U.S. District Court Chief Judge Christiana Reiss’ ruling follows the 2013 settlement of a class action lawsuit against CMS. The misunderstanding related to a training error that caused Medicare claims processors to wrongly believe they should deny occupational therapy and related coverage to beneficiaries who could not prove their health was improving. In the settlement, plaintiffs argued Medicare contractors took advantage of the regulation and denied coverage for certain home healthcare services if the beneficiary’s condition did not improve, was “unlikely to improve…or in retrospect[,] failed to improve, even when the patient needed skilled care to maintain [their] condition or prevent or slow further deterioration.”
In addition to the agency’s self-proposed corrective action plans, Judge Reiss specified that CMS must create a new website explaining how claims should be handled and clarify that the improvement of a patient’s condition should not be considered a criteria on which to deny coverage. CMS officials must also hold a second training session for claims processors, appeals judges and others to further eliminate any confusion.
CMS must complete the measures by Sept. 14. The agency has 14 days to file an objection to the decision.
The order will not affect beneficiaries who were previously denied coverage under the rule.
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