Providers should rely on settlement and facilitation processes when resolving Medicare audit appeals, according to a Health Care Compliance Association (HCCA) webinar presented by health care attorney Andrew Wachler of Wachler & Associates, P.C. In addition to providing advice regarding appeal processes and strategy, Wachler encouraged providers to rely on the newly reopened hospital appeals settlement process and the Settlement Conference Facilitation (SCF) Pilot.
CMS reopened the hospital appeals settlement process, allowing eligible hospitals to settle inpatient status claim appeals in exchange for timely partial payments (66 percent of net allowable amount). The settlement process is available, as of December 1, 2016, and the deadline for hospitals to submit an expression of interest is January 31, 2017. Eligible claims include claims denied by CMS on the basis that services may have been reasonable and necessary while treatment on an inpatients basis was not. Additionally, the settlement applies to claims with dates of admission prior to October 1, 2013.
In his discussion of the SCF pilot process, Wachler admonished listeners: “don’t wait, facilitate.” The SCF pilot was designed to bring CMS and an appellant together to discuss the potential for settlement of claims appealed to an administrative law judge (ALJ). When a settlement cannot be reached under the process, claims return to the ALJ level. Under Phase I of the program, which began in June 2014, the pilot facilitated settlements of Medicare Part B claim appeals, for ALJ hearing requests filed in 2013. In Phase I, the pilot resolved over 2,600 unassigned Part B ALJ Appeals. Phase II expanded the pilot in October 2015 for additional Part B claims and the program was further expanded for Part A claims in February 2016. However, each phase imposed specific claim eligibility requirements, regarding the kinds of claims at issue and the amount in controversy. Wachler noted, unlike the hospital settlement process, which mandates a 66 percent settlement rate, the SCF pilot allows providers to reach an agreement regarding the amount of the settlement.
In circumstances where settlement or facilitation is not available, providers may be forced to resolve claims before an ALJ. Wachler offered the following best practices for ALJ appeals:
- prominently list Medicare Appeal Number on the request;
- ensure beneficiary information matches Medicare Appeal Number;
- list beneficiary’s full identification number;
- include first page of the qualified independent contractor (QIC) decision or prominently list full name of the QIC;
- document proof of service to other parties;
- do not submit a courtesy copy to the QIC
- submit only one request per Medicare Appeal Number;
- mail requests via tracked mail to the Office of Medicare Hearings and Appeals (OMHA) Central Operations;
- do not submit evidence already submitted at a lower level;
- do not attach evidentiary submissions or submit additional filings to OMHA Central Operations; and
- submit directly to the ALJ when an ALJ is assigned.
Additionally, Wachler recommended the OMHA case-processing manual as an important resource regarding ALJ process for any parties appealing to the ALJ level.