{"id":192,"date":"2018-04-26T07:00:20","date_gmt":"2018-04-26T07:00:20","guid":{"rendered":"https:\/\/advantagehcconsulting.com\/blog\/?p=192"},"modified":"2018-04-20T15:01:49","modified_gmt":"2018-04-20T15:01:49","slug":"appeals-weigh-new-appeal-options-carefully","status":"publish","type":"post","link":"https:\/\/advantagehcconsulting.com\/blog\/2018\/04\/26\/appeals-weigh-new-appeal-options-carefully\/","title":{"rendered":"Appeals: Weigh New Appeal Options Carefully"},"content":{"rendered":"
\"\"

Appeal<\/p><\/div>\n

Your ALJ success rate should factor into your decision, legal experts advise.<\/em><\/strong><\/span><\/p>\n

Don\u2019t forget that the Low-Volume Appeals route isn\u2019t the only way to speed your resolution of Medicare claims appeals. The\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>also has expanded its Settlement Conference Facilitation option.<\/p>\n

\u201cSCF is an alternative dispute resolution process at [the Office of Medicare Hearings and Appeals] that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals,\u201d the\u00a0Department of Health & Human Services\u00a0<\/strong>says on its website.<\/p>\n

To be eligible for SCF, the request must come from a Medicare provider\/supplier that hasn\u2019t filed for bankruptcy; involve request(s) for Administrative Law Judge hearing or Medicare Appeals Council review at the Departmental Appeals Board filed on or before Nov. 3, 2017; involve 500 or more appeals pending or more than $9,000 in billed charges; arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision; and have an amount per each individual claim of $100,000 or less.<\/p>\n

Plus:<\/span>\u00a0<\/strong>\u201cCertain appellants that have or have had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations will be ineligible,\u201d HHS adds.<\/p>\n

The program also excludes other types of appeals, including those seeking OMHA review of QIC dismissals or Council review of ALJ dismissals, notes the\u00a0National Association for Home Care & Hospice\u00a0<\/strong>in its provider newsletter.<\/p>\n

For SCF, \u201cit is not clear what terms will be offered to settle such claims,\u201d notes attorney\u00a0Brian Daucher\u00a0<\/strong>with law firm\u00a0Sheppard Mullin\u00a0<\/strong>in Costa Mesa, California, in online analysis. \u201cBut the conference is an opportunity to discuss, and so cannot hurt,\u201d Daucher allows.<\/p>\n

\u201cCMS\u2019 longstanding policy of refusing to negotiate overpayment findings has been a significant factor in clogging the appeals system,\u201d Daucher notes. \u201cWith no settlement options, each case must be decided on its merits, imposing a huge (indeed unmanageable) burden on the appeals system.\u201d The good news is that the SCF and LVAprograms \u201ccomprise a decent, if tentative, start,\u201d Daucher judges.<\/p>\n

Is Avoiding The Delay Worth It?<\/strong><\/span><\/p>\n

The SCF program \u201coffers providers an opportunity to potentially expedite a large number of outstanding claims by settling multiple large dollar claims through dispute resolution, rather than through the normal course of Medicare appeals,\u201d observe attorneys\u00a0Amy Hooper Kearbey\u00a0<\/strong>and\u00a0Nicholas Francis Alarif\u00a0<\/strong>with\u00a0McDermott Will & Emery\u00a0<\/strong>in online analysis. \u201cThus, if a provider opts for Settlement Conference Facilitation, in theory, the claims will not be subject to the extraordinary delays usually associated with the traditional Medicare appeals process.\u201d<\/p>\n

On the other hand:\u00a0<\/strong><\/span>\u201cThe claims will not receive review from an ALJ and will not receive an individualized hearing,\u201d Kearbey and Alarif point out. \u201cRather, OMHA acts as a facilitator between the provider and CMS in what amounts to a settlement negotiation.\u201d<\/p>\n

The \u201cnew programs from OMHA may offer some relief, and providers should carefully weigh their strategic options based on the nature of the claims and the associated disputes, the financial implications of waiting years for resolution, and whether the claims at issue are pre-payment denials, overpayments or a combination,\u201d Kearbey and Alarif advise. \u201cUltimately, the optimal strategy for a particular provider requires an individualized approach tailored to their specific circumstances.\u201d<\/p>\n

Tip:<\/span>\u00a0<\/strong>\u201cProviders should carefully analyse their pending appeals and prior success rates at the ALJ level to determine whether the settlement option is more advantageous than waiting for an ALJ hearing,\u201d recommend attorneys\u00a0Anna Grizzle\u00a0<\/strong>and\u00a0Julia Tamulis\u00a0<\/strong>with\u00a0Bass Berry & Sims\u00a0<\/strong>in online analysis.<\/p>\n

Note: See more details about the SCF option at\u00a0www.hhs.gov\/about\/agencies\/omha\/about\/special-initiatives\/settlement-conference-facilitation\/index.html<\/a>.<\/em><\/p>\n

Source- SuperCoder<\/span><\/i><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Your ALJ success rate should factor into your decision, legal experts advise. Don\u2019t forget that the Low-Volume Appeals route isn\u2019t the only way to speed your resolution of Medicare claims … Continue Reading →<\/a><\/p>\n","protected":false},"author":1,"featured_media":193,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18],"tags":[11,12,13,14],"class_list":["post-192","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-lawsuit","tag-home-care","tag-hospice","tag-ltc","tag-snf"],"_links":{"self":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/192","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/comments?post=192"}],"version-history":[{"count":1,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/192\/revisions"}],"predecessor-version":[{"id":194,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/192\/revisions\/194"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media\/193"}],"wp:attachment":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media?parent=192"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/categories?post=192"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/tags?post=192"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}