This post may be of interest to those on Medicare.
This New York Times article is about the fact that skilled nursing facilities, home health agencies, and outpatient therapists deny continued therapy or treatment for Medicare beneficiaries with the rationale that the patients are “not improving” or “have reached a plateau.”
This issue was supposedly settled in a 2013 lawsuit. According to the settlement, Medicare must cover skilled care and therapy when they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.” The judge required CMS (Centers for Medicare and Medicaid Services) change its policy manuals and “begin an educational campaign to publicize the change.”
According to the article: “By early this year, however, the Center for Medicare Advocacy [one of the plaintiffs in the 2013 case] was hearing from many sources that despite the settlement, providers and the contractors reviewing Medicare claims were still denying coverage when beneficiaries didn’t demonstrate improvement.”
So the plaintiffs in the 2013 case went back to court. The judge has given CMS until early October to come up with a plan as to how it with launch an educational campaign.
As the article points out, there is an appeals process if Medicare denies therapy or skilled care but most patients don’t appeal. The authors notes:
“Of course, patients and families have the same right to appeal coverage denials that they’ve always had. (A notice to this effect is buried somewhere in the paperwork they sign.) They also have the same odds of prevailing they’ve always had: very low, said Judith Stein, the executive director of the Center for Medicare Advocacy. Patients generally have 72 hours to appeal, a process that involves seeking a ‘redetermination’ and then, if that fails, a ‘reconsideration.’ If families go all the way to a hearing before an administrative law judge, Ms. Stein said, they have a good shot. But most families don’t persevere, in part because they can’t afford to pay for care while the appeal proceeds. (If they do spend their own money, though, they can appeal for reimbursement.)”
Here’s a link to the full article:
www.nytimes.com/2016/09/13/health/medicare-coverage-denial-improvement.html
The New Old Age
Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage
The New York Times
Paula Span
September 12, 2016
Robin