found many providers have not received any information about the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit," Dunn says.

    CMA argues that the CMS education efforts amounted to a single briefing for providers and adjudicators in early December 2013, with nearly nothing done since. "Unfortunately, providers and contractors continue to illegally deny Medicare coverage and care based on the 'improvement standard,' resulting in beneficiaries nationwide failing to obtain needed skilled nursing and therapy coverage," CMA states in a news release.

    In the CMA release, Executive Director Judith Stein says that CMS could be helping to eliminate incorrect denials, "but has refused to provide any more education or written information—although attorneys for the plaintiffs have repeatedly provided evidence of problems, dozens of examples, and even prepared much of the material needed to provide further education and information."

    CMS will reportedly file a response to the motion by April 26.

    APTA maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.


    • It is my understanding that the current rules for skilled maintenance require that it can only be delivered by a PT. We must get this changed to include PTA.

      Posted by Brent Applebaum, PT on 3/9/2016 4:09 PM

    • Thank you so much for doing this For those patients who have been denied their right to maintain their independence and for those dedicated PTs who risk illegal audits to help them.

      Posted by Scott on 3/9/2016 8:13 PM

    • This whole idea sound like CMS is trying to increase denials or lat least delay them. I have practiced 43 years and it seems that CMS has issued rules that are a way to decrease Medicare payments for therapy as a way to cut their budget. With the population getting older the need for therapy is only going to rise. Making it more difficult to get payment is not in the best interest of the patient. If there are practitioners who are filing claims incorrectly just to increase their profits, go after them. The majority of therapists want to do the necessary therapy for decent period of time to reach their goals. Since we do not have a great Lobbying company that is funded like the AMA, we have to find a way to be heard. Most therapist either do not join the APTA or actively try to inform their congressman about our needs and the needs of our patients. If it is not taught in schools, they should think about bring in average therapists to talk about the importance of being politically active. It only take the stroke of a pen knock out coverage for the elderly and thereby costing the therapy community many jobs.

      Posted by Thomas Herman on 3/9/2016 8:16 PM

    • I'm very interested in viewing the webinar on maintenance physical therapy but I decided against it when I see the price is $99 for APTA members. Other webinars are half that price. Sincerely, Ellen Colley PT

      Posted by Ellen Colley on 3/9/2016 9:52 PM

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