Medicare Maintenance Series ~ The JIMMO Settlement clarified that skilled maintenance therapies (and nursing) are covered by Medicare. As we enter the Jimmo maintenance accountability phase it is good to review the basics of this important legal case. As a result of the Settlement Agreement CMS was required to revise pertinent sections of the Medicare Benefit Policy Manual, which included clarification to the SNF, Home Health and Outpatient Therapy chapters that included specific case samples showing how skilled maintenance therapy and skilled nursing are covered. CMS also concluded an educational campaign to both the provider community as well as to the adjudicators (those that review records and approve or deny coverage). We are now entering a phase of accountability. The educational materials are available on the CMS website as well as updated FAQs.
Jimmo Maintenance Accountability Phase – Holding Reviewers Accountable
We are now in the what is considered the Jimmo maintenance accountability phase wherein CMS is doing accountability reviews by random sampling the Qualified Independent Contractor’s (QIC) decisions to determine if any errors were made in denying coverage for skilled maintenance. The Jimmo Settlement Agreement calls for regular meetings (5 meetings over a 3 year period) with the Plaintiff’s counsel to address and correct errors per individual cases. The Center for Medicare Advocacy, in a recent update webinar on Jimmo, noted that a regional ZPIC was issuing letters to providers containing incorrect Medicare coverage standards for home health.
The Center for Medicare Advocacy, one of the lead plaintiffs in the Jimmo case is looking for anecdotal examples of success stories, as well as cases that have been denied. This will assist in their process of holding the CMS reviewers and adjudicators responsible for following the CMS updated manual guidance.
Have you treated patients where you discontinued therapy because the patient plateaued, but could still benefit from therapy in order to not regress? Have you evaluated patients that you think might qualify for skilled maintenance therapy but you are not confident that your documentation would support medical necessity? Are you uncertain about providing skilled maintenance therapy or a skilled maintenance plan for fear of not being reimbursed?