CMS erases Medicare “Improvement Standard”


Nursing homes and others have for years cut off people from Medicare payments (and therefore therapy) when they were no longer “improving” or had “plateaued.”

These words should be red flags for you.

If you hear them, it is possible your loved one is being prematurely denied Medicare and perhaps therapy.

For the actual language of CMS, see here. (Choose the MM download.)

The CMS in explaining the “new” rules says: “No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.” [Emphasis in original.]

It will take some work to educate nursing homes to the rights of their patients. If you think this applies, speak up.

:- Doug.

About dgermann

Elder Caring Lawyer
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