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Spread the Word: Medicare’s Improvement Standard No Longer Applies!

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For the fifteen years of my geriatric care management practice in San Diego, it was just the way it was: elders who needed extended post-acute therapy got cut off far too soon. No one got all the therapy they needed, and that’s just what all of us thought was par for the course.  Elders recovering from strokes and broken hips etc. were discontinued from their physical, occupational or speech therapy far too soon with sad and often tragic outcomes.  Everyone knew the drill: therapy would be denied if the patient failed to make what Medicare deemed “significant progress” in a fairly short amount of time.

What Grace Care clients often did in that situation was to find and hire private physical therapists. Many of my clients worked literally for years with these dedicated professionals to maintain their health status and mobility. This activity has no doubt extended life and wellness well past what would have been without it. Yet I recently discovered that we now have another avenue to get people the help and therapy they need.

Phil Lindsley, a CELA (Certified Elder Law Attorney) we work with through San Diego Elder Law Center, enlightened me a year ago about the systemic misunderstanding and misapplication of the Medicare law in this arena.  Phil assured me that that rehab therapy services necessary to “maintain the patient’s current condition” had been the required Medicare law for some time. However, since the Medicare manuals used by skilled nursing homes and fiscal intermediaries stated (incorrectly) that continued coverage was only possible if the patient showed a “likelihood” of medical or functional improvement, the original intent of the law has simply not been honored. I was surprised to say the least.

Early in 2013, there was a class-action law suit called “Jimmo v. Sebelius” brought by the Medicare Center for Center for Medicare Advocacy. San Diego Elder Law Center writes in a recent online publication that Under Jimmo v. Sebelius, “the Federal government agreed that Medicare beneficiaries are covered for skilled services needed to maintain the patient’s current condition or prevent or slow further deterioration, even if the patient’s condition is not expected to improve.”

This means, that as patient advocates we need to know the Medicare law as it applies to our clients so we can assist them in receiving all the therapy they need to achieve their rehabilitation goals, maintain functional mobility and preserve quality of life. Often times this means we need to engage the therapy staff of the skilled nursing centers, or the home health providers, and educate them on recent changes to the Medicare Policy Manuals.

For further assistance in these matters, you can contact us directly at Grace Care Management by calling (760) 789-9177. We also encourage you to visit the Center for Medicare Advocacy’s website at www.medicareadvocacy.org or San Diego Elder Law Center at www.sandiegoelderlaw.com.

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