The settlement in the Jimmo vs. Sebelius case means that Medicare coverage does not depend on a patient demonstrating improvement or even the potential to improve. Rather, as long as the patient needs skilled care to deliver safe and effective nursing or therapy services, Medicare coverage should be available to maintain, prevent, or slow deterioration of his or her medical condition.
But what happens when a health care provider decides to furnish nursing or therapy services to a Medicare beneficiary that seemingly fall within Jimmo’s coverage criteria and a Medicare Contractor disagrees, denies coverage, and holds the provider liable for not issuing an advance notice of non-coverage to the patient? Under these circumstances, a provider should appeal the decision to get coverage but also be aware that it should not be held liable for any uncovered services.
Medicare’s waiver of liability statute, 42 USC 1395pp(a)(1), provides that, in cases where Medicare coverage is not available and neither the patient nor the provider of the services knew or could not be reasonably expected to know that Medicare coverage wouldn’t be available, Medicare payment will be made notwithstanding the denial of coverage. In plain English, this means that providers should not be penalized when they, in good faith, deliver services that meet the standards discussed in the Jimmo settlement.
For more information on the Jimmo settlement, please click here.
For more information on waiver of a provider’s liability, please contact Pamela Meliso, Director of Consulting and Regulatory Affairs at email@example.com.