On November 16, 2016, the Centers for Medicare & Medicaid Services (“CMS”) hosted a 2016 MLN Connects National Provider Call (“Provider Call”) for purposes of outlining the parameters of the 2016 Hospital Appeals Settlement Process, which CMS initially launched in August 2014 for certain eligible inpatient provider types. During the 2014 Hospital Appeals Settlement Process, CMS reported that it settled approximately 346,000 claims for 2,022 eligible hospitals.
Below are highlights from the Provider Call:
- Beginning December 1, 2016, CMS will reopen the settlement process for certain eligible inpatient status claims at the Administrative Law Judge or Departmental Appeals Board levels.
- The settlement process will enable eligible inpatient provider types to settle certain pending inpatient status claims for 66% of the net allowable amount in exchange for withdrawing the pending appeals subject to settlement. Note that under the 2014 Hospital Appeals Settlement Process, CMS proposed to settle pending claims for 68% of the net allowable amount.
- Providers have between December 1, 2016 and January 31, 2017 to submit an Expression of Interest to CMS requesting participation in the settlement process. After receipt of the Expression of Interest, CMS will generate a spreadsheet of all claims eligible for settlement. During the Provider Call, CMS representatives explained that CMS anticipates it will provide the spreadsheet of eligible claims within 7-10 days of receipt of the provider’s Expression of Interest. Providers will then be responsible for both validating the information contained in the spreadsheet and reconciling any differences with the provider’s internal records. The provider must notify CMS of any discrepancies within 15 days of receipt of the spreadsheet.
- The following provider types are eligible to submit an Expression of Interest: (1) Acute Care Hospitals (including those paid under the Prospective Payment System (“PPS”), Periodic Interim Payments, and Maryland waiver) and (2) Critical Access Hospitals.
- The following provider types are not eligible to submit an Expression of Interest: (1) Psychiatric Hospitals (paid under the Inpatient Psychiatric Facilities PPS); (2) Inpatient Rehabilitation Facilities (IRFs); (3) Long-Term Care Hospitals (“LTCHs”); (4) Cancer Hospitals; and (5) Children’s Hospitals.
- CMS emphasized during the Provider Call that eligible claims include those claims with dates of admission prior to October 1, 2013. Claims with dates of admission after October 1, 2013 are not eligible and will not be included in the settlement process.
CMS provides additional guidance concerning the 2016 Hospital Appeals Settlement Process here.