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Polsinelli Shughart Health Reform and Related Health Policy News
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An executive summary of political, legal and regulatory issues that may impact your business, prepared by Polsinelli Shughart Health Care legal and Public Policy professionals.

 

Health Reform + Related Health Policy News

Update for October 24, 2012

 

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Proposed Settlement Changes 'Medical Improvement' Standard for Skilled Nursing, Therapy Services

CMS has agreed to change its requirement that beneficiaries show a likelihood of medical or functional improvement before Medicare will pay for skilled nursing and therapy services.   The policy change is part of a proposed settlement in a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who were denied coverage for home health, physical and occupational therapy, skilled nursing stays and outpatient therapy because their conditions were unlikely to improve.  While neither the Medicare statute nor regulations require beneficiaries to show a likelihood of improvement, the Medicare coverage manual and guidelines used by Medicare contractors have a stricter requirement that indicates coverage for such services should end if a patient is not improving or is stable.  Under the proposed settlement, which is expected to be approved by Christina C. Reiss, the chief judge of the Federal District Court in Vermont, Medicare would pay based on the need for skilled care and not “the presence or absence of an individual’s potential for improvement.”  Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, said the settlement is “a landmark decision for Medicare recipients with chronic illness and especially those with disability.”  She added, “Disability frequently accompanies many chronic conditions and we often have no cures, so people are likely to experience progressive disability. Rehabilitation, physical and occupational therapy and skilled care are incredibly important in maintaining a person’s functional ability, performance and quality of life.”  Additional details are available here.  The proposed settlement is available here.

 
 

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Additional Reading


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Federal Register


Click here to preview a summary of notices which appeared in the October 19 - October 25, 2012 Federal Register.

 

 

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