Why Settlement of the “Improvement Standard” Lawsuit Still Matters

It has been close to three years since the Jimmo v. Sibelius, or the “Improvement Standard,” settlement was announced. Since then, both clinicians and Medicare beneficiaries are unaware of the settlement and what it means for them.

The lawsuit rules that patients have a right to continue to receive reasonable, necessary care to maintain their medical conditions and to prevent or slow a decline in their condition. The ruling allows for skilled therapy to continue in cases where discontinuing therapy would cause a decline in a person’s functional status that would otherwise be prevented if therapy was continued.

Documentation of achieving a higher level of function is not necessary; documentation of maintaining and/or slowing the decline of a person’s condition is the main focus. Documentation needs to include why the therapist is required to safely, effectively treat the patient versus a non­skilled caregiver.

Additionally, documentation must show that without skilled therapy that patient’s functional status would decline. The focus shifts from making functional gains to maintaining functional status and preventing and/or slowing the deterioration of function.

Prior to discharging a patient, professionals should ask, “Are the skills of the therapists necessary to maintain, prevent, or slow the decline of the patient’s functional status?” If yes, skilled physical therapy can be continued and justified.

Author: Katie Pring, MPT, of the SOWH Reimbursement Committee, works in the outpatient orthopedic practice, Mendelson Kornblum Orthopedics, in Warren, Michigan. The women’s health program she developed there includes treatment of lymphedema, pregnancy and postpartum care, and pelvic floor therapy.