Mythbusters: Harmony Healthcare International and Center for Medicare Advocacy Team-Up to Dispel Myths On Medicare Coverage for Maintaining a Patient’s Condition

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Jimmo v. Sebelius Proves Law Never Required People Improve In Order to Get Medicare Coverage

This is a huge victory for countless individuals who were held to an improvement standard that never existed.

Helping to implement and spread the word about the settlement of a nationwide class action lawsuit (Jimmo v. Sebelius, Civil Action No. 5:11-CV-17, District of Vermont) and seeking to end Medicare’s practice of denying skilled maintenance care to patients who did not meet an “improvement standard”, Harmony Healthcare International and the Center for Medicare Advocacy are releasing a video conversation with Ali Bers, Litigation Attorney, Center for Medicare Advocacy and Kris Mastrangelo, President and CEO, Harmony Healthcare International. The video details the myths surrounding the misunderstood application of the law and the efforts of the Center for Medicare Advocacy, the plaintiffs and the supporting organizations that helped stop denied coverage due to lack of improvement.

“This is a huge victory for countless individuals who were held to an improvement standard that never existed,” said Mastrangelo, “We believe it is important to make our client base, the skilled nursing and assisted living markets and the general public aware of this groundbreaking settlement.” Massachusetts-based Harmony Healthcare International is the leader in long term care compliance, reimbursement, operations and denied claims appeal consulting and talent management services. The company offers training and education programs and created the video as part of its ongoing outreach and education initiatives.

Plaintiff Glenda Jimmo of Vermont was denied Medicare coverage for skilled home health maintenance care benefits in 2007 by the Medicare Appeals Council based on her “lack of improvement”. As a result of the class action settlement, Medicare updated its policy manuals in December 2013 to clarify that improvement is not necessary for coverage of skilled nursing and therapy services. Skilled care may necessary to maintain or to prevent or slow further deterioration of the patient’s condition.

A second, individual federal court case for Ms. Jimmo was necessary because she was again denied coverage in 2014 by the Medicare Appeals Council, the last step in the Medicare administrative appeals system. That case settled in favor of coverage for Ms. Jimmo.

"The resolution of this federal case completely vacates the Appeals Council denial for her skilled maintenance home care," says Judith Stein, Executive Director of the Center for Medicare Advocacy and an attorney who brought the Jimmo v. Sebelius class action lawsuit. "The maintenance home care she received will now be paid in full. And coverage for similar skilled maintenance care may also be available."

Ms. Jimmo’s individual case was settled on October 29, 2014 and resulted in full payment of her Medicare claim. It also completely vacated the decision of the Medicare Appeals Council that denied coverage due to lack of improvement.

Because of the settlement, SNFs, outpatient, home health and assisted living facilities now have the latitude to offer patients maintenance therapies such as specialized Range of Motion and skilled mobility training knowing that costs will be covered by Medicare.

“This gives the facility the added security of knowing that optimum care can be provided in maintaining a patient’s current medical state without the fear of additional audits or claims denials,” added Mastrangelo, “This is powerful news for someone suffering from ALS, advanced MS and Parkinson’s disease.”

“The video sets the record straight and gives those who work for skilled nursing and assisted living organizations, those who have loved ones in care and those who care for these patients a clear and succinct understanding of the impact of the Jimmo settlement,” said Bers.

The video can be viewed at: https://www.youtube.com/watch?v=50APCP-BwIk.

A copy of a Fact Sheet issued by CMS on the Jimmo v. Sebelius settlement is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/jimmo_fact_sheet2_022014_final.pdf

About Harmony Healthcare International
Harmony Healthcare International was founded in 2001. With headquarters in Topsfield, MA, Harmony Healthcare International services clients in the skilled nursing, acute care, home health and assisted living markets with operational and compliance consulting, training and educational programs and talent management services. With a staff of accomplished healthcare clinicians who serve as consultants to For-Profit, Not-For-Profit, Standalone and Multi-Facility Chains across the country, Harmony Healthcare International has been ranked among the top 5,000 fastest growing private companies in the U.S. for 3 consecutive years by Inc. Magazine. Harmony Healthcare International, “We care about care.”

Visit us at: http://www.harmony-healthcare.com/

About the Center for Medicare Advocacy
The Center for Medicare Advocacy, Inc., established in 1986, is a national nonprofit, nonpartisan law organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain fair access to Medicare and necessary health care. The Center is headquartered in Connecticut and Washington, DC with offices throughout the country.

The Center is staffed by attorneys, nurses, legal assistants, and information management specialists. The Center’s work includes:

  • Representing thousands of individuals in appeals of Medicare denials.
  • Responding to approximately 7000 telephone and email inquiries each year.
  • Producing a wide array of electronic and hard copy educational materials.
  • Advocating in administrative, judicial, and legislative forums,
  • Pursuing Medicare coverage for individuals and for dually eligible beneficiaries (individuals who are eligible for both Medicare and Medicaid).
  • Providing legal training and support nationwide as well as for Connecticut's state health insurance and assistance (SHIP) program, known in Connecticut as CHOICES.
  • Visit us at: http://www.medicareadvocacy.org

Media Contacts
Jon A. Di Gesu        
Vice President of Marketing
Harmony Healthcare International
jdigesu(at)harmony-healthcare(dot)com
@JonDiGesu
(O) 978.887.8919 (C) 603.770.5731

Matt Shepard
Communications Director
Center for Medicare Advocacy
mshepard(at)medicareadvocacy(dot)org
(O) 860.456.7790

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