New appeals/resolution process announced by HHS

Categories: Policy.

The HHS Office of Medicare Hearings and Appeals (OMHA) has announced a pilot alternative dispute resolution process to allow all Part A and Part B providers and suppliers to settle ALJ claims without waiting for an ALJ hearing. This will allow hospice providers to reach a settlement with the government and collect a portion of the cash currently waiting for an ALJ hearing. 

OMHA has announced that current appeals to the ALJ now top 800,000, with an estimated 84,000 home health and hospice claims. The ALJ hearing wait time is 5 years or more before an appeal is heard.  

How It Works
During the settlement process, an OMHA employee uses mediation principles to determine a mutually agreeable resolution to an appeal and a settlement conference is scheduled, where a settlement document is reviewed. As a part of the agreement, the request(s) for an ALJ hearing for the claims covered by the settlement will be dismissed. OMHA states that the first phase of this pilot began with Medicare Part B claims in June 2014. To date over 2,000 Medicare Part B ALJ appeals have been settled. In the fall of 2015, Phase II began, which expanded the pilot to include most Part B provider/supplier appeals where the appeal request for an ALJ hearing was filed prior to October 1, 2015.  This is Phase III of the pilot, which opened on February 25, 2016.

It is not clear whether the settlement amounts will be advantageous to hospice agencies; however, exploring the Settlement Conference Facilitation (SCF) process is still an option, while remaining in the queue for an ALJ hearing. 

OMHA encourages all Medicare Part A providers who have ALJ appeals pending to read the materials on this website to familiarize themselves with the eligibility requirements and request the process for settlement.

Hospice providers with questions regarding the Settlement Conference Facilitation pilot should submit inquiries via email to OMHA.SCF@hhs.gov.

Downloads from OMHA

 NHPCO members will find a Regulatory Alert with additional commentary avaiable online.