Updated on: August 17, 2018

Deadline Quickly Approaching for Appellants to Consider Low-Volume Appeal Initiative

Original story posted on: April 18, 2018

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June 8, 2018 is the deadline for participation.

Like watching the sunset approach the horizon, time is running out for hospitals and health systems weighing their participation in new initiatives being offered by the Office of Medicare Hearings and Appeals (OMHA) to settle backlogged claims at the Administrative Law Judge (ALJ) level of the Medicare appeals process.

Among the new initiatives from OMHA is the low-volume appeals category, but the deadline to request participation is June 8. Other new initiatives include the Office’s expanded Settlement Conference Facilitation (SCF) program, the statistical sampling initiative, and the qualified independent contractor (QIC) formal telephone discussion demonstration.

“Due to the backlog of pending appeals, it may take years before a provider or supplier has a hearing at the ALJ level of the Medicare appeals process,” said Andrew Wachler, a healthcare attorney. “The special initiatives are part of a growing effort to reduce the backlog.”

According to Wachler, managing partner at Wachler and Associates, Medicare providers and suppliers should understand the new initiatives, evaluate and assess the eligibility of their appeals under these programs, and consider how these programs may impact appeals strategy.

“Although there is no guarantee that you may be accepted in any particular settlement option, it is likely that most providers will have the opportunity to exercise the option of their choice,” Wachler said. “The outcome is likely to result in a lump sum payment agreed to by the provider, as opposed to utilizing valuable resources at the ALJ hearing level over the next several years.”

Wachler said there is little downside in moving forward with one of these options. In fact, with the SCF option, appellants are not required to accept a settlement unless they agree to it at the time.

With respect to the low-volume appeal option, Wachler said it also includes claims at the Medicare Appeals Council level, as well as medical necessity denials for surgical procedures as long as the value of those procedures is less than $9,000.

“The low-volume appeal settlement, the SCF settlement, and the statistical sampling initiative would apply to both inpatient and outpatient appeals,” Wachler said. “With regard to settlement options, providers would have to waive any 935 interest that would be due to them if they were successful at the ALJ level.”

On a cautionary note, Wachler said that if there is any question with regard to whether the Medicare Administrative Contractor (MAC) processes claims at the right payment, a provider would waive their right to appeal the payment determination.

As reported recently by RACmonitor, on March 30, 2018, the Centers for Medicare & Medicaid Services (CMS) extended the deadline for providers to submit an expression of interest for the low-volume appeals initiative. That deadline is June 8.


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Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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