CMS not saying much about a payment deal that could be a game changer

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John O'Connor
John O'Connor

In recent years, many skilled care operators have nervously watched the Centers for Medicare & Medicaid Services reduce and sometimes eliminate payments for physical, occupational and speech therapy services.

But thanks to a recent class-action lawsuit settlement, the funding pendulum might be about to change direction. As a result, the skilled care sector could be in for a massive funding windfall.

Under the accord, Medicare can no longer deny people coverage for skilled care services simply because they have reached a plateau and their conditions have stopped improving. In other words, residents with chronic conditions and disabilities can continue to receive skilled care for as long as it's needed, provided they meet other coverage requirements. Think of what this could mean for Alzheimer's care alone.

If you haven't heard much about this development, don't be embarrassed. As it turns out, CMS is not required to mention it.

And you can probably understand why federal officials might be reluctant to pass along news that could net skilled care operators billions of additional Medicare dollars. But there it is.

We can expect more clarification early next year, when regulators will be required to issue revised manuals. But some of the new coverage guidelines have already emerged:

  • Skilled services will be covered when “necessary to maintain the patient's current condition or prevent or slow further deterioration.”
  • Skilled therapy must be based on a patient's clinical condition and be provided by a registered nurse, licensed practical nurse or therapist.
  • Medicare will cover up to 100 days in a nursing home per “benefit period,” which starts when a beneficiary enters the hospital or a nursing home for skilled care and ends 60 days after the skilled care has been discontinued.
  • Even if residents do not qualify for Medicare for their stay in the nursing home, Medicare may cover physical therapy and other skilled care for those who meet the requirements for outpatient therapy. The $1,900 outpatient therapy caps also apply.
  • A special review process will be set up for patients whose claims were denied after the lawsuit was filed on Jan. 18, 2011.

For long-term care, the potential fruits of this settlement are hard to overestimate. It sure marks a nice departure from the raw deals CMS has been serving up lately.

John O'Connor is the editorial director at McKnight's. Follow him on Twitter at @ltcritr.

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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.