New York Times | September 12, 2016

September 12, 2016

Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage

... Though never part of Medicare regulations, the improvement standard was written into the C.M.S. manuals that providers and claims administrators relied on. “It was a policy they followed for 30 years,” Mr. Deford said.

The lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid in 2011 became known as the Jimmo case, after Glenda Jimmo, an elderly Vermont plaintiff. A settlement reached in 2013 required C.M.S. to rewrite its manuals and to begin an educational campaign to publicize the change. ...

By early this year, however, the Center for Medicare Advocacy 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.

The Centers for Medicare and Medicaid Services showed no inclination to take further steps, so the plaintiffs’ lawyers went back to court, seeking enforcement of the agreement. The federal judge in Vermont who oversees the settlement ruled in August that C.M.S. didn’t have to further revise its manuals, but did have to mount a better educational campaign.

By early next month, it has to explain how it plans to do that. A C.M.S. spokeswoman said the agency had reviewed the court’s order, but would make no other comment.