In the past, patients receiving skilled care such as physical therapy in nursing facilities, outpatient centers, home health, or rehabilitation hospitals were treated to a point where they hit a plateau. At this point, if a provider deemed the patient no longer had the ability to improve their condition, care was stopped, and Medicare claims for continuing therapy were denied.
Patients with dementia, stroke, neurological diseases, or other medical conditions that require skilled care often need and benefit from physical therapy. Even though they may not be restored to their previous level of health, the benefits of maintenance therapy cannot be denied. You may have heard, “If you don’t use it, you lose it.” This old adage rings true for those suffering from chronic medical conditions requiring skilled care.
If therapy for patients with chronic conditions is stopped, these patients inevitably begin to experience a decline in mobility, strength, and overall physical condition. Continuing therapy, even with no promise of improvement, can help maintain their current level of health and help slow further decline.
Thankfully, a nationwide class action lawsuit, Jimmo v. Sebelius, 2013, put an end to Medicare denials and abolished the idea of an “improvement standard.” The settlement conditions note that, “…when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.”
Why are we talking about this now?
Unfortunately, according to the Center for Medicare Advocacy’s 2018 national survey of providers, “40% of respondents had not heard about the Jimmo Settlement and 30% of respondents were not aware that Medicare coverage does not depend on a beneficiary’s potential for improvement.”
This means that you or your loved one may have been told that you “plateaued,” and if your provider is not aware of the Jimmo settlement, they may have discontinued services that could and should have been continued. In response to this all-too-common problem, the Center for Medicare Advocacy released a new provider brief in the hopes of educating and updating all providers and stakeholders.
I encourage you to share the brief with your care providers and facilities. If physical therapy has been discontinued, ask that it be reinstated. If you need help understanding how the Jimmo settlement applies to you or your loved ones, or if you have other questions related to patient advocacy or care coordination, just give us a call at (516) 584-2007 or email [email protected].