Medicare Compliance & Reimbursement

Settlements will only include a 62 percent partial recoupment.

The Medicare claims appeals process can be a major headache. However, thanks to a new CMS program, providers with fewer than 500 Medicare appeals pending can fast track through the sometimes cumbersome and complicated ordeal.

Review: This past fall, CMS announced a new accelerated option for 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 Medicare Appeals Council at the Departmental Appeals Board (known informally as the Council), combined, as of Nov. 3, 2017, with a total billed amount of $9,000 or less per appeal (see Medicare Compliance and Reimbursement, Vol.43, No. 22). The reasoning for the program was to alleviate the staggering "backlog" of Medicare appeals currently bogging down the agency.

Now: CMS began accepting Expressions of Interest (EOIs) on Feb. 5 for "Medicare Fee-For-Service providers, physicians, and suppliers (appellants)" under its new program called the Low-Volume Appeals Initiative (LVA), says the agency. But, the expedited appeals process does have a catch - eligible appeals will only be settled at "62 percent of the net allowed amount," which is non-negotiable, CMS notes.

However, the LVA reduced settlement may not sit well with ever appellant, say industry groups. "Interested providers may want to assess their eligibility for the settlement and the value for them of participating," warns the American Hospital Association (AHA) in a Feb. 15, 2018 release on the subject.

Legal experts agree and caution interested providers to weigh the benefits, but to do so quickly. "Considerations should include a review of the substantive strength of their Medicare appeals, the relative impact of a 62 percent reimbursement on the subject appeals, the time value of expedited payment, and whether another alternative Medicare appeals program may be a better fit," advise attorneys Amy Hooper Kearbey and Nicholas Francis Alarif of McDermott Will & Emery out of the Washington D.C. office in online analysis of the LVA options.

Know the Eligibility Details and Timeframes

There will be two rounds of EOIs, which are dependant on your National Provider Identifier (NPI). Appellants with NPIs "ending in an even number (0, 2, 4, 6, 8)" have the option of submitting EOIs now through March 9, 2018, CMS says in a newly updated Frequently Asked Question set about LVA. "For appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), EOIs will be accepted on March 12, 2018 through April 11, 2018," the guidance indicates.

In order to qualify for the LVA option, your appeals must meet certain CMS requirements. Take a look at this checklist garnered from information in the LVA's Frequently Asked Questions section before you proceed:

• The submitted claims are for Medicare Part A or B only.
• The billed amount of the appeals must be $9,000 or less.
• Providers with fewer than 500 appeals pending across all NPIs are eligible to apply.
• The appeals were pending at OMHA and/or the Council as of Nov. 3, 2017 and were properly filed in a timely manner by that date.
• The claims were denied by a MAC and are still in a denial status in the system.
• The included claims in the appeal are not part of an "extrapolation."
• When the "administrative agreement" is finally processed, the appeal must still be under review by OMHA and/or the Council.

Exclusions: Appellants can be excluded for a variety of reasons even if they do meet all the eligibility requirements. Those Medicare Part A and B providers under "False Claims Act litigation or investigation" or who have "filed for bankruptcy" will be excluded from the LVA option and will be notified by letter that they cannot participate, CMS guidance suggests.

If you are interested in the LVA Initiative, the agency will conduct a Medicare educational call on Tuesday, March 13, 2018. The call will cover LVA's "current status, and how the settlement process works," the agency says. "CMS speakers discuss how to identify whether you are eligible, which of your pending appeals may be settled, and upcoming submission timeframes."

Register at https://blh.ier.intercall.com/.

Resource: To review CMS's guidance on the LVA Initiative, visit www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Appeals-Settlement-Initiatives/Low-Volume-Appeals-Initiative.html.