The decades-long practice of automatically denying Medicare benefits when a patient’s condition has stabilized will end if the agreement signed by the parties in Jimmo v. Sebelius1 is accepted by Judge Christina Reiss, chief judge of the U.S. District Court for Vermont. This decision would fundamentally alter Medicare coverage of nursing home care, home health care and outpatient therapy by eliminating a restrictive interpretation of coverage.
Improvement Standard
Medicare pays for reasonable and necessary medical care. It has virtually been an article of Medicare faith that once a patient is no longer improving, coverage ceases. This was accepted by almost all of the professionals in the field, despite the fact that there was no statutory or regulatory provision to support it. Patients would be denied coverage based upon chart notes such as “chronic,” “requires maintenance therapy,” “medically stable” or “plateaued.” This became known as the “improvement standard.” It led to rule of thumb denials instead of individualized clinical assessments of coverage.
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