Sep 13, 2016

Some Medicare beneficiaries improperly denied benefits based on defunct "improvement standard"

It always pays to be your own health advocate! 

In 2012 I informed you that Medicare had eliminated its so-called "improvement standard." Under the new rule, beneficiaries are covered for short-term skilled nursing or rehabilitation services even if they fail to show improvement. A patient is covered for these services so long as the services keep the patient stable and prevent deterioration. (You can read my prior posts on this topic here and here.)

This was great news, particularly for those with chronic conditions like Parkinson's, arthritis, Alzheimer's, etc. However, it appears that not everyone got the message. A September 13, 2016 New York Times article notes that four years on, many health providers and contractors are still citing lack of improvement as the basis for denying claims for short-term rehabilitation and skilled nursing care. Denials force beneficiaries to either pay out of pocket, or go without therapy and thus, risk losing their current level of functioning.

Now, a federal court has ordered the Centers for Medicare and Medicaid Services to devise a plan that will bring providers and contractors up-to-date on the new rule. That plan is due to be rolled out next month. But as always, it's wise to stay informed and to be your own advocate (or a strong advocate for a loved one). Be aware of the new rule and alert your providers. If you should find yourself improperly denied coverage based on the old improvement standard, an appeal may be your only option. Access Medicare's fact sheet on the appeals process here.

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