Published on:

OMHA Expands the Settlement Conference Facilitation Pilot to Part A Claim Appeals

The Office of Medicare Hearings and Appeals (OMHA) recently announced its Phase III expansion of the Settlement Conference Facilitation (SCF) pilot program. The SCF pilot was originally launched in July 2014 to provide an alternative dispute resolution process for eligible Medicare providers to settle appealed Medicare claim denials pending at the Administrative Law Judge (ALJ) level of the Medicare appeals process. Under the SCF pilot, Medicare providers have the opportunity to enter into open settlement discussions with the Centers for Medicare & Medicaid Service (CMS) with the goal of coming to a mutually agreed upon resolution for the pending ALJ claims. Initially, the program was limited to Part B claims that met specific eligibility criteria. In October 2015, OMHA implemented Phase II of the SCF pilot, which expanded the eligibility requirements for Part B claims. Recently, OMHA announced that it will open Phase III of the SCF pilot, expanding the program to Part A claim appeals. Much like the previous phases, OMHA has provided eligibility requirements for participating in the SCF pilot, which include:

  • The appellant must be a Medicare provider (for the purposes of this pilot, “appellant” is defined as a Medicare provider that has been assigned a National Provider Identifier (NPI) number);
  • A request for hearing must appeal a Medicare Part A Qualified Independent Contractor (QIC) reconsideration decision;
  • 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 ALJ must be met for the request for hearing on all appealed claims;
  • The request for hearing must not be scheduled for an ALJ hearing;
  • The request for hearing must have been filed on or before December 31, 2015;
  • The amount of each individual claim must be $100,000 or less (for the purposes of an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less);
  • At least 50 claims must be at issue and at least $20,000 must be in controversy;
  • The request must include all of the appellant’s pending appeals for the same item or service at issue that meet the SCF criteria. For example, if an appellant has 50 hospice appeals pending that meet the requirements above, the appellant must submit a request for SCF for all 50 hospice appeals.
  • The appellant has not filed for bankruptcy and/or does not expect to file for bankruptcy in the future; and
  • The appellant has received an Office of Medicare Hearings and Appeals Settlement Conference Facilitation Preliminary Notification stating that the appellant may request SCF for the claims identified in the SCF spreadsheet. An appellant may not formally request a settlement conference until receiving this notice, but an appellant can initiate the process by filing its expression of interest.

More information on the SCF pilot can be found on OMHA’s website. In addition, OMHA is hosting a Medicare Appellant Forum to provide the appellant community with the current status, program updates, and initiatives regarding appeals at the ALJ level of the Medicare appeals process. The OMHA Appellant Forum will also be providing information pertaining to the SCF Phase III rollout. The OMHA Medicare Appellant Forum will take place on February 25, 2016, at 1:00pm-4:00pm EST. Interested attendees can still register for the event.

Wachler & Associates has already participated in multiple settlement negotiations on behalf of health care providers under the SCF pilot program. We will also be attending the OMHA Medicare Appellant Forum to ensure our experienced attorneys are up-to-date on all matters related to the SCF program and ALJ appeals. If you or your health care entity needs assistance in pursuing the SCF program or appealing Medicare claim denials, or if you have any questions relating to the SCF program, please contact an experienced healthcare attorney at (248) 544-0888, or via email at wapc@wachler.com.