The proposed settlement that would eliminate a common cause of denial for maintenance therapy and skilled nursing claims by chronic-care patients appears close to being finalized, a source close to the case reports.
 
Gill Deford, director of litigation with the Center for Medicare Advocacy in Willimantic, Conn., tells us that the judge has “tentatively approved the settlement” hammered out between HHS as well as the Center and Vermont Legal Aid, which brought the Jimmo v. Sebelius suit that led to the settlement.
 
The judge has also ordered HHS to post a notice informing class members of the decision by Dec. 10, 2012, and set Jan. 24, 2013 for a fairness hearing where class members can appear in court and state how they feel about the settlement.
 
While “we can’t assume the judge will give final approval on or after Jan. 24, if she does, then the settlement agreement will take effect,” Deford says.
 
The class-action suit had charged that CMS intermediaries had for years been denying skilled nursing and therapy claims based on an unwritten “improvement standard” – that is, a standard that disallowed services that did not lead to improvement, even when maintenance or decline prevention was the goal of the service (HHL 12/3/12).