Do you have appeals pending in the Medicare appeals process? Are you aware there is a new option in Medicare Appeals if you meet certain criteria? There is a good possibility that many therapy providers that went over the $3700 therapy thresholds and were denied have reviewed their medical documentation and made a decision regarding appeals. For most therapy providers the $3700 manual medical review process was the first time therapy records were reviewed. The process of getting feedback on denials is challenging enough without having to put up with the other inconveniences surrounding submission of medical records for review: claims of records not being received, claims of records being received late, claims of records that were incomplete, as well as host of other reasons.
Office of Medicare Hearings and Appeals (OMHA) chief Judge, Nancy Griswold, has announced a new project that will be managed through the OMHA system in a mediation fashion. Sounds good, doesn’t it, what’s the hitch?
New Option in Medicare Appeals – Settlement Conference Facilitation Pilot
The Settlement Conference Facilitation Pilot was described as (Source: Senate Committee Reports) “an alternate dispute resolution process designed to bring the Centers for Medicare & Medicaid Services (CMS) together with providers to agree on a resolution to claims pending at the ALJ level.”
A fact sheet prepared by OMHA will be of interest to those providers considering participating in the Settlement Conference Facilitation Pilot. Highlights of the process of interest to rehab providers:
A request for hearing must appeal a Qualified Independent Contractor (QIC) reconsideration of a claim for Medicare Part B items or services;
- The appellant must be a Medicare provider or supplier;
- The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration;
- All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims;
- The request for hearing must have been filed in 2013 and not be currently be assigned to an Administrative Law Judge;
- The amount of each individual claim must be less than $100,000. For the purposes of an extrapolated statistical sample, the extrapolated amount must be less than $100,000.
- At least 20 claims must be at issue, or at least $10,000 must be in controversy if fewer than 20 claims are involved;
- There cannot be an outstanding request for OMHA statistical sampling for the same claims; and
- The request must include all of the appellant’s pending appeals for the same item or service at issue that meet the SCF criteria.
The new option was discussed in the U.S. Senate’s Special Committee on Aging Roundtable last week, as well as in testimony before the U.S. House of Representatives Committee on Oversight and Government Reform and its Subcommittee on Energy Policy, Health Care & Entitlements (whew!). RAC Monitor has filed a special report on the topic here, and the Monitor Monday panel will be interview Chief Judge Nancy Griswold on a special Monitor Monday live broadcast – please join me for this event. IN addition to the Fact Sheet, OMHA has provided a number of other documents that you will need to participate in the Settlement Conference Facilitation Pilot.
Do you have appeals pending from 2013? Are they Part B appeals that meet the criteria? Are you giving strong consideration to participating in the Settlement Conference Facilitation Pilot?
Photo: Robert Reukema via CompFight