Harmony Healthcare Blog

Jimmo Settlement: Improvement is Not a Requirement

Posted by The Harmony Team on Tue, Dec 06, 2016


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

ManInWheelcareTherapy.jpgThe presence of underlying diseases such as Multiple Sclerosis, Parkinson’s, ALS, and many other degenerative diseases is not an indicator of whether a patient can participate, gain or benefit from skilled therapy interventions in the skilled nursing home setting.  Further documented progress or lack thereof is not a rational for the denial of a skilled claim.  Per the Jimmo Settlement, when the skills, knowledge and judgment of the therapist are indicated for the delivery of skilled therapy modalities or the patient is medically complex (to the extent that the skills of the therapist are indicated), improvement is not a requirement.   

For many years, the SNF industry and Medical Claim Reviewers imposed the “False Improvement Standard”.  The notion that Medicare Part A and Medicare Part B services only paid for therapy treatments if the patient improved during the course of his/her rehabilitation program.  However, this is simply not the regulation.

In fact, a useful question to ask yourself and your staff is: 

“Whether or not a non-licensed staff person would not have the knowledge,
skill and judgment to safely treat the patient with the modalities, techniques and
strategies given the patient’s medical complexities”.

Jimmo and Improvement Standard

Under the Maintenance Coverage Standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will “improve.”  Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to: 

  • Maintain the individual’s condition, or
  • Prevent or
  • Slow the patient’s decline. 

Skilled services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified professional (“skilled care”) are necessary for the performance of safe and effective maintenance services.  Maintenance services to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective delivery of those services. 

Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. 

The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.  Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.  Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. 

  • While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. 
  • The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

Harmony Healthcare International (HHI) advocates for patient rights and is available to assist your staff with gaining a better understanding the complexities of the Medicare rules and regulations.  You can contact harmony by clicking here or calling 800.530.4413.

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Topics: Maintenance Therapy, Jimmo, Improvement Standard

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