4 Years Later, Jimmo Case Settled Again
Posted On: March 7th, 2017
Regulatory Analyst, Change Healthcare
When settlement was reached in the Glenna Jimmo case in 2012, it was touted as a new era for home health. The agreement with Medicare dismissed a standard that therapy had to result in improvement in mobility, setting up reimbursement for “maintenance” therapy and skilled nursing services for those judged to be in need.
However, Jimmo’s particular case continued until 2014 and plaintiffs and Medicare officials appeared before a judge this January arguing the same points that Jimmo was supposed to clarify.
According to coverage about the latest agreement, the government will build a website that explains the 2013 settlement and also provides information on how claims should be handled. The website also will explain how improvement isn’t the sole criteria for coverage. Other parts of the order include a training session for claims processors and appeals judges about the policy, including the language to use in describing coverage.
Medicare officials and advocates for seniors had recently gone before a federal judge because plaintiffs charge that denials still are occurring for services that should have been covered. For Parkinson’s patients for example, maintaining current mobility against a progressive disease would be considered a “win” for patients, thus meeting the criteria for reimbursement.
As we know, patients want to remain in their homes for as long as possible. Home health services that enable that—even if the interventions don’t show marked improvement—can prove less expensive than institutional settings.
An ongoing issue
Attorneys for the plaintiffs contended they should be able to oversee Medicare education efforts on the issue, which was rejected by the federal judge. They wanted to write a new policy standard that counteracts the former policy known as the “improvement standard.” The Centers for Medicare & Medicaid Services, on the other hand, believed that accepting help in this manner “would also grant their counsel undue control in developing CMS educational materials and an outsize role in CMS’ corrective action efforts.”
When the original settlement was announced in 2012, Jimmo was 76. The Lincoln, VT, resident had been blind since childhood, and an amputation resulting from a diabetes complication required her use of a wheelchair. She was receiving home health for wound care and other issues, but Medicare rejected coverage based on policies that stated patients must show a likelihood of either functional or medical improvement.
Jimmo sued Medicare again two years later after the highest Medicare appeals panel rejected her original 2007 claim for coverage—the one that resulted in the 2012 settlement. According to coverage at the time, the “judges said they agreed with the original ruling that her condition was not improving—criteria the settlement was supposed to eliminate.”
Days after the second lawsuit was filed, however, the government vacated the appeals panel ruling and agreed to pay not only Jimmo’s home health provider $11,500 but her legal fees.
Legal action outlives Jimmo
As those on the front line of providing home care can attest, a little assistance can go a long way to help patients be more secure in their homes. Physical therapy, training in activities of daily living, skilled nursing and health aides’ assistance can be invaluable to keeping people where they want to be, at home.
Regardless of this latest outcome, Mrs. Jimmo will not be able to personally benefit. She passed away just before Christmas at the age of 80. Her obituary noted, “She lived for her family and loved a great story.”
And we all can hope this story finally has an ending.