January 31, 2014
For years, it has been an article of faith that Medicare would not pay for services such as skilled nursing or physical therapy unless that care improved a patient’s health status. I cannot tell you how many times I’ve heard doctors, nursing homes administrators, and even case workers say Medicare would stop paying once a patient was no longer getting better.
It turns out that guideline—often called the “improvement standard”—never existed. Exactly a year ago, Medicare settled a lawsuit called Jimmo v. Sebeliusthat clarified the real rule: Medicare will pay for skilled services if they are “reasonable and necessary to prevent or slow further deterioration.” Medicare coverage “cannot be denied based on the absence of potential for improvement or restoration.”
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