CMS issues new and updated FAQs related to its appeals settlement offer to hospitals


The Centers for Medicare & Medicaid Services (CMS) recently added new and updated FAQs specifically related to its proposed appeals settlement program for short-stay denials. The FAQs address a variety of topics including claim validation, form of settlement payment, and abandoning the settlement process.

In a prior bulletin on this topic, we noted that we had reached out to CMS for clarification as to whether the settlement offer applied to claims denied by the Office of Inspector General (OIG) and whether appeals involving extrapolated overpayments were eligible to participate in the settlement. In its updated FAQs, CMS clarified that claims denied by the OIG and appeals involving extrapolated overpayments are eligible to participate in this settlement process. In addition, in response to questions whether it will validate all claims on a hospital’s eligible claims list or only a sample, CMS indicated that it will validate a sample of information about the Administrative Law Judge (ALJ) and Departmental Appeals Board (DAB) level cases. Furthermore, after the settlement payments are issued, the Office of Medicare Hearings and Appeals (OMHA) and the DAB will conduct a full review on all cases at their level. If the ALJ or DAB identify errors in the settled claims, CMS will direct the Medicare Administrative Contractors to take recovery actions for claims that were ineligible for settlement that were inadvertently included in the agreement or pay providers the settlement amount for claims pending appeal that were inadvertently omitted from an agreement.

Eligible hospitals and providers should review the new and updated FAQs as well as other relevant FAQs on the Inpatient Hospital Reviews web page. In addition, hospitals seeking general information regarding the process and the FAQs can attend another teleconference as part of the MLN Connects™ National Provider Call Program on October 9, 2014, at 1:30 p.m. EST.

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