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.
Continue Reading Medicare Appeals Settlement Program Expanded
Medicare Appeals Council
Fifth Circuit Reinstates Provider’s Collateral Challenge to the Medicare Appeal Process
On March 27, 2018, the United States Court of Appeals for the Fifth Circuit held that a health care provider can seek an injunction in federal court against recoupment by Medicare of alleged overpayments despite not exhausting its administrative appeal remedies, in part because the current delay in scheduling of hearings before an Administrative Law Judge could cause the provider to go out of business before it has an opportunity to exhaust its administrative challenge of the recoupment. This decision could provide a template for other providers facing significant Medicare recoupment demands amidst the “colossal backlog” in Medicare appeals to delay such recoupments until their appeals receive a hearing.
Continue Reading Fifth Circuit Reinstates Provider’s Collateral Challenge to the Medicare Appeal Process
CMS Final Rule Streamlines Appeals Process
By Robinson+Cole's Health Law Group on
Posted in Medicare and Medicaid, Reimbursement
The Centers for Medicare and Medicaid Services (CMS) recently issued a Final Rule to streamline and address the substantial backlog of Medicare administrative appeals at the Administrative Law Judge (ALJ) and Departmental Appeals Board (DAB)/Medicare Appeals Council levels.
Among other changes to the appeals process, the Final Rule:
- Permits the designation of Medicare Appeals Council decisions as precedential, in order to provide clarity
- Gives attorney adjudicators certain authority that had been previously reserved to the ALJs, including the authority to decide appeals that can be determined without a hearing, to review dismissals by the Qualified Independent Contractors (QIC) and Independent Review Entities (IRE), to issue remands to CMS contractors, and to dismiss requests for hearing when a request is withdrawn by an appellant
- Limits the number of CMS or CMS contractors that can be a participant or party at the hearings
- Creates efficiencies by, among other things, allowing ALJs to vacate their own dismissals as opposed to requiring the appellants to appeal a dismissal to the Medicare Appeals Council, using telephone hearings, and requiring appellants to provide more information on what is being appealed
- Establishes an adjudication time frame for cases remanded from the Medicare Appeals Council
- Revises remand rules to keep cases moving forward and simplifies the escalation process
- Provides increased specificity on what would be considered good cause for new evidence to be introduced at the ALJ level