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CMS and OMHA Broaden Appeal Settlement Options

08 Nov

CMS and OMHA Broaden Appeal Settlement Options

On November 3rd, the Centers for Medicare and Medicaid Services announced on their website:

“…CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.”

The additional settlement option is referred to as the “low volume appeals settlement option (LVA)” and will be limited to appellants with a low volume of appeals pending at OMHA and the Council, the 3rd and 4th levels of the Medicare Appeals process, respectively. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined as of November 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met. CMS will settle eligible appeals at 62% of the net allowed amount.

CMS went on to also say that OMHA would separately be expanding the Settlement Conference Facilitation (SCF) Process for certain appellants that are not eligible for the LVA option. CMS posted a link to the section of the OMHA website regarding SCF for more information regarding this expansion. At this time, the SCF website states “Please continue to monitor this website for additional details about the SCF expansion in the coming weeks.”


Cain Outlook:
While more options to resolve denied claims mired in the Medicare appeals process appears mindful on the part of CMS, there are still too many unknowns with these new settlement options to get excited about positive outcomes for Providers. The criteria that was detailed by CMS in their announcement is potentially very stringent and the low settlement percentage of 62% does not encourage participation by Providers.

Cain has reached out CMS for clarification on the LVA criteria and are waiting on their response. We will continue to monitor these new settlement options and report on any developments as they happen. If you’d like more information on the official CMS announcement, please visit the links below:

Low Volume Appeals Settlement Announcement

Settlement Conference Facilitation Expansion

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