On February 25, 2016, the Office of Medicare Hearings and Appeals (OMHA) hosted a Medicare Appellant Forum for Part A and B providers and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers with important updates on management of the appeals backlog within OMHA, the Centers for Medicare & Medicaid Services (CMS) and Departmental Appeals Board (DAB) launch of the Appellant Public Portal, and the Phase III rollout of the Settlement Conference Facilitation (SCF) pilot program. OMHA’s initiatives aim to reduce the administrative burden associated with the hearing process and minimize the backlog of pending appeals to advance the disposition process.

Highlights from OMHA’s Medicare Appellant Forum include:

Increased functional capacity with funding from the FY 2016 Omnibus Bill. OMHA reported that the FY 2016 Omnibus Bill marks the greatest increase in funding OMHA has ever received. The budget will enable OMHA to hire additional teams and maximize its capacity.

Preparing for Launch of the Appellant Public Portal. OMHA believes that the Appellant Public Portal (Electronic Case Adjudication Processing Environment, or “ECAPE”) will have the greatest impact on the appellant community. The first ECAPE release is scheduled for Spring / Summer 2016 and aims to provide appellants with an opportunity to electronically file requests for hearing, submit electronic evidence, and electronically check on appeals status. ECAPE will provide appellants the opportunity to develop personalized user profiles and manage their appeals in a single electronic location. OMHA expects to expand ECAPE’s functionality during the second and third release phases, preliminarily scheduled for late Winter 2016 and Spring 2017, respectively.

DME QIC Demonstration Launched January 2016. The DME Qualified Independent Contractor (QIC) Demonstration provides an opportunity for appellants and the DME QIC to discuss appealed claims prior to the issuance of an Administrative Law Judge (ALJ) decision. During the process, the DME QIC will request missing documentation from the appellant, clarify existing Medicare policies, and explain to providers what information would yield a favorable reconsideration decision. If contacted to participate, providers are encouraged to work with the DME QIC because the process will (1) provide helpful information for providers that will ultimately reduce the number of claims submitted improperly and denied at the Medicare Administrative Contractor (MAC) level and (2) reduce the number of appeal receipts at the MAC, QIC and higher levels of appeal. The DME QIC Demonstration is explained in greater detail here.

Launching Phase III of the SCF pilot program. The SCF pilot program is an alternative dispute resolution process designed to bring both the appellant and CMS together to discuss a mutually agreeable resolution for claims appealed to the ALJ hearing level. Phase III of the SCF pilot program expands the pilot program to include certain Part A claims. Phase I and II of the SCF pilot program were limited to Part B claims. OMHA envisions that the process will help remove appeals from the backlogged queue in larger quantities.

Both Part A and Part B providers should understand that if they want an appeal to go through the SCF process, the eligibility requirements are extensive. The complete list of eligibility requirements for participation in the SCF pilot program may be found here. As a preliminary matter, if an appellant has already received a Notice of Hearing from the ALJ, the appeal is no longer eligible for participation in the SCF pilot program. We provide clarification and guidance on certain of the eligibility requirements below:

  • Appellant must be a Medicare provider or supplier (i.e., a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI) number). Acute care hospitals are eligible to request participation in the SCF pilot program. However, claims that were eligible for the CMS Part A Hospital Appeals Settlement option are ineligible for the SCF pilot program regardless of whether the provider in fact participated in the CMS settlement process. During the forum, OMHA clarified that there will be no exceptions to this eligibility condition.
  • The amount of each individual claim must be USD $100,000 or less, which is a statutory limit that cannot be modified. This eligibility requirement could be a concern when a provider appeals claims that are part of an extrapolated statistical sample. If the MAC deter mines that the extrapolated overpayment amount exceeds USD $100,000, the claims would be ineligible for the SCF pilot program.
  • OMHA clarified that, as a condition of eligibility, the provider must have at least fifty (50) pending claims totaling an amount in controversy of at least USD $20,000.To initiate the SCF process, appellants must submit an SCF Expression of Interest (only accepted via e-mail), which requests that OMHA run a preliminary report of the appellant’s pending appeals. OMHA establishes the preliminary report and spreadsheet listing those appellant claims that are eligible to participate in the SCF pilot program and requests CMS’s participation. While OMHA runs the preliminary report, the provider is ultimately responsible for confirming that the report and spreadsheet capture all SCF-eligible claims.Providers should enter the SCF process with the expectation of reaching, finalizing, and signing a settlement agreement with CMS on the same day. When agreement is reached, a settlement conference facilitator will draft a settlement agreement, which must be signed by both parties on the same day of negotiations. If agreement is not reached, appealed claims will return to their appropriate position in the queue – i.e., if appealed claims were assigned to an ALJ, these claims will return to the same ALJ, or if appealed claims were not assigned to an ALJ, these claims will go back to their original place in the queue for assignment. Providers should not be concerned that they will lose their place in line for electing to participate in the SCF pilot program.

 

*Blake Walsh is admitted only in Tennessee. Her practice is supervised by principals of the firm admitted in the District of Columbia.