The Department of Health and Human Services (HHS) recently announced several updates to its Medicare Part A and Part B appeals processes, including the following:
- An expanded Settlement Conference Facilitation for claims appealed to the Office of Medicare Hearings and Appeals (OMHA) level or the Medicare Appeals Council (Council) level of the Medicare claims appeals process;
- A voluntary appeals settlement option for certain pending Inpatient Rehabilitation Facilities (IRF) appeals; and
- An expansion of the QIC Telephone Discussion and Reopening Process Demonstration to home health and hospice-related appeals.
Any beneficiary or their designated representative, provider, or supplier that was party to the claim may appeal a Medicare claim denial by requesting a redetermination after an initial determination is made. The Medicare Part A and Part B claims denials appeal process consists of five levels, which include the following:
- Redetermination by a Medicare Administrative Contractor (MAC)
- Reconsideration by a Qualified Independent Contractor (QIC)
- Decision by the Office of Medicare Hearings and Appeals (OMHA)
- Review by the Medicare Appeals Council (Council)
- Judicial review in Federal District Court
First, the OMHA recently announced an appeals process update that expanded Settlement Conference Facilitation (SCF) to all eligible Part A and Part B claims filed by or before March 31, 2019. SCF is an alternative dispute resolution designed to allow Part A and Part B providers and suppliers and the Centers for Medicare & Medicaid Services (CMS) to discuss a mutually agreeable resolution of appealed claims with a neutral OMHA employee. However, SCF is separate and distinct from CMS’s offered settlement options. To qualify for SCF consideration, an appeal must not be actively engaged in another CMS Medicare appeals initiative, including the QIC Demonstration Project and the CMS Serial Claims Initiative. The claim must also arise from a QIC reconsideration decision. Appeals that have been scheduled or conducted for an Administrative Law Judge (ALJ) hearing or that have been involved in OMHA’s Statistical Sampling Initiative are not eligible for SCF. Settlement agreements with any individual claims or extrapolated overpayments over $100,000 will require Department of Justice (DOJ) approval prior to executing the settlement.
The OMHA also removed the cap on dollar amounts allowed in SCF. Previously, the dollar amount was capped at $1 million in extrapolated overpayments. In addition, OMHA is now offering SCF Express for providers and suppliers whose appeals have billed less than $100,000 in total or that have an extrapolated overpayment that is $100,000 or less. SCF Express appeals are not given the option of a settlement conference and instead are given a settlement offer by CMS based on the preliminary data available. Appellants with less than $10,000 in total billed charges may not participate in SCF and may only utilize SCF Express.
CMS also announced a voluntary appeals settlement option for certain pending Part A IRF appeals. As of June 17, 2019, CMS will accept Expressions of Interest (EOIs) for qualified pending settlements that have not exhausted appeal rights for IRF-related claims at the MAC, QIC, OMHA and/or Council levels and that have filed for redetermination with the MAC no later than August 31, 2018. Additionally, claims that were part of an extrapolation are not eligible for the settlement option. For eligible appeals, CMS will pay 69 percent of the net payable amount for all claims associated with pending IRF appeals that do not meet special criteria. CMS will pay 100 percent of the net payable amount of the appealed claim(s) for the following two categories:
- When the claim was denied solely because “justification for group therapy was not documented in the medical record”; or
- When the claim was denied based solely on patients not satisfying the threshold of therapy time in the absence of a more comprehensive medical necessity review.
The appellant must accept the resulting settlement for all eligible appeals and may not choose to appeal other eligible claims if chosen to participate in the EOI process.
Additionally, CMS has expanded the QIC Telephone Discussion and Reopening Process Demonstration (Demonstration) to home health and hospice (HHH)-related appeals within MAC Jurisdictions J6 and J15 as of May 1, 2019. Now, all eligible providers and suppliers may participate in a recorded telephone discussion regarding appealed claims with the QIC prior to the QIC rendering a decision. The discussion will allow suppliers to submit any missing or critical documentation that the QIC has identified necessary to support a favorable resolution. Suppliers may also learn Medicare coverage policies, root causes of denials, and documentation trends that are critical to the outcome of appeals by voluntarily participating in telephone discussions. Hospital discharge reviews, reconsiderations for service termination, and claims or providers that are already involved in another CMS initiative are not eligible for telephone discussions and/or reopenings under the Demonstration.
Under the Demonstration, the QIC is also analyzing previously completed unfavorable reconsideration decisions issued on or after January 1, 2013, to identify potential appeals that can now be favorably resolved through the reopening process. The QIC is further granted authority to conduct reopenings on previously adjudicated unfavorable claims that are currently pending ALJ assignment at OMHA, and/or that have been decided by the QIC, but not yet appealed to OMHA.
More information regarding the SCF process is available at:
More information regarding the IRF appeals process is available at:
More information regarding expansion of the Demonstration process is available at: