Starting Today, Medicare Claims for Rehabilitation Services Can’t Be Denied Because the Patient Hasn’t Improved

January 7, 2014—Many patients and family caregivers have heard some variation of this assertion: “Medicare won’t continue to pay because you aren’t making any improvement/reached a plateau/aren’t going to get any better.”  This practice should end as providers follow the revisions in the policy manual that goes into effect today. Beneficiaries are entitled to continued services as long as there is a need for skilled services “to prevent further deterioration or preserve current capabilities.” The policy applies to rehabilitation programs in skilled nursing facilities, home health agencies, and outpatient clinics, as well as independent contractors. Physical therapy, occupational therapy, and speech-language pathology are the services covered.

Two Next Step in Care family caregiver guides—Planning for Inpatient Rehabilitation (Rehab) Services and Home Care: A Family Caregiver’s Guide
—have been updated to reflect the changes.

To comply with the agreement in the case of Jimmo v. Sebelius, approved in January 2013 by the U.S. District Court of Vermont, the Centers for Medicare and Medicaid Services (CMS) revised portions of its program manuals. The lawsuit was brought by the Center for Medicare Advocacy on behalf of 76-year-old Glenda Jimmo of Bristol, Vermont, who is blind and disabled from complications of diabetes. She and other plaintiffs argued that Medicare claims involving skilled care were being inappropriately denied based on a rule-of-thumb standard that required continued improvement.

CMS states that there was never any official improvement standard and that “even in situations where no improvement is expected, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition).” Coverage should be based on an individualized assessment of the beneficiary’s medical condition and need for skilled services. Providers are put on alert that appropriate and complete documentation of this need is critical; the policy manual has enhanced guidance on appropriate documentation and suggests avoiding vague phrases, such as “patient tolerated treatment well.”

Because this explicit interpretation of Medicare policy is new, it is important for family caregivers to know about it and to be prepared to advocate for an individualized assessment of their family member to gain approval for the necessary skilled services. If necessary, denials can be appealed.

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