A. Response to the Jimmo Problems Contrary to what the Medicare representative told the beneficiary’s son, the Jimmo Settlement absolutely still represents official Medicare policy. There is no end to the Settlement’s conclusions.
Full Answer
What does the Jimmo settlement mean for Medicare?
The Jimmo Settlement means that Medicare beneficiaries should not be denied maintenance nursing or therapy when skilled personnel must provide or supervise the care for it to be safe and effective. Medicare-covered skilled services include care that improves, maintains, or slows the decline of a patient’s condition.
What is an example of the Jimmo settlement?
Example: A patient with cancer of the spine (which is not one of the 60% qualifying conditions) may need inpatient rehabilitation, and Medicare coverage, to address deteriorating function in conjunction with his health issues. The premise of the Jimmo Settlement applies equally to such a patient as to patients who have a condition on the 60% list.
What is the Jimmo vs Sebelius summary?
What Is the Jimmo vs. Sebelius Summary? Jimmo vs. Sebelius was a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who were denied Medicare coverage for skilled care on the basis that they were not improving or did not demonstrate a potential for improvement.
Can Jimmo v Sebelius help you fight Medicare denials?
As a result of the landmark decision in Jimmo v. Sebelius, Medicare policy now clearly states that coverage decisions for skilled care (nursing care or therapy) cannot hinge solely on whether a patient is improving or expected to improve. Understanding this case may help you fight inappropriate Medicare coverage denials. Learn how.
What is jimmo settlement?
The Jimmo Settlement means that Medicare beneficiaries should not be denied maintenance nursing or therapy when skilled personnel must provide or supervise the care for it to be safe and effective. Medicare-covered skilled services include care that improves, maintains, or slows the decline of a patient's condition.
What was the jimmo vs Sebelius case?
The court case, Jimmo v. Sebelius (Jimmo), ended in a settlement where the federal government confirmed that Medicare coverage is determined by a beneficiary's need for skilled care and does not rely on any potential for improvement.
How do you document maintenance therapy?
Documentation: Narratives: spell it out and show your work. Make sure your documentation highlights the response to treatment and changes and shows communication among members of care team. Establish a Maintenance goal or goals that prevent or slow decline. Consider a patient defined goal.
What is the goal of maintenance therapy?
Maintenance therapy goals include preventing unnecessary, avoidable complications from a chronic condition, such as deterioration of communication skills and reduced functional independence in activities of daily living.
What is a functional maintenance program?
Functional maintenance Programs (FMP's) are clinical programs that can be designed to augment or maintain a residents functional status and wellbeing.
What is the code of ethics for physical therapist?
Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life.
What is a maintenance documentation?
Maintenance documentation is any record containing information that you might need to complete maintenance tasks and inspections. It tells you what you have, shows you how to maintain it, and has records of all your past work.
What is record maintenance and documentation?
Proper documentation and record maintenance is a principal step in good manufacturing practice regulations that a pharmaceutical manufacturer must follow. Documentation provides a thorough knowledge of the history and the present status of the manufacturing batches.
Why do we need to document all maintenance work done?
Documenting every repair or maintenance work done on your equipment will help you process warranty claims much easier. Keep a record of the type of maintenance work done to your equipment as well as the exact time and date repairs were done as this information will help determine your rights for the warranty claims.
Is maintenance a therapy?
Maintenance therapy is the ongoing treatment of cancer with medication after the cancer has responded to the first recommended treatment. Maintenance therapy, sometimes called continuous therapy, is used for the following reasons: To prevent the cancer's return.
What is Jimmo v. Sebelius?
5:11-CV17 (D. Vt., 1/24/2013), was a nationwide class-action lawsuit brought against the Centers for Medicare & Medicaid Services (CMS) on behalf of individuals with chronic conditions who had been denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement. In 2013, a U.S. District Court approved the settlement agreement, which required CMS to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. Plaintiffs were represented by the Center for Medicare Advocacy and Vermont Legal Aid.
What is Jimmo Implementation Council?
Jimmo Implementation Council (November 2019) – A panel of experienced providers discuss the documentation and provision of successful maintenance therapy.
How Do PDPM and PDGM Affect Jimmo?
While both the Patient Driven Payment Model (PDPM) and the Patient-Driven Groupings Model (PDGM) create a new set of financial incentives for skilled nursing facilities and home health agencies, respectively, these payment models do not change Medicare coverage and eligibility criteria. In FAQs, CMS specifically states that “PDPM does not change the care needs of SNF patients, which should be the primary driver of care decisions, including the type, duration, and intensity of skilled therapies, made on behalf of SNF patients.” Likewise, in the PGPM Final Rule, CMS states that it expects “the provision of services to be made to best meet the patient’s care needs and in accordance with the home health [Conditions of Participation] CoPs at §484.60 which sets forth the requirements for the content of the individualized home health plan of care . . . .” Thus, patient care needs must still be based on clinical standards and judgment related to individual care needs.
Who represented the plaintiffs in the 2013 Medicare settlement?
Plaintiffs were represented by the Center for Medicare Advocacy and Vermont Legal Aid.
Does Jimmo apply to Medicare?
The Jimmo Settlement applies to all Medicare beneficiaries throughout the country, regardless of whether an individual is in traditional Medicare or has a Medicare Advantage plan.
General
Question: Are professional therapy services available under Medicare only for patients who are improving or who are expected to improve?
Home Health Care
Question: Are there time limits in how long skilled nursing or skilled therapy can be provided in home care?
Outpatient Therapy
Question: If a physical therapist discontinues a Medicare patient’s outpatient therapy because the patient’s improvement has plateaued and the patient is not expected to return to his or her prior level of function, can the physician prescribe additional therapy?
Skilled Nursing Facilities
Question: Are there time limits in how long skilled therapy can be provided in a skilled nursing facility?
Inpatient Rehabilitation Hospitals
Question: Can an inpatient rehabilitation hospital (IRH) stay be covered if a patient is not able to return to his or her prior level of functioning but can achieve some improvement in function through IRH care?
Does the settlement expand Medicare?
It’s important to note that this settlement does not expand Medicare’s coverage. In fact, the actual settlement agreement specifically states that nothing “in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”.
Is solid documentation good for patient satisfaction?
After all, solid documentation doesn’t just keep you out of hot water—it’s also good for patient satisfaction. So if you want to keep your revenue stream flowing, there’s never been a better time to make sure your documentation is top-notch and fully defensible. Kylie McKee.
Did CMS complete the Jimmo v. Sebelius settlement?
Hey, have you heard the good news? CMS has completed all required action items laid out in the Jimmo v. Sebelius settlement. If you’re scratching your head and wondering why that matters, here’s the rundown: a few years ago, a group of Medicare providers alleged that CMS contractors made determinations on claims for skilled care based on an inappropriate “Improvement Standard.” These providers took CMS to court, and the court determined that CMS needed to clarify and educate providers on the definition and proper application of medical necessity. (For the full run-down on Jimmo, check out this resource .)
Is Jimmo settlement good for rehab?
While the Jimmo settlement is good news for rehab therapists and their patients, it also means that providers need to be even more diligent about proving medical necessity. Defensible documentation isn’t a new concept, and hopefully, it’s something you’re already putting into practice. After all, solid documentation doesn’t just keep you out of hot water—it’s also good for patient satisfaction. So if you want to keep your revenue stream flowing, there’s never been a better time to make sure your documentation is top-notch and fully defensible.
Will CMS be extra critical of documentation?
This isn’t pure speculation. In fact, the revised manual now includes language that speaks to the role of documentation in determining accurate coverage for claims involving skilled therapy. According to this CMS fact sheet, “While the presence of appropriate documentation is not, in and of itself, an element of the definition of a ‘skilled’ service, such documentation serves as the means by which a provider would be able to establish and a Medicare contractor would be able to confirm that skilled care is, in fact, needed and received in a given case.” That’s right—despite the fact that this explicit reference to documentation requirements was not a part of the settlement terms, CMS is covering their assets, so to speak.
Where can I learn more about the Jimmo vs. Sebelius case?
You can read various Jimmo vs. Sebelius FAQs on Medicare.gov, the official government website for Medicare. You can also call 1-800-MEDICARE.
What Is the Jimmo vs. Sebelius Summary?
Sebelius was a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who were denied Medicare coverage for skilled care on the basis that they were not improving or did not demonstrate a potential for improvement.
Does the Jimmo Settlement Agreement Apply to Beneficiaries of Medicare Advantage Plans?
Yes, Medicare Advantage (Medicare Part C) plans cover the same Part A and Part B benefits as Original Medicare, and they must comply with the Jimmo vs . Sebelius Settlement Agreement. Some Medicare Advantage plans may also cover benefits that help you age healthy and comfortably at home, such as home meal delivery, home upgrades like bathroom grab bars and more.
Does Jimmo v. Sebelius Mean Medicare Will Cover My Skilled Care Services 100% of the Time?
No, Medicare determines coverage based on an individualized assessment of your medical condition (provided by your doctor) and other criteria. The Jimmo vs. Sebelius Settlement Agreement simply means Medicare must look at the big picture – not just whether your health will improve.