Low Volume Appeals settlement option announced


Medical claim

The Centers for Medicare & Medicaid Services (CMS) recently announced the Low Volume Appeals (LVA) settlement agreement option, which allows Medicare Fee-For-Service providers, physicians and suppliers (Appellants) to receive partial payment for Medicare Part A or Part B claims that were fully denied by a Medicare contractor and are currently (as of November 3, 2017) pending before the Office of Medicare Hearings and Appeals (OMHA) or the Medicare Appeals Council. For eligible claims, CMS is offering to pay 62 percent of the net claim approved amount. To be eligible, Appellant must have less than 500 pending appeals across all of its affiliated National Provider Identifiers (NPIs). Of those pending appeals, only appeals with total billed amounts of $9,000 or less will be eligible for settlement. 

In order to participate, appellants must submit an Expression of Interest (EOI) to CMS. Appellants with NPIs ending in an even number must submit an EOI between February 5 and March 9, 2018. Appellants with NPIs ending in an odd number must submit EOIs between March 12 and April 11, 2018. Appellants with multiple NPIs must submit a separate EOI for each NPI. 

Unlike the current state of the appeals process, CMS expects the LVA process to move quickly and will expect Appellants to be responsive; on the January 9, 2018, LVA call, CMS emphasized that Appellants must keep in continuous contact with CMS throughout the process, or CMS will deem the Appellant to have abandoned the process.  After an Appellant submits an EOI, and CMS deems the Appellant eligible, CMS will provide the Appellant with a spreadsheet of potentially eligible appeals and an Administrative Agreement within 30 days. Within 15 days of receipt, the Appellant must validate the spreadsheet and sign the Administrative Agreement (or submit an Eligibility Request Determination if the Appellant wishes to dispute any of the listed or missing appeals). CMS will countersign the Administrative Agreement, and the MACs will price the associated claims and issue payment to the Appellant within 180 days of CMS’ signature. Note that the MACs will price each claim individually and calculate the 62 percent after the Administrative Agreement is signed, so Appellants will not have the benefit of knowing the total amount prior to signing.   

All eligible appeals must be settled; Appellants may not pick and choose among eligible appeals. They may, however, withdraw from the settlement process at any time before the Administrative Agreement is signed. If an Appellant withdraws, its appeals will return to the normal appeals process. 

Appellants are encouraged to weigh the possible outcome of the traditional appeals process versus the likely return on the LVA settlement option in deciding whether to participate.  

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