HHS Casts Larger Net to Reach Appellants and Reduce ALJ Backlog

Two new programs have significant potential in collectively effectuating a meaningful reduction in the appeals backlog.

In casting a larger net, the Office of Medicare Hearings and Appeals (OMHA) hopes to engage more providers and suppliers in settlement agreements as it seeks to improve the Medicare claims appeals process by expanding its current Settlement Conference Facilitation (SCF) program.

The announcement last week by the U.S. Department of Health and Human Services (HHS) comes on the reels of an announcement made in late December 2017, in which the agency announced that providers and suppliers with fewer than 500 appeals pending at OMHA and the Medicare Appeals Council could be eligible to participate in a new low-volume appeals (LVA) settlement offer. HHS, in its announcement last week, was quick to point out that this latest SCF offer is separate and distinct from the LVA, which was issued by the Centers for Medicare & Medicaid Services (CMS). 

SCF is an alternative dispute resolution process that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals. 

“OMHA’s prior SCF programs were attractive and popular opportunities for Medicare providers and suppliers to negotiate a settlement payout from CMS to achieve an efficient and expedited resolution to their pending, eligible appeals,” said healthcare attorney Andrew Wachler in an email to RACmonitor.

The prior SCF programs were more limited in scope, Wachler noted, applying only to Part A or Part B Medicare providers and suppliers, and to appeals involving administrative law judge (ALJ) hearing requests filed on or before specific dates in fall or winter of 2015.

According to Wachler, the expanded SCF applies to both Medicare Part A and Part B providers and suppliers, and both ALJ hearing and Council requests for review regarding eligible claims filed on or before Nov. 3, 2017. The most recently announced SCF expands both the scope of eligible participants and the scope of eligible claims.

“Under the Part A SCF, at least 50 claims and $20,000 had to be in controversy, and requests for (an) ALJ hearing had to be filed on or before  Dec. 31, 2015,” Wachler said. “Under the Part B SCF, at least 20 claims or at least $10,000 had to be in controversy … and the request for ALJ hearing had to be filed by Sept. 30, 2015.”

Wachler said this expansion of the SCF applies to appellants with 500 or more appeals pending at the ALJ or Council levels combined, or any number of appeals pending at the ALJ or Council levels combined if each appeal has $9,000 or more in billed charges. Under all three SCF programs, the value of each individual claim or extrapolated sample must be $100,000 or less.

“The expanded SCF program to be initiated in April 2018, in conjunction with the LVA settlement, has the potential to collectively resolve a large volume of the appeals backlog,” Wachler said. “Because these two alternative dispute resolution processes collectively appear to cover nearly every appeal under $100,000 that were pending with the ALJ or Council levels as of Nov. 3, 2017, we believe there should be few appeals that are not eligible for resolution under either the expanded SCF or the LVA settlement.”

Wachler urged Medicare Part A and Part B providers and suppliers to review “expeditiously” their pending appeals for eligibility, as the participation timeline for the LVA Settlement is limited.

“Appellants with NPI numbers that end in an even number have from Feb. 5, 2018 through March 9, 2018 to submit an expression of interest,” Wachler said. “Appellants with NPI numbers that end in an odd number have from March 12, 2018 through April 11, 2018 to submit an expression of interest. The expanded SCF is expected to open in April 2018.”

Wachler believes that as a result of the broad appellant and appeal eligibility criteria, these programs have significant potential in collectively effectuating a meaningful reduction in the appeals backlog.

Read the HHS/SCF announcement click here.