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Written by: Darlene D'Altorio-Jones (1959-2015) on Wednesday, August 28, 2013 Posted in: Inpatient Rehab

I was very fortunate to have attended the AMRPA conference in Washington D.C. back in March.  These conferences provide a burst of information for the rehabilitation industry. It is often extremely hard to duplicate in nearly any other venue if you maintain a grass root desire to understand public policy and its affect on not just one discipline in rehabilitation, but the broad spectrum of how disciplines act together to advocate for access and appropriate levels of service for the patient populations.  No matter who you are, you leave these conferences charged with purpose.

As an industry, inaction more than ever can lead to the demise of care access. Defining medical necessity and/or medically reasonable care has many different flavors depending on who is speaking. We like to believe that in health care we speak and advocate for the patient, imagining that any given patient could be ourselves or a family member seeking the needed level of care. Although this particular topic I am about to discuss has been picked up in many a blog and discussions within professional practice organizations, I too need to push this information to your inbox so that you have a reference and links at your fingertips should the need arise.

As I reflect on the list I created for myself now nearly four months ago, where a presenter named Judith Stein, JD, of the Center for Medicare Advocacy asked us to take her message and to push it far and wide, I dropped the ball. Time has a way of getting away. This information must be understood by everyone that performs utilization review and/or the decision makers as to when services are appropriate and covered under a skilled level of care.

What was the message?  The message was that despite years of Medicare contractor practices, a patient could not be denied skilled professional services (either nursing or therapy) because a patient possessed a chronic condition, a terminal condition, or a slow deteriorating condition as long as the care required was needed to maintain, prevent and/or slow deterioration of the patients condition. A skilled professional is needed to ensure those services are safe and effective.  A tear swells at the thought of that victory.

This right was won by the JIMMO SETTLEMENT, or more exact JIMMO VS. SEBELIUS, CIVIL NO. 5:11-CV-17 (D.VT.1/24/2013)  This was a federal class action to eliminate improvement standard from the expectation to provide continued care as a predominant decision factor leading to denial.

There were five individuals and six organizations that participated.  The organizations are those that deal with the most discriminatory practices of denied care: the National MS Society, The Alzheimer’s Association, The Paralyzed Veterans of America, The Parkinson’s Action Network, The United Cerebral Palsy Association and the National Committee to Preserve Social Security and Medicare.

I think back on my nearly 30 years of either practicing therapy and/or managing its services and cannot begin to imagine the number of individuals that I too provided ABNs and/or a dreaded non-coverage discussion that limited access to the very needed services that could enable them dignified sustained independence. This decision is so long overdue.

What else did this decision provide? The settlement means that CMS must develop and implement an educational campaign so that providers follow this clarified ruling. The education must explain the settlement and policies of support to access to Medicare contractors, Medicare adjudicators, providers, and yes, beneficiaries and caregivers.  A FACT SHEET is now available through CMS.

If you haven’t already, or if the time has just gotten away from you as it had for me, print the fact sheet. Educate your staff on how they must document to demonstrate appropriate professional skilled services for individuals who previously may have been cut short or worse yet, never tried to access needed care because they too heard through the grapevine that the challenges they face were not ‘covered’ as a service under Medicare.