Harmony Healthcare Blog

The False Improvement Standard: Are Your Therapists Treating All Patients Appropriately?

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Feb 09, 2017
Kris Mastrangelo, OTR/L, LNHA, MBA
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Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


improvement standard-1.jpgAs a hospital Occupational Therapist recruited into the long term care industry in the early 90s, I had a lot to learn about the rules and regulations of Medicare.  I was blessed to be trained by expert nurses (Jim Long and Pat Hurd) in a company called HillHaven.  I attended their trainings repeatedly in order to hear their information over and over again.  During this time, Rehabilitation Services in a SNF setting was a new concept and it evoked an excitement at the facility level to “change the perception” of the typical nursing home image. The therapy teams gravitated towards the short term patients with discharge plans to home.  These cases fell in the “wheel house” of any clinician as goals were obvious and success was simply measured by a discharge home. However, the long term patients were more difficult to treat given the perception of the rules.

Therapists were trained to only treat if the patient demonstrated the potential for improvement.  If the patient did not make gains and the medical record was reviewed by the Fiscal Intermediary, the claim would be denied.  This became common knowledge and lead to the non-treatment of many patients secondary to the fear of non-payment. (I.e., The False Improvement Standard).

I never forgot the rules repeated by Pat and Jim:

“A patient requires the skills of a therapist in order to prevent decline, promote recovery or slow the progression of a disease.

This knowledge afforded our team the ability to treat patients with debilitating conditions, yet, know that our interventions where beneficial, reimbursable and clinically appropriate.  But even as much as we cited the regulations, naysayers would judge the interventions as “inappropriate” or “gaming the system”.  All I could think about was “What if I were that patient.”

The above excerpt is extremely potent and invaluable in guiding a clinician in understanding his/her role with treating a senior destined to reside in a long term care setting for the rest of his or her life.  Couple this with OBRA 87 which has been reinforced in the recently released Requirements of Participation (RoP):

Regulatory intent is to accommodate multiple care delivery models to meet needs of diverse populations served by nursing centers and ensure that residents receive care that allows them to maintain or attain their highest practicable physical, mental and psychological well-being.”

In other words, it is not okay to be admitted to the nursing facility and decline.  Combine the above two quotes and this gives any clinician the foundation for care.  Fast forward to this past week and note that on February 2nd, 2017 the federal judge overseeing the Settlement Agreement in the Medicare “Improvement Standard” case (Jimmo v. Burwell) ordered the Secretary of Health & Human Services to carry out a Corrective Action Plan to remedy the Department’s noncompliance with the Settlement.CHHiRPThe Judge ruled that the Secretary failed to explain that a consideration of the need for skilled care, not the potential for improvement, should govern Medicare coverage determinations – for skilled nursing facility, home health, and outpatient therapy. Medicare covers skilled nursing and therapy to maintain or slow decline as well as to improve the patient’s condition.

The judge ruled that the Corrective Action Plan will include a new CMS webpage dedicated to Jimmo, a published Corrective Statement disavowing the improvement standard, a posting of Frequently Asked Questions (FAQs), and new training for contractors making coverage decisions.  In addition, and significantly, the Court largely adopted the Corrective Statement drafted by plaintiffs, and ordered the Secretary to conduct a new National Call to explain the correct policy.

Cyndi Zagieboylo, CEO of the National Multiple Sclerosis Society reinforces this ruling by stating:

“Rehabilitation therapy is essential for people with multiple sclerosis to maintain the flexibility, strength, and independence they need to avoid falls or other injuries, and to live their best lives.  More and better education about Medicare coverage of these benefits will help ensure that beneficiaries with MS are never again told they cannot get all the rehabilitation therapy they need as their doctors prescribe.”

Please join me this year and become a Certified Harmony Healthcare International Rehabilitation Professional (CHHiRP). This 3-day training provides your clinicians with the knowledge, tools and resources to treat your Medicare patients appropriately.  Click here to see view our upcoming CHHiRP trainings.

If you need assistance with understanding the latest Improvement Standard ruling, please contact us by clicking here or calling our office at (800) 530-4413. 


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Topics: Jimmo, Improvement Standard

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