CMS: Low Volume Appeals Settlement Initiative

January 17th, 2018 / By Barbara Aubry, RN

I attended the January 9, 2018 CMS Medicare Learning Network conference call covering the logistics of the settlement process offered by CMS for providers with pending appeals. This impacts:

“The low volume appeals (LVA) settlement option will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at the Office of Medicare Hearings and Appeals (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”

According to CMS, this initiative was established in an effort to improve the Medicare appeals process. This is an additional settlement option for providers and suppliers with appeals pending at OMHA and the Medicare Appeals council at the Department Appeals Board – “third and fourth” level appeals.

CMS covered the eligibility and other requirements to participate in this settlement:

  • Part A or Part B providers with third and/or fourth level appeals totaling less than 500 open Fee-for-Service cases (Part C and Medicaid appeals do not qualify).
  • Billed amount of the claim under appeal is capped at $9,000 – or less, pending as of Nov 3, 2017.
  • The option will allow for settlement of the outstanding appeal in exchange for timely partial payment of 62 percent of the net approved amount of the appeal (not the billed amount).
  • To participate, all eligible appeals must be settled; providers may not choose to settle some and not others.
  • Failure to reply to or complete administrative paperwork within the allotted 15 days windows will result in CMS removing a provider from the settlement process.
  • Providers may begin the process and then decide they want to opt out, but that means that all eligible appeals will not be settled under the LVA settlement.
  • Payment will be made to providers 180 days after CMS counter signs the settlement agreement.
  • CMS is imposing a 15-day turnaround for providers to submit administrative information via excel spreadsheet format. Failure to meet the turnaround dates can result in loosing eligibility for the settlement process. However, CMS understands that unforeseen events can arise and is willing to work with providers who keep lines of communication open.

CMS Specifics

Eligibility

An appellant (You) may be eligible if:

  • You are a Medicare Part A or Part B provider, physician, or supplier.
  • You have less than 500 appeals across all your associated National Provider Identifiers (NPIs) pending in total as of November 3, 2017 at both OMHA and the Council levels of review.

An appellant (You) are not eligible if:

  • You are a beneficiary, enrollee, their family member, or estate
  • You are a State Medicaid Agency
  • You are a Medicare Advantage Organizations (Medicare Part C) or Part D sponsor
  • You are currently in bankruptcy or expect to file for bankruptcy

Certain appellants may be excluded from this settlement opportunity based on False Claims Act litigation or investigations, or other program integrity concerns, including pending civil, criminal, or administrative investigations.

An appeal is eligible if:

  • The appeal was pending before the OMHA and/or Council level of appeal as of November 3, 2017.
  • The appeal has a total billed amount of $9,000 or less.
  • The appeal was properly and timely filed at the OMHA or Council level as of November 3, 2017.
  • The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system (this is important – line item denials on otherwise paid claims are not eligible).
  • The claims included in the appeal were submitted for payment under Medicare Part A or Part B (Part C and Medicaid are not eligible for this settlement).
  • The claims included in the appeal were not part of an extrapolation.
  • As of the date the executed Administrative Agreement (Agreement) is fully executed, the appeal was still pending at the OMHA or Council level of review (important – the billed amount is $9,000 or less rather than the eligible payment amount).

Initiating Settlement

The settlement can be initiated by submitting an Expression of Interest (EOI)  during the allotted submission timeframes below:

  • Appellants with NPIs ending in an even number (0, 2, 4, 6, 8), EOIs will be accepted between February 5, 2018 and March 9, 2018
  • Appellants with NPIs ending in an odd number (1,3,5,7,9), EOIs will be accepted between March 12, 2018 and April 11, 2018 (important – if you have multiple NPIs ending in both odd and even numbers, you will need to initiate separate settlements following the dates specified above)

Note: Submission of an EOI outside the above defined timeframes will result in rejection of the EOI and request to resubmit during the allotted timeframe.

Settlement Process

Once CMS receives the EOI they will take the following steps:

  • Verify you submitted during the allotted timeframe, meet appellant eligibility criteria, and have eligible appeals. If you don’t meet eligibility criteria, CMS will notify you within 30 days of submitting your EOI, along with instructions on how to dispute eligibility decision via the Eligibility Determination Request process.
  • If you pass the eligibility review, you will receive an Administrative Agreement (Agreement) and Spreadsheet of potentially eligible appeals (Spreadsheet) within 30 days of submitting their EOI.

Once you receive the Agreement and Spreadsheet and agree with the Spreadsheet, sign the associated Agreement and send it to CMS within 15 days of receipt of the Spreadsheet and Agreement.

If you are not in agreement with the Spreadsheet, submit an Eligibility Determination Request (EDR) to request appeals be added or removed from the spreadsheet within 15 days of receipt of the Spreadsheet and Agreement.

Settlement Process-Eligibility Determination Request

The Eligibility Determination Request (EDR) can be used to dispute appellant and/or appeal eligibility

  • The EDR template with instructions is available here.
  • The completed EDR should be submitted to CMS within 15 days of CMS’ appellant eligibility decision.
  • CMS will notify you of their final appellant eligibility decision within 30 days.

CMS will countersign the Agreement.

A copy of the fully executed Agreement will be sent to you once signed by CMS. At this point, your appeals included in the Spreadsheet are removed from the appeals process and a copy of the fully executed Agreement is sent to your associated MAC for final eligibility verification, and pricing.

There is a possibility that during the final validation, appeals and associated claims may be removed from settlement for not meeting eligibility criteria; you will be notified if this occurs.

Payment will be made within 180 days of CMS’ signature on the Agreement.

The appeals associated with settled claims are dismissed, and appeals associated with unsettled claims, if any, are returned to their position in the appeals queue to continue in appeals process.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.


Resources:

FAQs will be updated regularly 

LVA Website

LVA Email address for submissions: CMSMedicareAppealsSettlement@cms.hhs.gov

Email address for questions: MedicareSettlementFAQs@cms.hhs.gov.

OMHA’s Settlement Facilitation Conference

Conference call slides