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“Low Volume Appeals Settlement” Announced by CMS to Ease Medicare Appeals Gridlock

on Friday, 2 February 2018 in Health Law Advisory: Zachary J. Buxton, Editor

The details of the Low Volume Appeals Settlement (LVA) initiative were explained during a Medicare Learning Network Call with CMS on January 9, 2018. The initiative is designed to partially relieve what is now estimated to be a 3-year backlog of claims stacked up for hearings before an Administrative Law Judge. Pending cases processed under the LVA initiative will be uniformly (partially) paid at 62% of the net Medicare approved amount.

General Qualifications. The LVA is available to Part A and B providers with fewer than 500 appeals pending (as of November 3, 2017) at the Office of Medicare Hearings and Appeals and the Medicare Appeals Council across all NPIs.

The initiative is not available to Part C and D providers, entities who have filed bankruptcy or those expected to file for bankruptcy. Providers involved in False Claims Act litigation, investigations or other pending program integrity matters may also be excluded from the initiative. Appeals of claims involving extrapolations are not eligible.

Claims Value Limit. The total billed amount of the appeal (not the allowable amount) may not exceed $9,000.

LVA Initiative Process. Providers enter the LVA by filing an “Expression of Interest” (“EOI”) form with CMS. Both the form and the LVA “inbox” for submissions are available on the CMS website.

Deadlines. EOIs are being accepted from providers with NPIs ending in an even number between February 5, 2018 and March 9, 2018. CMS will accept EOIs from providers with NPIs ending in odd numbers between March 12, 2018 and April 11, 2018. Providers with both odd and even NPIs are required to submit one EOI per NPI during the required timeframes. Once received, the provider’s eligibility will be verified for meeting the pertinent deadline and meeting the qualifications to participate in the LVA process. If the provider is qualified to go to the next step, it will receive an “Administrative Agreement” along with a spreadsheet of its eligible claims.

The provider is expected to sign and return the Administrative Agreement to CMS within 15 days. Extensions may be granted and providers are permitted to dispute the spreadsheet data by filing an Eligibility Determination Request (EDR) to add or delete claims. The EDR must be submitted with the 15-day deadline or any extension thereof. CMS allows 30 days to address and resolve disagreements in the claims data. Once the Administrative Agreement is signed by the provider and CMS, the claims are removed from the Medicare appeal process. A copy of the Agreement will be sent to the provider’s Medicare Administrative Contractor by CMS for final eligibility verification and pricing. CMS stated that it will make payment to the provider within 180 days of the execution date of the Administrative Agreement.

One Choice. If a provider choses to settle its claims under the LVA initiative, it must settle all eligible appeals under this process. Providers may not hold back some claims for hearing and settle others under the LVA.

Is This a Good Deal? As the LVA is limited to a fairly narrow band of smaller dollar appeals. Some providers may find this an efficient way to cross some claims off the backlog list. Others may find that their odds of payment on appeal greatly exceed 62% and decide to go for the standard appeal process even after considering the time value of money. It is unknown at this time how many providers will opt for this expedited process or the extent to which the LVA initiative will reduce the backlog and move other appeals up in line but the deadlines require a decision soon.

Julie A. Knutson

1700 Farnam Street | Suite 1500 | Omaha, NE 68102 | 402.344.0500