By John Marmarou, DPT, MSCS – Executive Director, Total Rehab & Fitness
For the last 15 years, all of my professional work and efforts have been devoted to keeping those with multiple sclerosis (MS) in their communities and out of the hospital. I am a doctor of physical therapy, MS specialist and an executive director. I oversee two very effective programs that specialize in the treatment for those with MS. Early in the development of these programs, I made the difficult decision to stop discharging patients prematurely due to insurance restrictions. This was a very promising decision, as our patients would usually decline after discharge. Taking this new approach, our patients were getting better or not regressing at such a rapid pace. This new way of practicing was difficult at times. Often, we were not being reimbursed for the vital services that we were providing.
After the Jimmo ruling in 2013, we would now be reimbursed for the pro-bono work we had been performing. But in 2016, Medicare auditors began aggressively targeting our practices. These auditors claimed that our patients, with progressive MS, did not need skilled services to prevent further decline or to make gains. In one instance, an auditor who was a physician, suggested that our patients could simply go to a fitness center. Reasoning behind this aggressive campaign seemed removed from reality at times. We felt like Cinderella, in the sense that we were working very hard to keep Medicare beneficiaries out of the hospital. We were saving Medicare money and resources. Yet we were being viewed as bad actors doing something wrong just because we were following Jimmo, which is the law of the land. These aggressive efforts went on until recently. Two major audits, one that went all the way to an Administrative Law Judge (ALJ) and the other that went to a Qualified Independent Contractor (QIC), were both overturned. Almost 100% of the findings were in our favor. Jimmo was finally recognized, after 5 years of fighting audits that had unreasonable and preposterous justification.
The findings of the ALJ and QIC are bigger than our practices and patients alone. It sets precedent and establishes a path for more therapists to use Jimmo in the way that it was intended. Rehospitalization for those with chronic illness is very costly for Medicare. Now there is an opportunity for therapists to develop new models of care that take the burden away from the acute-healthcare-system, potentially breaking the cycle of rehospitalizations for these vulnerable populations. Since these rulings have come back in our favor, myself and my staff can focus on keeping our patients safely in their homes and communities. The Jimmo ruling is profound for many reasons. One, is that it gives therapists the necessary time to stabilize very sick patients. Another reason, is that it allows those treating therapists to continue with their care in an effort to prevent further decline. These patients are very vulnerable and many are not able to maintain gains achieved without their therapy teams.
Now that we have established the medical necessity of the care we provide, we can start to imagine the possibilities the Jimmo ruling may allow. Can Jimmo set a path for physical therapists or other therapy disciplines to act as primary caregiver for patients with chronic illness? Does the Jimmo ruling allow therapists to, over time, develop a new healthcare setting with a primary focus of keeping patients out of the hospital and in turn significantly decreasing hospital readmissions? Could the Jimmo ruling be part of the solution to help CMS address the insolvency it faces? These are all questions myself and my team can begin to think about and potentially answer. Only time will tell, but after 5 years of battling with the nonsensical nature of these auditors, the future is bright and exciting for my team but more importantly, for our patients. My hope is that other caregivers in our position will utilize Jimmo in the way it was intended.