Tuesday, February 21, 2012

Medicare "Improvement Standard" Improperly Applied

The Center for Medicare Advocacy talks about the improper interpretation and erroneous implementation of an "improvement standard." Basically, treatment under Medicare should not be denied on the grounds that a patient's underlying condition will not improve. From their self-help packet:
As an overarching principle, the Medicare Act states that no payment will be made except for items and services that are "reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member." 42 USC §1395y(a)(1)(A). While it is not clear what a "malformed body member" is, clearly this language does not limit Medicare coverage only to services, diagnoses or treatments that will improve illness or injury. Yet, in practice, beneficiaries are often denied coverage on the grounds that they are not likely to improve, or are "stable," or "chronic," or require long-term care, or "maintenance services only." These are not legitimate reasons for Medicare denials.
Also from the Center for Medicare Advocacy is an article about the improper denial of coverage:
Neither the Medicare statute nor its implementing regulations mentions or suggests an improvement standard in the context of diagnosis or treatment of illness or injury...The general statutory standard for Medicare coverage is one of medical necessity; that is, the standard is whether a given service is 'reasonable and necessary.' The same subsection of the law does use the word 'improve,' but only in the specific and limited context of authorizing Medicare coverage 'to improve the functioning of a malformed body member.' This use of 'improve' is the only reference to improvement in the statute...[T]here is no overarching improvement standard in the Medicare statute."
From the self-help packet, your first step after a denial would be to ask that a claim be submitted:
Submit a Claim: If a Medicare beneficiary is told that Medicare coverage for therapy is not available.... ask the health care provider to submit a claim to Medicare. The submission of a claim to Medicare is the only way to obtain a formal Medicare coverage determination and to access the Medicare appeals process if coverage is denied. The provider must submit a Medicare claim at the patient’s or representative’s request.
I did send letters to my representatives, including Obama, about this issue, a copy of which I posted elsewhere on my website. Also, there is a lawsuit about this improvement standard underway, with an update posted here.

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