Medicare Payment Policy Revision Allows for More Coverage

Recent revisions to Medicare’s policy on physical therapy and other services are leading to more coverage for those requiring skilled care from outpatient therapy, home health, and skilled nursing facilities. Prior to this revision, many individuals were unable to obtain insurance coverage for treatments, including physical therapy and occupational therapy, if it was found that the beneficiary’s condition was not improving. However, the settlement of the lawsuit, Jimmo v. Seblius, prompted this revision.

This lawsuit was filed against the secretary of the Health and Human Services Department, which oversees Medicare. It was alleged that patients were inappropriately denied coverage for skilled care due to the “improvement standard“. This “improvement standard” was a rule-of-thumb under which a claim for treatment would be denied, due to the beneficiary’s lack of improvement in restoration potential, even though the beneficiary required the treatment in order to prevent or slow the deterioration of their condition. This standard proved problematic for many patients, particularly those with chronic or degenerative diseases, as their treatments and services would be denied because their condition would plateau, or fail to improve.

However, it was found that there were certain instances where no improvement was to be expected, but where skilled care would still be necessary in order to prevent or slow a beneficiary’s deterioration, so that the beneficiary would be able to maintain their maximum level of function practicable. As such, a beneficiary’s lack of restoration potential could not serve as the sole basis of denial. Rather, an assessment must be conducted to see whether the skilled care requested is required.
This revision provides clarification to therapists and Medicare contractors regarding coverage, stating that if a patient requires treatment to prevent or slow deterioration in their condition, then coverage cannot be denied in the absence of improvement. Despite this change, many have noted that they are still faced with difficulties in receiving maintenance care because many providers are still unaware of this revision.

It should be noted that if an individual was previously denied coverage for treatment due to their lack of improvement, their claim may qualify for a “re-review” if their claim became final. However, the re-review is not automatic. Rather, those seeking a re-review must apply for one. An application for a re-review may be found here.

Many of our loved ones seek skilled care from skilled nursing facilities, but may fail to receive the treatment and care to which they are entitled. Such neglect often arises due to factors such as understaffing of the facility, allowing for your loved ones to be placed in jeopardy of serious injury or death. The attorneys at the Law Offices of Ben Yeroushalmi are experienced in the field of elder abuse and neglect. If you or a loved one has been a victim of abuse or neglect within these facilities, or are at risk of abuse or neglect, we encourage you to contact our office today at (888) 606-3453 for a free consultation. We serve communities throughout California, and are dedicated to protecting the rights of victims of nursing home abuse and neglect.