Hopes are high for tweaks to settlement process

Friday, September 25, 2015

WASHINGTON – The Office of Medicare Hearings and Appeals plans to expand its Settlement Conference Facilitation pilot project and stakeholders hope the agency will make it more widely accessible.

Right now, to participate in the pilot project, providers must have a minimum of 20 claims or $10,000 in controversy; must appeal all claims for the same service; and must have filed the claims in 2013—none of which can be currently assigned to a judge.

Due to these strict criteria, very few HME providers have had the opportunity to come to the table with CMS and OMHA to work out a settlement.

“We’ve asked for changes to the minimum number of claims, the amount, the time frame for the appeals and things of that nature,”said Kim Brummett, vice president of regulatory affairs for AAHomecare.

OMHA is holding an open door conference call with Part B providers on Oct. 15 to brief them on how they can request a settlement and to discuss the new process.

Healthcare lawyer Ross Burris, who represented two O&P companies during the process, says the pilot project would also be more attractive to providers if CMS was able to discuss hard numbers.

“All CMS can do is tell you that they will pay a certain percentage of the claim,” said Burris, an attorney in the Atlanta office of Polsinelli. “I think it’s hard for suppliers to get their heads around exactly how much they’re giving up if they accept a settlement for less than the amount that they are appealing.”

One of the biggest hurdles providers face under the current system is understanding whether they are even eligible to participate.

“For some folks with claims from different time periods, different types of services, different types of denial reasons—just getting all the information together and organizing it to determine whether or not they even qualify has been a challenge,” said Wayne van Halem, president of The van Halem Group.

With wait and processing times still skyrocketing at the administrative law judge level, stakeholders say that, if fixed, the pilot project could be a viable alternative for providers.

“I can tell you from my experience, I know a lot of companies that would participate in a settlement conference,” van Halem said. “We’ve had a lot of requests for information about it, so I do think it is a reasonable solution (to the appeals backlog) if they are able to expand it enough to where people are able to participate.”