Home Health & Hospice Week

Medicare issues fact sheet following lawsuit settlement overturning policy.

Medicare contractors that have used the so-called "improvement standard" to deny home health and other post-acute claims are on notice to stop, thanks to a new fact sheet issued by the Centers for Medicare & Medicaid Services.

"The Medicare statute and regulations have never supported the imposition of an ‘Improvement Standard’ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition," CMS says in the sheet. "A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage."

Bottom line: "Coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves," CMS says.

CMS has issued the fact sheet after settling a lawsuit over the issue, Jimmo v. Sebelius (see Eli’s HCW, Vol. XXII, No. 6). The sheet doesn’t expand coverage, but merely clarifies existing coverage policies, the agency maintains.

Spreading the word: CMS plans to issue updated program manual language, new transmittals and MLN Matters articles, and other materials, it says. CMS will complete the manual revisions and educational campaign by next January.

CMS also will review a random sample of HHA, skilled nursing facility, and outpatient therapy coverage decisions "to determine overall trends and identify any problems," it says. It also will review "individual claims determinations that may not have been made in accordance with the principles set forth in the settlement agreement."

The fact sheet is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf