On October 15, 2015, the Office of Medicare Hearings and Appeals (“OMHA”) conducted a teleconference to address Phase II of the Settlement Conference Facilitation (“SCF”) Pilot, effective October 1, 2015.  SCF, launched in June 2014, is an alternative dispute resolution process for eligible claims pending appeal in front of an Administrative Law Judge. OMHA also announced that it plans to expand the settlement conference option to Part A claims as part of Phase III, which will begin sometime in 2016. 

What You Need to Know:

Eligible Part B claims filed before September 30, 2015 may now be eligible for settlement in Phase II. Providers should carefully consider the pros and cons of settling eligible claims, or letting them remain pending for an ALJ hearing.  Providers should also prepare for the Phase III expansion for Part A claims. In addition, Polsinelli's experience in advising and representing clients throughout the Medicare Appeals Process could be valuable to providers as the SCF Pilot Program continues to expand. More information about the Phase II Process can be found here. 

Phase II of the Pilot has expanded the eligibility requirements to include more pending appeals, and has also added other eligibility criteria. Four key takeaway changes include: 

• Expanding the eligibility requirement for the time frame of submitted claims.  The requested hearing must not be scheduled for an ALJ hearing and must have been filed by September 30, 2015.  
• Appellants cannot have filed for bankruptcy and cannot expect to file for bankruptcy in the future. 
• The appealed claims cannot involve items or services billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes.  Miscellaneous codes are used when a provider or supplier submits a bill for an item or service and there is no existing code that adequately describes the item or service.  These new criteria may address concerns by providers or suppliers attempting to negotiate miscellaneous codes. CMS will only discuss paying a percentage of a claim during the negotiation process, and miscellaneous codes may be more complicated to explain in a percentage format. 
• The appellant must receive an Office of Medicare Hearings and Appeals Settlement Conference Facilitation Preliminary Notification stating that the appellant may request SCF for the claims identified in the SCF spreadsheet.  An appellant may not formally request a settlement conference until receiving this notice, but an appellant can initiate the process by filing its expression of interest.