CMS Issues Fact Sheet-Jimmo Lawsuit

CMS has recently issued a Fact Sheet on the Jimmo v. Sebelius Settlement Agreement. The settlement agreement puts an end to the Medicare contractors inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care. ”It is intended to clarify that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration”.  

Forthcoming Activities:

1)     Clarifying Policy-Updating Program Manuals:  This is the first action CMS will undertake as specified in the settlement agreement, revising the relevant program manuals used by Medicare Contractors

2)     Educational Campaign-Informing Stakeholders:  CMS will conduct national conference calls with providers and suppliers, as well as, Medicare contractors, Administrative Law Judges, medical reviewers, and agency staff, to communicate the policy clarifications and answer questions. CMS will also begin an educational campaign for contractors, adjudicators, and providers and suppliers utilizing a variety of written materials, including:

• Program Transmittal;

• Medicare Learning Network (MLN) Matters article;

• Updated 1-800 MEDICARE scripts.

3)     Claims Review:  CMS will engage in accountability measures, including review of a random sample of home health coverage decisions to determine overall trends and identify any problems, as well as, a review of individual claims determinations that may not have been made in accordance with the principles set forth in the agreement.

According to the terms of the settlement agreement, CMS will complete the manual revisions and educational campaign by January 23, 2014, which is within one year of the approval date of the settlement agreement.


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