Monday, August 22, 2016 CMS Education Efforts on Jimmo Ruled Inadequate Though the Jimmo v Sibelius settlement reached in 2013 was supposed to have done away with the fallacy of the "improvement standard" as a basis for Medicare claims denials, many of the entities that make decisions about claims haven't been sufficiently educated on this reality, according to a US District Court judge. In the ruling, Judge Christina Reiss describes how the Centers for Medicare and Medicaid Services (CMS) did not live up to its responsibilities to educate stakeholders, and instead supplied "non-responsive answers" to questions, and "arguably incorrect" information on claims denials for skilled maintenance therapy. The August 17 opinion and order is a victory for the Center for Medicare Advocacy (CMA) and Vermont Legal Aid, which together represented 7 individual plaintiffs and 7 organizations in a complaint filed in March of this year. The complaint alleged that CMS did not comply with the requirement that it adequately educate stakeholders on why claims could not be denied simply because a patient has not demonstrated improvement. APTA submitted a declaration of support for this action, writing that the CMS education efforts were "introductory in nature" and "have not been sufficient" to educate members. The plaintiffs argued that the CMS education efforts amounted to a single briefing for providers and adjudicators in early December 2013, with nearly nothing done since. The court's decision in favor of the plaintiffs focused specifically on a CMS summary of questions and answers from that single briefing, a summary that Reiss writes "reflects virtually no effort to educate participants regarding the impact of the Jimmo settlement and the implementation of the coverage standard." Reiss further writes that "plaintiffs have provided persuasive information that at least some of the information provided by the Secretary in the Education Campaign was inaccurate, nonresponsive, and failed to reflect the maintenance coverage standard." The ruling cites several instances in which CMS was evasive in its answers to questions from contractors about how to handle claims, and asserts that in at least 1 instance, CMS may have provided "arguably incorrect" information on the appropriate language to use when denying claims. "At a minimum, plaintiffs bargained for the accurate provision of information regarding the maintenance coverage standard and their rights under the Settlement Agreement would be meaningless without it," Reiss writes. "The Secretary makes no claim to the contrary. At least insofar as the Summary is concerned, the Secretary breached the Settlement Agreement by failing to convey accurate information regarding the maintenance coverage standard." Under the order, CMS must develop "corrective action" for the education shortcomings. If CMS and plaintiffs can't agree on the plan, the issue could be presented to the judge again. APTA maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.