The Office of Medicare Hearings and Appeals (OMHA) has announced the expansion of their Settlement Conference Facilitation (SCF) program.  SCF is a dispute resolution process for Medicare appeals that provides for payments as percentage of the Medicare approved amount.  The percentage is negotiated during a telephone settlement conference utilizing a mediation facilitator.  Utilizing dispute resolution processes such as SCF will be very important in helping to reduce a very significant backlog of Medicare appeals, which the government estimates would take OMHA at least eleven years to process.

For a Medicare provider or supplier to be eligible under the SCF program, it:

  • Must have a National Provider Identifier (NPI);
  • Cannot have filed for bankruptcy or expect to file for bankruptcy in the future;
  • Must not have or have had False Claims Act (FCA) litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations.

For appeals to be eligible, all of the following are required:

  • The requests for hearing by an Administrative Law Judge (ALJ) or review by the Medicare Appeals Council must have been filed on or before November 3, 2017;
  • Either of the following must be satisfied:  1) a total of 500 or more appeals must be pending at OMHA and the Council combined; or 2) there may be any number of appeals pending at OMHA and the Council as long as each have more than $9,000 in billed charges;
  • Request(s) for hearing and/or review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision;
  • All jurisdictional requirements for OMHA and Council review must be met;
  • All pending OMHA and Council appeals associated with a single NPI and Provider Transaction Access Number (PTAN) must be included;
  • An ALJ hearing must not have been scheduled or conducted;
  • The amount of each claim must be $100,000 or less (with an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less);
  • Appeals must not be involved in OMHA’s Statistical Sampling Initiative;
  • The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration;
  • 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);
  • Appeals must not involve payment disputes (for example, where the provider was paid as billed, in full, by the contractor, but the appellant believes the fee schedule or contractor price amount is insufficient payment), however appeals involving downcoding are acceptable;
  • Appeals must not arise from a QIC or ALJ dismissal order; and
  • 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, or Part B and Part D income related monthly adjustment amounts (IRMAAs).

As the announcement pointed out, SCF is separate and distinct from the Low Volume Appeals Initiative, another settlement program option for Medicare appeals.