A family member just went into rehab for a fall after hospitalization. The facility informed me that if there was no improvement in her physical capability, say being able to walk again, that she would be discharged since that is the medicare requirement. There has to be continual improvement. But the way I understand it, there is no progress standard. That standard was applied for years incorrectly. If you look at the actual law that governs Medicare, it clearly states that the criteria is to prevent further deterioration, not improvement. Due to the Jimmo lawsuit settlement, Medicare agreed to inform people of this fact. Right in the revised Medicare manual, it says.
"No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care."
Here's the underlying law.
"(c) The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities."
Does anyone have any insight into this? What the SNF is telling me seems to be at odds with what Medicare says. How should I handle this? Should I ask them for clarification now or should I wait until, or if, they try to discharge due to no improvement?
Center for Medicare Advocacy
1025 Connecticut Ave NW, Suite 709
Washington, DC 20036
CT / (860)456-7790
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The Center encourages Medicare beneficiaries and their families to appeal unfair “Improvement Standard” denials, even though Medicare patients "and their families should not be in a position of having to educate providers, contractors, and adjudicators about Medicare policy."
They advise patients "and their families to continue citing to the Jimmo Settlement and related materials when challenging denials."
But the most effective way to avoid the need to fight a Medicare appeals (which is not likely to succeed) is to engage the physicians and caseworkers before the time they must make a decision to terminate their Medicare billing.
A Geriatric Care Manager or Advocate who understands the patient's needs, the medical providers, and their billing practices, gives you the best chance to gather the facts needed to continue care paid by Medicare. Hire the advocate as soon as the patient is in the hospital, before being discharged to a facility, and you give yourself the best chance to better results.
These professional Advocates are privately paid by the patient. But the cost is worth the benefit of having an objective advocate working alongside you and your family.
https://www.medicareadvocacy.org/jimmo-implementation-update-where-is-cms/
https://www.rd.com/health/conditions/save-money-fighting-hidden-hospital-policy/
My family received notice from my moms rehab / SNF that they are releasing her before they have completed the therapy as prescribed by her orthopedist . They were initially verbally telling us it was because she had plateaued and was not showing improvement . We appealed and their QIQ declined the appeal . Their stated reason is there is no longer a need for skilled nursing care and she could move to a lower level of care.
Our mother is 88 and was living independently until she had a fall and broke both ankles. The doc did surgery and put in plates and screws . He prescribed intense PT and OT , but non weight bearing . Since the last visit , he added range of motion to begin working to resolve her plantar flexion in both feet . This therapy was to continue daily at least until next doc appt .
Given the docs orders and my mother’s current state, we don’t understand how any rational person can suddenly declare she no longer has a need for this therapy. Jimmo clearly says that “need” is the main criteria for continued coverage , so they have now moved away from arguing that she has plateaued and now saying she no longer needs it, so they shifted their game to hit on the correct term. But the fact remains that she very much does need it, especially now . Otherwise she will regress and be relegated to a state of total dependency .
Your advice and tips in this situation would be appreciated .
Thank You
Plus, your are not guaranteed 100 days. Thats just how long Medicare will pays.
THERE IS NO PLATEAU, RESTORATIVE PHYSICAL THERAPY OR NO PROGRESS RULE PERIOD.
Whether it's short term, long term, whatever term. I don't understand how that came into the mindset of so many people. I've actually read the underlying law governing this aspect of medicare. Even there, the bottom line is to prevent deterioration. Period. Full stop.
Please try to read the links I've posted. In Medicare's own FAQ about there not being a no progress rule, they even mention the 100 day short term period.
It seems it's a common widespread misconception. Which I guess was the point of the Jimmo settlement. Medicare agreed to educate people that it wasn't a thing. I guess we have a long way to go.
I'm really curious how it ever even became a thing. It's like it popped out of nowhere and people just went with it even though it has no basis in federal law or medicare policy. How do these things happen?
"Q7: Can a patient change from an improvement course of care to a maintenance course of care, and vice versa?
A7: Yes."
"Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program."
https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html
While notes say she's exercising 3 hours, that's really not logical. People without injury seldom exercise 3 hrs a day. She may be in the PT room for three hours, but by observation you can note what she did on each machine and for how long. Ten minutes on leg machine. Fifteen minutes doing various arm exercises. Sat off to the side for an hour while other patients took their turn.
As for walking, how many steps did they tell her to walk today, tomorrow, the next day. Were they asking for more each day or were they creating the plateau by only asking for the same amount? Pay attention to the patient, is she calling it quits or just needs a rest before doing more steps. (Patient creates plateau when they refuse/want to return to room). If it is the facility doing same things every day without trying to do a little more (and patient has not refused) then speak up. Mom - after you take a little break, let's see if you can do two more steps....then 4 more steps...etc. Then state the improvement so PT people put in the notes.
Go to her house and take her size of steps to all of the rooms she walked to so you have an idea of how many steps she did each day and how often. That will be YOUR goal for her. The facility goal and your goal are two different things.
If they slapped a diaper on her as soon as she got there (common so that staff don't have to get in any hurry to help someone go to the bathroom), that is another goal you want while there. When you're in the room with her, call them for bathroom assistance...meaning they assist her to walk there, get on the pot, wipe and get off - goal being she can do it with someone only standing by for a while to catch her if she gets unsteady. When you push the button, note the response time. You'll find that many times it can be much longer than a young bladder can hold it - 30 minutes, an hour, no response at all. Those things you report to director of nursing or the administrator when you have several long delays in getting help. Going home in a diaper, when she did not wear one before, is not my idea of a plateau. You also have to remember the longer your brain says it's ok to pee in your pants, the longer it will be to reverse that thought. If it goes on long enough, you won't reverse it. The facilities do have what is known as toilet/bladder training.
Bottom line is someone has to be there most of the day, every day, to know for sure what is going on. Get a notebook and keep a diary. Otherwise, what they say goes because you will have no proof.
They set a date a week into her being admitted.She had a stroke after a bilateral mastectomy,and lost mobility on her left side.She lost the use of her hand and ability to walk independently.She needed PT and OT.I wasn't going to be bullied ,and a fought for my mom everytime.The DOR approached me after my third appeal, and admitted he had acted prematurely ,and if I stopped appealing he'd be more mindful before setting another discharge date.Needless to say my mom was admitted in Oct 2015 and wasn't discharged until Jan of 2016.
Fight for what is right and just.
Just to know, my father's recent snf admission was contolled by his Medicare Part C plan insurer, not Medicare. They granted a brief continued stay and then discharged to family paid board and care (assisted living) facility. He was evaluated weekly or for a shorter period . We were told on Easter Friday at 3 PM that he needed to be discharged on Tuesday. We got a short appeal and he was able to stay about 10 days more.
Also be careful of Part C Medicare advantage plans. My father's union said the benefit was no annual deductible of $300. His losses??? Limited OT and PT benefits in SNF. Only 3 per week were authorized. The usual is 5 under original Medicare. The facility appealed and got 5 treatments per week. And a rushed discharged. So be careful of the plan you choose.
This wasn't a trivial incident. You need to take action. Nothing about this was reasonable or ordinary.
Maybe it varies from state-to-state? But in Mississippi, they were very helpful in explaining to me how DH had to show improvement.
I already quoted the CMS manual explicitly saying there is no such standard.
Here is a quote directly off the Jimmo section of the CMS website.
"The Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have ERRONEOUSLY believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve."
https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html
I capitalized the keyword in. There is no such progress standard. Doesn't exist for medicare.
Looking at the Jimmo settlement, progress is not the criteria. In the update to the CMS manual, they clearly state that it's not. The bottom line criteria is to prevent deterioration in function. That's not even due to the Jimmo settlement. That's been the law for over 25 years. The Jimmo settlement was that Medicare needs to enforce that law instead of letting people get discharged for "no improvement".
I spoke to Medicare and they said I should appeal if there's a "no progress" discharge. Which I think now is the way to go. It could not be an issue. Why make it an issue now? I also spoke to our supplemental insurance company and they said there is no policy for "no progress" discharges during recuperation.
this will get kicked up to Medicare. If Medicare again refuses, then either she must pay herself, or she must move to a long term facility or home.