1. Challenging the Improvement
Standard: Jimmo v. Sebelius
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Barbara Patterson-Paul
BSN, RN, CRRN, RAC-CT
Director of Operations

2. Objectives
Review key points of the Jimmo v.
Sebelius
CMS Response
Practical Application for Part A and B
Documentation to Support
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3. Key Points
Jimmo v. Sebelius
CMS Response

4. Jimmo v. Sebelius
The Jimmo v. Sebelius case challenged
Medicare's use of an "Improvement
Standard" to make coverage
determinations
The lawsuit was brought on behalf of:
Six individuals representing a Nationwide
class of Medicare beneficiaries
National organizations representing people
with chronic conditions
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5. Individual Plaintiffs:
Glenda Jimmo
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Paul O. Boisvert for New York Times

6. Individual Plaintiffs
Lead plaintiff, Glenda Jimmo, is a 76-year-old
Medicare beneficiary from Bristol, Vermont
Blind since birth and has had her right leg
amputated due to complications from diabetes
Requires a wheelchair, and receives multiple
home health care visits per week for various
treatments for her complex condition
Medicare denied coverage for these services,
saying that she was unlikely to improve
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7. Individual Plaintiffs:
Rosalie J. Berkowitz
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New York Times October 22, 2012

8. Individual Plaintiffs
Rosalie J. Berkowitz is an 81-year-old
Medicare beneficiary from Stamford,
Connecticut
Multiple Sclerosis
Medicare denied coverage for home health
visits and physical therapy on the grounds
that her condition was not improving
Her family said she would have to go into a
nursing home if Medicare did not cover the
services
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9. National Organizations
National Multiple Sclerosis Society
Parkinson’s Action Network
Paralyzed Veterans of America
Alzheimer’s Association
United Cerebral Palsy
National Committee to Preserve Social
Security and Medicare, an advocacy
group
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10. Improvement Standard
The settlement addresses Medicare
terminating or denying coverage to
beneficiaries who are not improving for
Medicare Part A and Part B
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11. Improvement Standard
Plaintiffs alleged the “Improvement
Standard”:
Is "a covert rule of thumb" that is not
supported by the Medicare statute or
regulations
Operates as an additional condition of
eligibility which effectively denies
beneficiaries coverage of certain skilled
services
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12. Improvement Standard
According to the Complaint, Medicare has :
Failed to make assessments regarding a
beneficiary's "unique condition and
individual needs"
Does not rely on the Medicare statute,
regulations and manuals, but relies on
"more restrictive internal guidelines,
policies, and Local Coverage
Determinations ("LCDs")
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13. CMS Settlement
Attorneys from the Center for Medicare
Advocacy, Vermont Legal Aid and the
Centers for Medicare & Medicaid Services
(CMS) have agreed to settle the
"Improvement Standard" case, Jimmo v.
Sebelius
A proposed settlement agreement was filed
in Federal District Court on October 16, 2012
The Settlement was approved on January 24,
2013
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14. Jimmo v. Sebelius
The judgment indicates that as long as a
patient requires skills of a therapist or
a nurse, a patient would meet the
skilled coverage criteria despite not
making functional gains
Documentation must support the need
for skilled therapy intervention
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15. Skills of a Therapist or a Nurse
Must require the expertise, knowledge,
clinical judgment, decision making and
abilities of a therapist or a nurse that
qualified personnel, trained caretakers
or the patient cannot provide
independently
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16. Skills of a Therapist or a Nurse
The patient’s medical complexity require
the skills of a therapist or a nurse
OR
The services are of such complexity that
the skills of a therapist or a nurse are
required to perform the service
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17. Skills of a Therapist or a Nurse
Documentation must support:
Description of skilled treatment
Changes made to the plan of care due
to assessment of the patient’s needs
Medical complexity
Why the clinical and critical thinking
of a therapist or a nurse are required
(hands and/or brains)
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18. Questions/Answers
Harmony Healthcare International
(978) 887 - 8919
www.Harmony-Healthcare.com
Connect with Us!
@Harmonyhlthcare
facebook.com/HarmonyHealthcareInternational
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19. What is a CHHRP-LTC?
A Certified Harmony Healthcare
Rehabilitation Professional (CHHRP-
LTC) is an Interdisciplinary
Professional who has Successfully
Completed an Intensive and Clinically-
Founded Training Geared Specifically
to Patients in a Skilled Nursing Facility
(SNF) Setting
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20. What is a CHHRP-LTC?
3-Day Certification Includes:
CEUs
Medicare Therapy Documentation in
a SNF
Medicare Coverage Criteria
Rehabilitation Program Development
MDS Coding for the Therapy
Professional
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21. What is a CHHRP-LTC?
Hot Topics Discussed:
Office of Inspector General (OIG) Report
Functional Reporting of G-Codes
The Jimmo Settlement Agreement
Updated 2013 Process for Manual Medical
Review of Part B Therapy
2013 Multiple Procedure Payment
Reduction (MPPR)
Medicare Part A an B Denial Trends
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22. What is a CHHRP-LTC?
Upcoming CHHRP-LTC Certification
Program: Watertown, NY, June 11-13,
2013
Host a CHHRP-LTC Certification
Programs and earn free attendees
http://chhrp.eventbrite.com/#
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