A big payoff: Little-known Medicare lawsuit may bring help to millions
Dick Spero of Salem is an 80-year-old who wears an impish smile on his face, a cross on his chest, and a vest holding a life-saving device that keeps blood pumping through his heart 24 hours a day.
The LVAD, an artificial heart of sorts, has been keeping Spero alive for four years. But two years ago, it nearly killed him when it threw a clot to his brain, causing three debilitating strokes. There was a tear to his brain when the clot was removed. His wife, Nora, described him as “just a little better than a vegetable.”
Doctors told Nora it would be a year of recuperation, but the year came and went, and he wasn’t getting any better.
“I couldn’t even hold a phone,” Dick said.
Today, Dick is walking without assistance, pedaling at a Level 6 on the exercise bike, and pulling 30-pound weights with his arms on a resistance machine at Rehab 365 in Salem, where he has been receiving physical and occupational therapy since July.
Nora credits his progress to his physical and occupational therapists, his spirit, and a blind woman in Vermont suffering from ALS by the name of Glenda Jimmo.
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Four years ago, Glenda Jimmo took Medicare to federal court to demand the government insurance program pay providers for skilled maintenance care and therapy that would keep her condition from progressing and deteriorating. Jimmo’s lawyers argued Medicare was only reimbursing providers to the point where her condition either stabliized or she stopped improving.
In other words, she would have to worsen, suffer and be rehospitalized to retrigger the Medicare reimbursements. Without those reimbursements, no providers would provide the skilled care she needed to help stave off the progression of the disease.
Medicare settled the case, arguing it always paid for maintenance and preventative care; providers just weren’t documenting it right. As part of the settlement, the agency agreed to better educate providers about the availability of reimbursements within a year of the 2013 settlement. That didn’t happen until this past August.
“There are so many millions of patients this can help. It’s just mind-boggling,” said Renee Noel Keimig, director of partnership services at Rehab 365. “And it’s not limited to any conditions.”
Jimmo was backed by an alliance of Vermont Legal Aid, the Center for Medicare Advocacy, and dozens of associations representing such conditions as multiple sclerosis, Parkinson’s, and ALS.
Keimig said this settlement could cost Medicare “hundreds of millions, if not billions,” but it will save the government money in the long run. She said ongoing therapy will keep people from costly rehospitalizations and they will be living healthier.
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Keimig thinks back to one of her clients who met his goals, his condition plateaued, and he was done with his therapy. However, the man did not leave his house so therapy was his only socialization, and he wasn’t motivated to do the work outside the facility.
“He was a perfect person for this,” she said. “It would have made perfect sense.”
Kim Monette, the vice president of Rehab 365’s clinical and outpatient services, said they have been working with its therapists and employees on how to document these types of cases to ensure they receive the Medicare reimbursement. In 2017, they have not received one denial.
“We’re not afraid to treat these patients and fight Medicare if we were ever in an appeals process,” Monette said.
Both Monette and Keimig said there is still a reluctance by providers to offer this skilled maintenance and therapy out of fear Medicare will deny the reimbursement. Monette said if Medicare denies a reimbursement, providers have no recourse to get paid for their services.
“It’s a huge risk for companies,” she said.
Keimig said the slow response by Medicare to educate providers is not helping patients.
“If organizations have been slow in getting the education, how does a consumer find out about this?” she said. “There are so many patients that can apply for this. It helps the consumer if they know it’s a thing and to fight for continued service from a provider.”
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That’s what Nora Spero did. She said Dick spent months at other therapists and never made any progress. She said they were all about documenting goals, not about helping Dick get back on his feet.
“A lot of these other places went by the numbers,” she said. “Other rehabs just turned him down.”
She said if it weren’t for the Jimmo case and the therapy he’s getting now at Rehab 365, Dick would only back slide.
“We now have hope for a reasonably normal life,” she said. “If we had been here a year ago, we’d be dancing by now.”
Reporter Gretchen Grosky would like to hear from readers about issues related to aging. She can be reached at ggrosky@unionleader.com or w206-7739. See more at www.unionleader.com/aging.
Filed under: General Problems
This what and the way it should be done…NOT,,,, this Evidence Base Medicine Crap,,where all they go by is the ,”data,” thus looking good on paper and keeping the revolving door of monies commen in,,,maryw