CMS Low Volume Appeals Initiative

News

Beginning February 5, 2018, CMS will start accepting Expressions of Interest (EOIs) for a limited settlement agreement option for Medicare Fee-For-Service providers, physicians, and suppliers (appellants) with fewer than 500 appeals pending at the Office of Medicare Hearing and Appeals (OMHA) and the Medicare Appeals Council (Council) at the Departmental Appeals Board.

Specifically, CMS will make available an administrative settlement process for appellants with fewer than 500 appeals pending at OMHA and the Council, combined, as of November 3, 2017, to settle the portion of their pending appeals that have total billed amounts of $9,000 or less per appeal in exchange for timely partial payment of 62% of the net Medicare-approved amount.

To begin the process, appellants must complete and submit an Expression of Interest (EOI) as explained below.

Eligibility

Eligible appellants are:

Medicare Part A and Part B providers, physicians, and suppliers with fewer than 500 appeals pending at OMHA and the Council, combined, and that do not fit into one or more of the categories of “ineligible appellants” listed below.

Ineligible appellants are:

  • Beneficiaries, enrollees, their family members, or estates.
  • State Medicaid Agencies.
  • Medicare Advantage Organizations (Medicare Part C).
  • Those that filed for bankruptcy or expect to file for bankruptcy.
  • Certain appellants that have or have had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations.

Eligible appeals are appeals meeting all of the following criteria: 

  1. The appeal was pending before the OMHA and/or Council level of appeal as of November 3, 2017;
  2. The appeal has a total billed amount of $9,000 or less;
  3. The appeal was properly and timely filed at the OMHA or Council level as of November 3, 2017;
  4. The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system;
  5. The claims included in the appeal were submitted for payment under Medicare Part A or Part B;
  6. The claims included in the appeal were not part of an extrapolation; and,
  7. As of the date this Agreement is fully executed, the appeal was still pending at the OMHA or Council level of review.

If an appellant’s National Provider Identifier (NPI) is approved for participation in this process, the resulting settlement will apply to all eligible appeals from that appellant. The appellant cannot choose to settle some eligible appeals but not others.

Settlement Process

The detailed settlement process is outlined in the Downloads section below.

The settlement process is initiated by the appellant submitting their Expression of Interest (EOI) to CMS at MedicareAppealsSettlement@cms.hhs.gov. Appellants with multiple NPIs will be required to submit one EOI per NPI with eligible appeals.

If the appellant is approved for participation, CMS will send the appellant (1) a Spreadsheet of potentially eligible appeals and the associated claims (Spreadsheet) for the appellant’s review; and (2) an Administrative Agreement (Agreement).  The appellant will validate the Spreadsheet and sign and return the Agreement to CMS. CMS will counter sign and send a copy of the fully executed Agreement to the appellant.

If, during validation, the appellant discovers discrepancies on the Spreadsheet, the appellant must notify CMS by submitting an Eligibility Determination Request (EDR) to CMS at MedicareAppealsSettlement@cms.hhs.gov within 15 calendar days of receiving the package containing the Spreadsheet and Agreement.

CMS and the appellant have 30 days to resolve any discrepancies. If discrepancies are resolved, the appellant will sign and return the Agreement to CMS. CMS will counter sign and send a copy of the fully executed Agreement to the appellant.

At any time prior to the appellant returning the signed Agreement, the appellant may withdraw from the process and will retain full appeal rights. Proceedings on all eligible pending appeals will be stayed once the appellant returns the signed Agreement.

Expression of Interest Period 

To ensure timely processing, CMS has designated specific EOIs submission windows, based on NPI.

  • For appellants with NPIs ending in an even number (0, 2, 4, 6, 8), EOIs will be accepted on February 5, 2018 through March 9, 2018.
  • 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.
  • For all appellants, EOIs will be accepted between April 12, 2018, and June 8, 2018.

Appellants with both odd and even NPIs will be required to submit one EOI per NPI during the appropriate designated timeframe, as described above.

To request participation in the process, appellants must complete the EOI and submit it to MedicareAppealsSettlement@cms.hhs.gov.

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