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Medicare Settlement – How will it change things?

Last week I was discussing the recent settlement in the case of Jimmo v. Sebelius that will have a huge impact on Medicare recipients who need rehabilitative services at home or in a skilled nursing facility.  We’ll have to wait and see how this affects care in the long term but what immediate changes will result?

There is a re-review process for certain Medicare beneficiaries who were denied benefits for these services.  The denial must have become final and appealable after January 18, 2011.  A further appeal need not have been filed.  The re-review process only applies to services that were actually received by the Medicare beneficiary.  In other words, if Medicare denied benefits and no further rehabilitative services were received the Jimmo settlement will not help you.  Medicare can only pay for services received.

If skilled care was stopped because Medicare wouldn’t cover, you may be able to get it restarted under this new standard.  First, you’ll need your doctor to explain in writing why skilled care or therapy is necessary.  And keep in mind that all the normal Medicare requirements still apply.  For example, skilled nursing care requires the 3 day hospital stay first.

Going forward, what if you are denied coverage for rehabilitative services or therapy?  There is an expedited appeal process that should be followed.  The notice of denial from Medicare provides information on how to go about it.  You must contact the state Quality Improvement Organization within 24 hours and a decision is usually made within 72 hours.  A second appeal is possible to a Qualified Independent Contractor and after that, the next appeal is to an administrative law judge.  At that point you are looking at a time frame of approximately 60 days for a hearing and then a decision.

If you are unsuccessful on appeal you’ll need to pay for the services you received.  And, again, you have to continue to receive the services, in order for Medicare to cover.   In other words, you can’t stop treatment, appeal the denial of services and then restart them if your appeal is successful.  This is what makes it so difficult for many Medicare recipients on a fixed income.  You could be incurring thousands of dollars of medical bills without knowing whether Medicare will cover it.