CMS Expands Appeals Settlement Efforts

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The Centers for Medicare & Medicaid Services (CMS) announced that as part of the commitment by the Department of Health & Human Services to improve the Medicare claims appeals process, the Office of Medicare Hearings and Appeals (OMHA) will expand its current Settlement Conference Facilitation (SCF) program to reach more providers and suppliers. SCF is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals.

SCF is separate from CMS' Low Volume Appeals (LVA) Settlement Option, which CMS announced in February, and for which expressions of interest are to be received by June 8. 

Eligibility criteria for the SCF program includes the following:

·        The appeals must involve request(s) for Administrative Law Judge (ALJ) hearing or Medicare Appeals Council (Council) review filed on or before November 3, 2017, with 500 or more appeals pending at OMHA and the Council combined, or with any number of appeals pending at OMHA and the Council that each have more than $9,000 in billed charges

·        The request(s) for ALJ hearing and/or Council review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision

·        All jurisdictional requirements for OMHA or Council review must be met for the eligible appeals

·        All pending OMHA and Council appeals associated with a single NPI and corresponding Provider Transaction Access Number must be included in the SCF

·        Appeals must not be scheduled for an ALJ hearing or an ALJ hearing must not have been conducted

·        The amount of each individual claim must be $100,000 or less (for the purposes of an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less)

·        Appeals must not be involved in OMHA's Statistical Sampling Initiative

·        The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration

CMS has not announced what terms will be offered to settle the claims.

To see the complete list of eligibility requirements, visit www.hhs.gov and search for SCF.

Questions about the SCF program can be emailed to OMHA.SCF@hhs.gov.