Prevent mistaken Medicare denials

Have you or a loved one been denied Medicare covered services because you’re “not improving”?

Many health care providers are still unaware that Medicare is required to cover skilled nursing and home care even if a patient is not showing improvement. If you are denied coverage based on this outdated standard, you have the right to appeal.

For decades, Medicare applied the so-called “improvement” standard to determine whether residents were entitled to coverage of particular care. The standard, which is not in Medicare law, only permitted coverage if the skilled treatment was deemed to contribute to improving the patient’s condition, which can be difficult to achieve for many ill seniors.

In 2012, the federal Centers for Medicare & Medicaid Services (CMS) agreed to settle a related lawsuit and acknowledged that there was no legal basis for the “improvement” standard and that both inpatient skilled nursing care and outpatient home care and therapy may be covered under Medicare as long as the treatment helps the patient maintain her current status or simply delays or slows her decline.

In other words, as long as the patient benefits from the skilled care, which can include nursing care or physical, occupational or speech therapy, then the patient is entitled to coverage.

Medicare will cover up to 100 days of care in a skilled nursing facility following an inpatient hospital stay of at least three days and will cover home-based care indefinitely if the patient is homebound.

Unfortunately, despite the settlement, the word hasn’t gotten out entirely to the care providers and insurance intermediaries that actually apply the rules. As a result, the plaintiffs from the suit and CMS recently agreed to a court-ordered corrective action plan. This includes a statement from CMS reminding the Medicare community that skilled nursing services should be covered “where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.”

This doesn’t change the rights Medicare patients have always had, but should make it easier to enforce them. If you or a loved one is denied coverage because the patient is not “improving,” you should appeal.