Jimmo v. Sebelius Settlement Agreement in the News Again

The Jimmo v. Sebelius settlement agreement came about in 2013 when the US District Court for the District of Vermont approved a settlement between the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare Advocacy (CMA). In a nutshell, CMA’s position was that Medicare beneficiaries were being denied skilled care because of an implied “improvement standard” that necessitated discharge when a patient achieved maximum level of function. An argument was made that patients with chronic, debilitating conditions require additional skilled care to prevent further deterioration in level of function. CMS contended that there was never an “improvement standard” set to determine whether a client qualified for services but agreed to provide further education to providers to ensure that all beneficiaries who qualified for skilled services were able to receive them.

Fast forward to 2016 and the parties are headed back to the courtroom. CMA has filed a Motion for Resolution of Non-Compliance with the Settlement Agreement. CMA states that “the settlement should improve access to skilled maintenance nursing and therapy for thousands of older adults and people with disabilities whose Medicare coverage for skilled care is denied or terminated because their conditions are ‘chronic,’ ‘not improving,’ ‘plateaued’ or ‘stable.’” CMA believes that CMS has not lived up to the terms of their initial settlement.

What does this mean for you? The discharge reasons you give for your patients should clearly show that the client no longer requires skilled services. Merely stating “patient plateaued” or “client reached maximum potential” may not be enough by itself. Especially if that client has a chronic or debilitating condition, which may or may not have been the focus of your treatment. Vague, general, or unclear language could give Medicare, the client, or their family grounds to overturn or appeal your discharge decision.

Here at therapyBOSS, we aim to create unassailable documentation for all clinicians who use our system. We give you several checkbox options under Reason for Discharge but ultimately you must use your clinical judgment to decide if these options are enough to address your needs. If you determine that more information is required to thoroughly explain your discharge reasons, you can check the “other/comments” box and write in any additional information necessary.

For more information about the updated motion, please check out CMA’s article here.