The Jimmo scorecard and CMS compliance update

In some ways, 2014 has been a monumental year. But it’s not over yet, especially with regard to Centers for Medicare & Medicaid Services requirements to take steps to implement the historic Jimmo settlement agreement signed on Jan. 24, 2013.

According to the terms of the agreement, CMS agreed to issue revised portions of the related program manuals used by Medicare contractors, conduct educational sessions in order to clarify coverage of skilled nursing and skilled therapy services, and establish a claims review process for claim denial based on use of an ‘improvement standard.

What has happened during 2014 to meet the terms of the settlement?

Clarifying Policy — Updating Program Manuals (DONE)

o   On December 13, 2013, CMS released Transmittal 176, which was replaced by Transmittal 179 on January 14, 2014, with some language changes related to therapy delivery. This transmittal reinforced that an “improvement standard should not be applied in determining Medicare coverage for maintenance claims that require skilled care.” In addition, portions of the revised manual were updated, enhancing guidance on appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.

Educational Campaign — Informing Stakeholders (DONE)

o   Program Transmittal;

o   Jimmo v. Sebelius Settlement Agreement Fact Sheet

o   Medicare Learning Network (MLN) Matters article for relevant providers with more detail regarding manual updates (#MM8458);

o   Updated 1-800 MEDICARE scripts; and,

o   A national conference call with providers and suppliers was conducted on December 19, 2013, to clarify long-standing coverage for skilled services and misuse of the “improvement standard” as criteria for coverage.

Re-review of Denied Claims (IN PROGRESS)

o   In June 2014, CMS posted a link for beneficiaries to download the form, “Request for Re-review of Medicare Claims Related To The Settlement Agreement in Jimmo v. Sebelius” that provided the steps to resubmit claims within two time periods for re-review is the claims was denied because of “not improving or no longer had the potential to improve.”

o   The first period for denied claim re-review ended July 23, 2014.

o   January 23, 2015, is the final deadline date for submitting claims for re-review for denials between January 25, 2013, and January 23, 2014.

o   CMS implementation of accountability measure through a review of a random sample of SNF, HH and OPT coverage decisions to determine overall trends and identify any problems

So, it appears that CMS met the terms of the settlement agreement. However, is all the education needed really done? I would argue not, since the original claim from Glenda Jimmo went through the re-review process and was denied in April 2014 at the fourth level of appeal due to lack of “improvement” prompting another lawsuit that quickly settled in October 2014. While the value of the Glenda Jimmo claim was $11,586, plus $4,400 in legal aid was finally agreed to be paid, the full real value of this landmark win is still to be determined.

Have operators embraced the opportunity to provide maintenance services for beneficiaries with chronic and/or progressive conditions that are at risk for decline in health and function without skilled interventions performed by qualified individuals, and that cannot be safely and effectively be performed by the patient or non-skilled caregivers? Quality outcomes and satisfaction scores may measure the impact of this settlement on the providers and beneficiaries.

Only time will tell if there is a shift in coverage to lower level therapy or coverage of maintenance restorative therapy services delivered to neither improve nor restore but to maintain a level of function consistent with quality of life for many beneficiaries.

How many providers, like the appellant judge, are still operating on old beliefs about the mythical improvement standard? Have we done enough to ensure the full value of Glenda Jimmo’s victory is realized by all beneficiaries?

You might say the jury is still out. 

Taken from McKnights