FutureFocus February 7, 2018 Post-Acute Cost By Care Settings For The Dual Eligible: Eight Things To Know

Lisa Remington

In this week’s FutureFocus, we explore post-acute costs by care settings for the dual eligible. Important data helps to understand why costs are higher within the entire post-acute discharge period and in particular areas of post-acute. This important data ties back to Medicare Spending per Beneficiary. In another article, we discuss medication non-adherence solutions for Medicare patients. Our Washington Report addresses how CMS is launching a low volume appeals initiative.

Lisa Remington, President, Remington Health Strategy Group

The Centers for Medicare & Medicaid Services has begun accepting Expressions of Interest (EOIs) for a limited settlement agreement option for Medicare Fee-For-Service providers, physicians, and suppliers (appellants) with fewer than 500 appeals pending at the Office of Medicare Hearing and Appeals (OMHA) and the Medicare Appeals Council (Council) at the Departmental Appeals Board.

Specifically, effective February 5, CMS began making available an administrative settlement process for appellants with fewer than 500 appeals pending at OMHA and the Council, combined, as of November 3, 2017, to settle the portion of their pending appeals that have total billed amounts of $9,000 or less per appeal in exchange for timely partial payment of 62% of the net Medicare approved amount.

Eligible appellants are: Medicare Part A and Part B providers, physicians, and suppliers with fewer than 500 appeals pending at OMHA and the Council, combined, and that do not fit into one or more of the categories of “ineligible appellants.”

"CMS would encourage appellants to weigh the pros and cons of using this settlement option. Any appellant who is confident in a more advantageous outcome through the traditional appeals process may continue to pursue adjudication.”

If an appellant’s National Provider Identifier (NPI) is approved for participation in this process, the resulting settlement will apply to all eligible appeals from that appellant. The appellant cannot choose to settle some eligible appeals but not others.

To ensure timely processing, CMS has designated specific EOIs submission windows, based on NPI:

  • For appellants with NPIs ending in an even number (0, 2, 4, 6, 8), EOIs will be accepted on February 5, 2018 through March 9, 2018.
  • For appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), EOIs will be accepted on March 12, 2018 through April 11, 2018.

Appellants with both odd and even NPIs will be required to submit one EOI per NPI during the appropriate designated timeframe, as described above.

A 12-page CMS LVA FAQs, issued January 4, notes the choice providers should consider: “Why should I take a discount when I am likely to win the appeals I have filed? CMS would encourage appellants to weigh the pros and cons of using this settlement option. Any appellant who is confident in a more advantageous outcome through the traditional appeals process may continue to pursue adjudication.”

For details on the agency’s Low Volume Appeals (LVA) Initiative eligibility process for submitting an EOI, click here.

Low Volume Appeals Settlement Option Call

Providers are urged to register for this Medicare Learning Network event scheduled for February 13 from 1:30 to 3 pm ET. Target Audience: Medicare fee-for-service providers, physicians, and other suppliers with fewer than 500 appeals pending at OMHA and the Council.

During this call, learn more about the LVA Option, the current status, and how the settlement process works. CMS speakers will discuss how to identify whether providers are eligible and which pending appeals may be settled.

A question and answer session follows the presentation; however, attendees may email questions in advance to MedicareSettlementFAQs@cms.hhs.gov with “Low Volume Appeals Settlement February 13 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.

For Providers Ineligible for LVA Option

Separately, OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA Option. OMHA expects to implement the expanded SCF program in April 2018.

More information on this Process will be available on the OMHA website.

By: Ronald M. Schwartz