Many skilled nurses and therapists have been taught, either through their academic teachings or employer, when patients reach their "max potential" or are no longer showing "improvement" with their care, they are to be discharged from skilled services. Albeit this is how the majority of our healthcare model continues to manage its patients, our dedicated home health team is competent with managing care for those patients who require on-going therapy or nursing to maintain their chronic, long term conditions.
Frequently Asked Questions Regarding Maintenance Services
Simply: It is a service for beneficiaries with chronic conditions. The Medicare program recognized the need for skilled care and related services for chronic, long-term conditions.
"For decades, Medicare beneficiaries – particular those with long-term or debilitating conditions have been denied necessary care based on the "Improvement Standard." This illegal practice has resulted in Medicare coverage for vital care being denied to thousands of individuals on the grounds their condition was stable, chronic, not improving, or that the necessary services were for "maintenance only." [A] lawsuit, Jimmo v. Sebelius, was brought [in 2013] on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions, to challenge the use of the illegal Improvement Standard."
Depends on the source. For us, yes! Our home health agency has successfully implemented many patients into the maintenance program. However, many physicians—and even insurance adjusters and claims auditors - are still unaware of the changes and are erroneously denying coverage for valid services. In August of 2016, a federal court in the District of Vermont found that The Centers for Medicare and Medicaid Services (CMS) has only partially succeeded in its orders to fulfill the educational terms of the Jimmo settlement; and has ordered CMS to implement corrective actions within the next two months.
The U.S District Court judge reported CMS has not done a very good job educating beneficiaries, providers and claims auditors on how "maintenance therapies" are covered. So many are not still aware of this!
Our agency provides Maintenance Therapies as we believe we are the industry leader in this specialty area. It is our responsibility to promote organizational behaviors and business practices that will benefit patients, family members, and society; where others choose not to.
As to why other providers do not attempt to provide this invaluable service is not an easy question to answer. Ultimately the provider will have their own answer to this question. However, our agency believes it is because the provider:
- Does not want to take the financial risk to provide skilled maintenance therapy.
- Does not have the resources to plan, develop and execute the program.
- Is not even aware of the Jimmo Settlement.
Yes. The settlement applies equally to both programs.
No. The Settlement is not limited to certain conditions or diseases. It applies to anyone who’s program requires the skills of a clinician (nurse or therapist) to maintain and/or slow down the deterioration regardless of the underlying illness, disability or injury.
Yes. Nursing, physical, speech and occupational therapies are covered services under the Medicare home health benefit. A patient's residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative's home, Assisted Living Facilities or Personal Care Homes.
If the individual meets the other Medicare home health qualifying criteria, the Jimmo Settlement makes it clear that "maintenance therapy" can be covered under the home health benefit if a qualified therapist is required to ensure the care is safe and effective.
Our policy is neither the patient, power of attorney, nor any other family members or person affiliated with the patient will be responsible for this denial of payment. Our agency has built conditions to help prevent this from ever happening. However, if it does, our agency at our cost will fight this denial through the court systems to secure payment.
Since "Maintenance Therapy" is a very difficult program to implement and there are minimal to no other providers attempting to execute this program, it is best for our therapists to be treating your loved one as we need to continually re-evaluate their functional mobility, balance, and strength. Traditionally, our therapists have had to treat most patients several times, sometimes over several years, before we transition them to the maintenance program. This model of continued nursing or therapy with the same provider (Compass Home Health & Rehab) allows us to collect the necessary functional data to transition them to the maintenance standard.
No results can be guaranteed. However, our team works very hard using evidence based principles to allow you to obtain the best possible outcome. This outcome can be functional to maintain transfers, balance, or walking; or manual (hands-on) to promote reductions in pain management.
- The services must be reasonable and necessary
- The patient must be confined to his or her home
- Services Are Provided Under a Plan of Care Established and Approved by a Physician (You must have a primary doctor and that doctor has to agree to the maintenance services)
Yes, Compass calls this the improvement or restorative standard. These are the traditional services that you would normally receive from any home health care provider. The conditions remain the same as in item #12 in order for you to receive any type of home health care services.
Every person has the right to choose their home health care provider. If you are being discharged from the hospital, emergency room, or skilled nursing facility, you or a family member have the right to inform the social worker, discharge planner, or medical doctor that you are requesting Compass Home Health & Rehab as your provider. If you have an appointment with your family physician and your doctor orders skilled nursing and/or therapy, you can educate your doctor you would like Compass to provide your services.
If you have any questions regarding our Maintenance Program, please contact us at either of the numbers listed below.
Do I Need Maintenance Services?
The best way to evaluate this need, is to contact your primary care physician if you are unsure if your program requires the skills of a physical therapist or you can contact us at (570) 287-4800 if you have further questions.
Compass Home Health & Rehab complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, religion, national origin, age, disability, communicable disease or sexual orientation (an individual’s sex, gender identity, sex stereotyping, pregnancy, childbirth and related conditions).