August 24, 2016

Reopening the 68-Percent Settlement: A Provider Speaks Out

By


Michelle McAdoo

Michelle McAdoo advocates for second chances – especially when it comes to the the Centers for Medicare & Medicaid Services’ (CMS’s) once-lauded 68-percent settlement, an option the agency no longer offers. 

“My position is to promote a second-chance option to those (providers) who passed the first time and simultaneously (to) sound the warning to all providers that the denial and appeal landscape, at least at the administrative law judge (ALJ) level, is just as treacherous and backlogged as we remember,” McAdoo wrote in a recent email to RACmonitor.  “We need to support each other.”

McAdoo is the RAC coordinator at Pardee UNC Hospital in Hendersonville, N.C. She is also a registered nurse and has a Master of Science degree and Bachelor of Science in Nursing degree.

“Our organization did participate in the initial settlement, in what now seems like decades ago,” she recalled. “We got a percentage of the recouped money, but more importantly, we were able to close those accounts for good and move forward.” 

McAdoo said she could imagine still managing all those cases, some dating back as far as 2009.  

“I certainly commiserate with the facilities that are now ruing their initial declination,” she added. “From the information I am able to gather, there is still significant backlog in the Office of Medicare Hearings and Appeals (OMHA), so from the peer/colleague point of view, I can appreciate the frustration they must be experiencing. They have, after all, continued to expend resources communicating and reporting, still with no reimbursement.” 

“If we consider the justification behind the (68-percent) settlement ‘way back when,’ it was to alleviate a problem resulting from too few ALJs and a disproportional amount of cases entering the system,” McAdoo continued. “Apparently, all those who removed their cases by accepting the settlement did little to open up docket time.”  

McAdoo reasons that as positive and promising as the OMHA solutions appeared to be, evidently they were not enough to “clear the slate,” in her words. 

“All providers should be extrapolating from this stagnation situation all manner of auditing (that) is rampant, and this is against the delusional backdrop of the Recovery Audit Contractors’ (RACs’) short stay (medical necessity) hiatus,” she said. “If and when the RACs commence, it will again be everyone’s quagmire.”  

Steven Greenspan, vice president of regulatory affairs for Optum Executive Health Resources, voiced his agreement. 

“Michelle raises an excellent point,” Greenspan told RACmonitor. “Our current situation poses a threat not only to those who still have appeals in the backlog, but to every provider, as new audits will begin to sprout in the very near future.” 

According to Greenspan, even those providers that availed themselves of the original settlement could quickly find themselves again in the same situation if the backlog is not addressed soon.  

“As Michelle points out, the cost to manage appeals, even if they are in a backlog situation, is not insignificant,” Greenspan warned.

Greenspan and healthcare attorney Andrew Wachler participated in an Aug. 9 special-edition RACmonitor broadcast on the 68-percent solution, during which a poll was conducted asking listeners whether their organization would consider participating in the 68-percent settlement if it were reopened.

The poll results from the respondents were interesting: 48 percent indicated that their organization would consider it; another 48 percent were unsure of their organization’s position regarding participation; and only 4 percent indicated that their organization would not participate.

“These results demonstrate that there is considerable interest in the provider community for reopening of the 68-percent settlement,” wrote Wachler, managing partner at Wachler & Associates. “The information gathered should assist CMS in concluding that doing so would reduce the backlog of appeals, thus allowing other providers to move through the appeals process more easily.” 

Furthermore, it will help CMS reduce the amount of interest that could have to be paid on the pending appeals. The 68-percent settlement is consistent with the currently active Settlement Conference Facilitation (SCF) pilot program, and it will help hospitals with pending appeals to resolve these claims in a more expedient matter, without waiting for an ALJ hearing.

If you are interested in the reopening of the 68-percent settlement, voice your support. Hospitals should organize to present a unified voice to CMS. 

Providers are invited to discuss this matter with their leadership and send any inquiries or opinions to Chuck Buck with RACmonitor at cbuck@panaceainc.com and Andrew Wachler at awachler@wachler.com

About the Author

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

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Chuck Buck

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

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