Settlement process still long shot for many providers

‘We are still 50% of the appeals backlog and it would be better for all of us if (the settlement conference) worked better’
Friday, November 13, 2015

WASHINGTON – The Office of Medicare Hearings and Appeals has made the settlement process slightly easier, but challenges remain, says AAHomecare’s Kim Brummett.

The biggest change OMHA has made: Providers can include appeals filed at the Administrative Law Judge level through Sept. 30, 2015. Previously, it was limited to appeals filed in 2013.

“That’s a much better deal,” said Brummett, senior director of regulatory affairs for AAHomecare. “Providers can settle on a much larger volume of appeals.”

In an Oct. 18 conference call, OMHA outlined this and other requirements and processes for Phase II of the Settlement Facilitation Conference pilot project.

Unfortunately, the same strict criteria for participating in a settlement conference remain: Providers must have a minimum of 20 claims or $10,000 at issue, and they must include all pending appeals for like services.

“It’s still all or nothing for any given category, which is problematic,” said Brummett.

OMHA is making the logistics easier for providers that do meet the criteria, however. Once a provider submits an “expression of interest” form, OMHA will create a report for CMS containing all eligible appealed claims. Once CMS approves the settlement conference, OMHA will create a spreadsheet with the relevant data and send it to the provider. Previously, providers created the spreadsheets themselves and they were likely to miss certain data, said Brummett.

Of the 2,400 appeals that were successfully settled in Phase I of the pilot, very few involved HME providers. Even without more substantive changes to the settlement conference, Brummett thinks more HME providers will participate as time goes on—and as the ALJ backlog grows. She knows of one provider that recently settled for about 60 cents on the dollar.

“For a lot of people, that’s better than four years of nothing,” she said. “But, we are still 50% of the appeals backlog and it would be better for all of us if (the settlement conference) worked better.”