On Feb. 25, 2016, the Office of Medicare Hearings and Appeals (OMHA) conducted a teleconference to address Phase III of the Settlement Conference Facilitation (SCF) project, which also became effective on Feb. 25, 2016. SCF, launched in June 2014, is an alternative dispute resolution process for eligible claims pending appeal in front of an Administrative Law Judge. OMHA first announced its plans to expand the settlement conference option to Part A claims during its open door forum last Oct. 15, 2015.
What you need to know:
During the recent teleconference, OMHA discussed several important eligibility and participation requirements for providers interested in resolving their appeals through the SCF, including:
-
All part A provider types are eligible to request SCF including acute care hospitals
-
Claims that were eligible for the CMS Part A Hospital Appeals Settlement Option offered in 2014 are not eligible for SCF regardless of whether or not the provider chose to take advantage of the CMS Part A settlement
-
The initial determination must not have found any Beneficiaries liable for the claim, and beneficiaries cannot have participated in the QIC reconsideration
-
The ALJ request must not currently be docketed for an ALJ hearing, but the request can be assigned to an ALJ
-
ALJ requests must have been filed by Dec. 31, 2015
-
The amount of each individual claim must be $100,000 or less, or, for the purposes of an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less
-
At least 50 claims must be at issue and at least $20,000 must be remaining in controversy
-
There cannot be an outstanding request for OMHA statistical sampling of the same claims
-
The appealed claims must not involve services, drugs, or biologicals billed under unlisted, unspecified, or misc. health care codes; however, equipment or items excluding drugs or biologicals ARE ELIGIBLE for SCF
-
The appellant cannot be in bankruptcy proceedings, and cannot be expecting to file for bankruptcy
As with previous phases of the SCF program, if a settlement is not reached, the claims will return to their place in the queue, and if the appeal has already been assigned to an ALJ, it will return to that ALJ’s queue.
