• News New Blog Banner

  • CMS Publishes More Clarification on Jimmo Settlement and 'Improvement Standard' Myth

    The US Centers for Medicare and Medicaid Services (CMS) is making it clearer than ever that the so-called "improvement standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy. The new clarity on the validity of skilled maintenance is part of the agency's efforts to comply with a federal court finding that CMS had made "virtually no efforts" to educate stakeholders on the 2013 Jimmo v Sebelius settlement.

    CMS now offers a webpage exclusively devoted to the Jimmo settlement, which established that the improvement standard was a myth (for its part, CMS maintains that it never explicitly supported that standard, even though it was commonly used by contractors as a reason to deny payment). The agency's low-key efforts to educate contractors in the wake of the Jimmo settlement prompted Medicare beneficiary advocates to go back to the courts to compel CMS to do more, arguing that the improvement standard still was being applied by many contractors. APTA was a supporter of those efforts.

    In February, a federal court agreed with the patient advocates and ordered CMS to take "corrective action" that included publishing a new webpage on Jimmo that would contain, among other elements, a clear disavowal of the improvement standard and a list of frequently asked questions about the settlement. The judge gave CMS until September 4 to make it happen.

    CMS complied. Its new webpage states that skilled therapy services are covered by Medicare when an assessment reveals that "the specialized judgment, knowledge, and skills of a qualified therapist … are necessary for the performance of a safe and effective maintenance program " intended to "maintain the patient's current condition or to prevent or slow further deterioration."

    "The Jimmo settlement agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve," CMS states on the webpage. "The Jimmo settlement agreement is consistent with the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and nursing and therapy in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide."

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

    APTA Provides Comments to CMS, House Subcommittee on Wide Range of Payment and Care Topics

    APTA has released another round of comment letters focused on the future of skilled nursing facility (SNF) payment under Medicare, the US Centers for Medicare and Medicaid Services' (CMS) Quality Payment Program (QPP), and a proposed CMS rule on hospital outpatient prospective payment. But that's not all: the US House of Representatives Ways and Means Committee also received APTA's perspective on a range of issues, including repeal of the Medicare therapy cap.

    Here's a recap of the comment letters. Click on each headline below to access the full version of each CMS comment letter.

    Proposed change to case-mix classification model used in SNF payment
    Although no formal proposed rule has been issued, CMS has signaled that it's interested in feedback on the possibility of replacing the current RUG Version 4 case-mix classification model with a new model called the Resident Classification System, Version I, known as RCS-I (read background on development of the model).

    The RCS-1 model is intended to move SNF payment away from service-based models and tie them to resident characteristics. It's a laudable goal, according to APTA, but the plan itself is based on an inadequate set of patient characteristics and a poor understanding of how comorbidities can impact mobility challenges and needs. The result, according to APTA, is that the model would likely reduce therapy for patients most in need. CMS has acknowledged that RCS-I may incentivize SNFs to reduce therapy services to increase margins.

    APTA's comments make it clear that the association opposes the new model, which it describes as an approach that "perversely disincentivizes the delivery of therapy services without regard for a patient’s clinical needs." Should CMS insist on adopting the RCS-I model, APTA recommends that the new model be phased in over 3 years, beginning no sooner than fiscal year 2020, and that CMS "engage in meaningful dialogue with stakeholders, including APTA, in advance of the release of any proposed rule."

    Proposed Outpatient Hospital Prospective Payment System (OPPS)
    For physical therapists, the biggest news about the proposed OPPS rule may be that CMS is considering paying for total knee arthroplasties (TKAs) as an outpatient procedure, but there's more to the proposal than that: CMS would also like to return to "nonenforcement" of direct supervision of outpatient therapeutic services for critical access and small rural hospitals.

    In its comments to CMS, APTA offers its support for both proposed changes. The association advises that CMS proceed carefully when it comes to outpatient TKA. Paying for TKAs in both the inpatient and outpatient settings would likely mean that the inpatient setting would be left to deal with the more complex cases—no big surprise, APTA writes, but something that CMS should keep in mind when it reviews data to make payment decisions, reviews that take in 3 years of data at a time. "If CMS does not make adjustments to the case-mix rates, it could lead to unintended consequences such as a decline in patient referrals to necessary postoperative services, such as physical therapy, in efforts to lower the episode cost to meet an unrealistic target," APTA writes.

    When it comes to backing off on enforcement of supervision requirements in critical access and small rural hospitals, APTA recommends that CMS make this change clear to contractors and prohibit them from conducting retroactive supervision reviews until the new rule is in place. "A retroactive policy will best reflect CMS’ acknowledgement of the unique burden that CAHs and rural hospitals face to employ a sufficient number of health care professionals to meet direct supervision requirements for specialty services such as physical therapy," according to APTA.

    Proposed updates to QPP
    CMS could expand its comprehensive QPP to physical therapists (PTs) as early as 2019, requiring to participate in programs such as the merit-based incentive payment system (MIPS) and advanced alternative payment models (APMs). These changes will be felt by PTs "across the entire spectrum of the therapy delivery system," APTA tells CMS.

    The association's extensive comments to CMS provide APTA's perspective on how CMS should bring PTs into QPP. Among the association's recommendations for MIPS: add PTs to MIPS in 2021 (starting with data from the 2019 reporting year), create a "pick your pace" program for participation, and include low-volume providers in MIPs. When it comes to APMs, APTA recommends that CMS rethink its thresholds and exclusions around qualified providers (QPs) permitted to participate in APMs, and to offer more guidance and education on participating in APMs.

    "Physical therapists are committed to providing care to Medicare beneficiaries through quality improvement programs and APMs," APTA writes. "APTA looks forward to working with the agency to ensure that MIPS and APMs are structured in a manner that is patient-centered, provides high-quality care, and seamlessly coordinates care throughout the health care continuum."

    House Ways and Means Health Subcommittee on the Medicare Red Tape Relief Project
    The House Ways and Means Health Subcommittee is asking for suggestions on how to reduce Medicare regulations and mandates that impact care delivery. APTA happens to have a few ideas in that department. Though not directly related to any proposed CMS rule, the association's comments to the House subcommittee echo at least 1 of the positions APTA shared with CMS earlier this year: getting rid of the Medicare therapy cap is in the best interests of patients and would make the Medicare system less burdensome.

    The letter to the House committee also recommends the elimination of the 30-day certification and 90-day recertification requirements for patients seeking physical therapy services, making functional limitation reporting more provider-friendly, and modifying the SNF 3-day inpatient stay requirement to count days spent in observation toward satisfying the 3-day inpatient hospital stay requirement for Part A coverage of SNF care.