February 2018
The Medicare Learning Network (MLN) recently held a second call, where it answered questions live about the Low Volume Appeals (LVA) Settlement Option and revealed more information that providers considering the option need to know. 

The details revealed during the February 13 discussion include:  

LVA Eligibility
  • Emphasis that eligibility amount turns on the billed amount not the allowable amount for claims in the appeal.
  • Partially denied claims are not eligible for the LVA settlement process.
  • For purposes of the LVA settlement option, the Centers for Medicare and Medicaid Services (CMS) will not be reviewing documentation for medical necessity, only appeal eligibility.
  • There is no time limit for how old the appeals may be, only an appeal filing cut-off date of November 3, 2017.
 Submission of EOI and Responses
  • There are no ramifications for submitting an Expression of Interest (EOI) to CMS to find out if there are any eligible appeals for the particular National Provider Identifier (NPI) number.
  • To submit the LVA Eligibility Determination Request, submit the excel spreadsheet only, not the PDF.
  • Mandated response periods of 15 days refer to calendar days (i.e. 15 calendar days).
  • On the EOI, submit the NPI that was submitted on appeal to ALJ or Council.
For purposes of professional claims, the physician group NPI, facility NPI and physician NPI may be included on the actual claims but none on the ALJ appeal. CMS could not answer at the time of the call whether all NPIs should be included in the EOI that were entered on the claims, and if so, given that the NPIs may be both even and odd numbered when the EOIs should be submitted. CMS instructed providers with NPIs ending in even numbers to submit EOIs between February 4, 2018, and March 9, 2018, and instructed providers with NPOs ending in odd numbers to submit EOIs between March 12, 2018, and April 11, 2018. CMS staff stated that guidance on this question is forthcoming.

  • To determine settlement amounts for each appeal, CMS will use the Medicare Fee schedule that was current at the time the claim was filed.
For Durable Medical Equipment (DME)
  • Enter the names of current contractors only.
  • Enter both the Medicare and DME NPIs and both the Medicare and DME MACs on the EOI.
Also, we wanted to note that President Trump has issued the FY 2019 President’s Budget for HHS. This budget includes the following nine proposals for reforming the Medicare Appeals Process:
  1. Include $127 million per year in mandatory funding to invest in addressing the backlog of pending Medicare appeals.
  2. Change the Departmental Appeals Board’s standard of review from de-novo to an appellate-level.
  3. Establish a post-adjudication user fee for the third level of appeals at the Office of Medicare Hearings and Appeals (OMHA) and the fourth level at the Departmental Appeals Board.
  4. Remand appeals to the redetermination level with the introduction of new evidence.
  5. Increase the minimum amount in controversy required for an adjudication to the Administrative Law Judge to the Federal District Court amount in controversy requirement ($1,600 in the calendar year 2018, and updated annually). Appeals that do not meet this threshold would be adjudicated by a Medicare magistrate.
  6. Allow OMHA to use Medicare magistrates for appealed claims that do not meet the newly proposed amount in controversy threshold.
  7. Allow OMHA to issue decisions without hearings if there is no material fact in dispute.
  8. Limit the right to appeal a redetermination of a claim that was denied because no documentation was submitted to support the items or services billed.
  9. Require a good-faith attestation on all appeals by appellants that they are entitled to receive Medicare reimbursement imposing liability for civil monetary penalties on appellants who submit attestations that are found to be unreasonable or made in bad faith.
OMHA had requested $251 million in program level funding, an increase of $144 million over the funding provided in FY 2018 Continuing Resolution. According to OMHA, this request would result in 106,000 additional dispositions per year.
Although the President’s budget is not likely to reflect the final FY 2019 budget, if one is ultimately passed, it is a preview of this administration’s position.