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  • Jimmo Message Hasn't Sunk In; CMS Needs to Do More

    When the Jimmo v Sebelius settlement was announced in 2013, patient advocates applauded what they saw as a landmark change for individuals who need care to maintain their medical conditions or slow their declining health. However, 3 years later, many providers and payment adjudicators are still making coverage decisions as if they're living in a pre-Jimmo world—mostly because the US Centers for Medicare and Medicaid Services (CMS) hasn't done enough to bring them up to speed, according to an advocacy group supported by APTA.

    Recently, APTA provided a supporting declaration to the Center for Medicare Advocacy's (CMA) efforts to get CMS to do a better job of making it clear that the "Improvement Standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy, and that skilled maintenance care can qualify for payment.

    "There are still many providers and contractors who do not know about, understand, or trust the change in the improvement policy," CMA wrote in a December 2015 letter to APTA and other stakeholders. "We believe this is largely due to the fact that CMS' Education Campaign was insufficient to make up for the rigor with which Medicare enforced the Improvement Standard—for decades." According to CMA, CMS conducted only 1 briefing for providers and adjudicators, in early December of 2013. Since that time, CMS "has refused to do more," CMA writes.

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

    "Approximately 2 years after the CMS National Education Campaign, APTA is still receiving inquiries from physical therapists regarding the coverage of skilled maintenance therapy under Medicare," APTA writes. "We have found that many providers have not received any information regarding the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit." The association suggests posting answers to frequently asked questions, sharing information briefs on what to do in case of denials, hosting national calls, and sponsoring regional town halls.

    Patients and physical therapists do have recourse: CMA has created a "self-help packet" for appealing denials of outpatient therapy that may have been made based on a pre-Jimmo understanding of payment policy. The webpage featuring the packet also contains background information on Medicare coverage and the "improvement myth," therapy cap exceptions, and appeals processes.

    APTA engaged in an extensive effort to educate its members on the Jimmo settlement, and maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.


    • I have a ton of patients that could benefit from this. I never even heard of the case until now

      Posted by Gregory LeMoine on 2/10/2016 9:44 PM

    • Thanks for the post. This sounds like a good first step. After the trial, CMS has insisted that they NEVER had a policy to limit care after a patient had reached a plateau or maintenance level of care. In reality, that wasn't true. Today, they continue refusing to accept any criteria we've used to gain care beyond the $3,700 level including both those patients who continued to demonstrate meaningful functional gains with treatment and those who could only realize pain management through treatment we provided. In all cases, the denial states that we had failed to provide information relevant to " medical necessity ". Additionally, all PT's are aware of Medicare's use of intimidation. As a result, statistics regarding billing continue to demonstrate decreases in both per episode care and daily care. CMS has successfully employed a negative reinforcement technique using a combination of subtle threats of investigation, regulatory threats that create the possibility that if we bill beyond the $3,700 level all reimbursement may be demanded if " medical necessity " is not demonstrated in the documentation ( and apparently, it NEVER is ) and yearly comparative statistics that demonstrate a dwindling average billing per patient ( with the implicit conclusion being that they are watching our every move ). CMS is engaged in a race to zero reimbursement. Without a Congressional mandate or a legal ruling, PT's will continue to provide much less care than our patient's deserve.

      Posted by Brian P. D'Orazio on 2/10/2016 10:18 PM

    • How does it apply to inpatient care?

      Posted by Jennifer Rosecrance on 2/11/2016 7:24 AM

    • How does this information apply to private insurance? Can the patient or therapist make an appeal based on the same criteria?

      Posted by Phil on 2/11/2016 8:19 AM

    • Do these standards apply to Medicaid as well?

      Posted by Nechama Karman on 3/15/2017 9:36 AM

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