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OMHA Expands Settlement Conference Facilitation (SCF) Program

CMS has announced that the Office of Medicare Hearings and Appeals (OMHA) will be expanding its current Settlement Conference Facilitation (SCF) program to reach additional providers and suppliers. SCF is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals. The SCF process is designed to bring the appellant and the Centers for Medicare & Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the third level of the Medicare claim appeals process.  If a resolution is reached, a settlement document is drafted by the settlement conference facilitator and the document is signed by the appellant and CMS at the settlement conference session.  As part of the agreement, the request(s) for an ALJ hearing for the claims covered by the settlement will be dismissed.

Note: SCF is separate and distinct from the Centers for Medicare & Medicaid Services’ (CMS) Low Volume Appeals (LVA) Settlement Option. For more information about LVA, please visit https://go.cms.gov/LVA or contact CMS with questions at MedicareSettlementFAQ@cms.hhs.gov.

Medicare Part A and Medicare Part B providers and suppliers who have OMHA or Medicare Appeals Council (Council) appeals pending may be eligible to participate in the expanded SCF process.  To be eligible, providers must meet the following eligibility criteria:

  1. The appellant must be a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI));
  2. The appellant cannot have filed for bankruptcy and/or expect to file for bankruptcy in the future;
  3. The provider or supplier must not 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.

SCF Appeals Eligibility Criteria will include the following:

  1. The appeals must involve request(s) for Administrative Law Judge (ALJ) hearing or Council review filed on or before November 3, 2017;
    • With a total of 500 or more appeals pending at OMHA and the Council combined; or
    • With any number of appeals pending at OMHA and the Council that each have more than $9,000 in billed charges;
  2. The request(s) for ALJ hearing and/or Council review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision;
  3. All jurisdictional requirements for OMHA or Council review must be met for the eligible appeals;
  4. All pending OMHA and Council appeals associated with a single NPI and corresponding Provider Transaction Access Number (PTAN) must be included in SCF;
  5. Appeals must not be scheduled for an ALJ hearing or an ALJ hearing must not have been conducted;
  6. 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);
  7. Appeals must not be involved in OMHA’s Statistical Sampling Initiative;
  8. The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration;
  9. Appeals must not involve items, services, drugs, or biologicals billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes (e.g., CPT Code 38999 Unlisted procedure, hemic or lymphatic system; K0108 Wheelchair component or accessory, not otherwise specified);
  10. Appeals must not involve payment disputes (e.g., the appellant was paid as billed, in full, by the contractor, but the appellant believes the fee schedule or contractor price amount is insufficient payment);
    • Appeals arising from down coding of claims are eligible for SCF.
  11. Appeals must not arise from a QIC or ALJ dismissal order; and
  12. Appeals must not arise from a QIC or ALJ dismissal order; and
  13. Appeals must not be beneficiary-initiated appeals of QIC reconsiderations or any appeals arising from Medicare Part C, Medicare Part D, or appeals of Social Security Administration decisions regarding entitlement, Part B late enrollment penalties, and Part B and Part D income related monthly adjustment amounts (IRMAAs).

OMHA has scheduled an open door call on May 22, 2018 to provide information to appellants interested in resolving their appeals through the SCF process. You can register for the call here.

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