On Jan. 24 of this year, the Jimmo vs. Sebelius class action lawsuit was settled. This was a significant win for us, the healthcare providers. As we continue to work out the details, I feel now is a good time for a reminder of the ins and outs the lawsuit. No doubt about it, it was a blockbuster decision.

At its core is an “illegal” concept that government regulators and its contractors had been propagating against patients and providers alike.

An October “OT Practice” issue characterized the lawsuit’s outcome this way: “The settlement agreement between the plaintiffs and the Department of Health and Human Services stipulates that skilled services to maintain an individual’s condition or prevent or slow his or her decline are covered by Medicare, and that the ‘improvement standard’ that the Centers for Medicare and Medicaid Services (CMS) and its contractors have been employing is illegal.”

A review of the case’s facts is revealing, even if you think you know everything about it already:

·       Jan. 11, 2011, CMS and its contractors began using the so-called “improvement standard” to determine payment for care. Basically, rehab claims were being denied if patients were unable to demonstrate significant progress, achieve independence or achieve a prior level of function.

·       The Jimmo case was settled by the U.S. District Court for the District of Vermont on Jan. 24, 2013.

·       The settlement reversed the “improvement standard” and has allowed healthcare providers to resubmit claims since 2011 that may have been previously denied for these reasons.

·       The settlement also recognizes that payment for rehab (PT, OT, and Speech Therapy) services should be based on the need for medical necessity of our discipline-specific skills, and not based on patient outcomes.

·       The settlement also promises to remove hurdles for care to our “neediest” residents, especially those with long-term, chronic, not-improving conditions that may require therapy to PREVENT further declines or maximize independence and function throughout the disease process.

·       The settlement also recognizes therapy as billable services to ensure “safe and effective maintenance programs” to help patients maintain their current abilities and function.

This lawsuit has profound implications across all of healthcare and in every setting with large varieties of patients. While we cannot treat a patient for non-skilled, maintenance level treatment, we can, however, bill for routine “check-ups” to ensure the maintenance programs and patient/caregivers are continuing to perform independent carry-over.

I feel you can justify your medically necessary skilled services to determine if the programs need to be modified, customized, upgraded/downgraded, changed completely, or no change necessary. For our patients with chronic conditions, it’s expected that rehab professionals would be the most appropriate and cost-effective healthcare professionals to ensure ongoing success with these programs.

When I’m teaching my seminars, many therapists have commented that they have been fearful or hesitant to “pick-up” and evaluate these types of patients for fear of denials.

I tell them to feel confident in their clinical decision-making skills, and if a denial is received stating patient outcomes as the reason, simply refer to the Jimmo settlement in the appeal letter and then look forward to the mail to receive your payment for services!