Regulators outline new process for manual medical review of therapy claims

Five national groups filed a class action lawsuit against the Department of Health and Human Services over a Medicare policy that requires a patient to exhibit “demonstrable improvements” in order to qualify for skilled nursing care and physical, speech and occupational therapy.

The suit was filed in a U.S. District Court in Vermont by organizations including the National Multiple Sclerosis Society, Parkinson’s Action Network, Paralyzed Veterans of America, National Committee to Preserve Social Security and Medicare, and the American Academy of Physical Medicine and Rehabilitation. These organizations charge that if a patient does not exhibit improvement, Medicare will not pay for additional services and that providers, such as nursing homes, hospitals and rehabilitation centers, will cut them off.

“Thousands of Medicare patients have been denied coverage for skilled services such as home health care, physical, occupational and speech therapies because their underlying condition will not improve,” said Judith Stein, founder and director of the Center for Medicare Advocacy.

Other critics of the policy warn that the policy keeps patients, such as stroke survivors or those with Parkinson’s or Multiple sclerosis, from receiving therapies that could help them achieve and maintain independence.