Publications & Presentations
November 2017
From Bloomberg BNA, Health Law Resource Center

Medicare Settlement Plan Could Relieve Appeal Backlog

by Matthew Loughran

A pair of initiatives announced recently by the Centers for Medicare & Medicaid Services could allow the agency to resolve a portion of its gargantuan Medicare administrative appeals backlog.

But although health-care attorneys hope the initiatives will help close some of the cases contributing to the $6.6 billion in disputed Medicare reimbursements, their success will depend largely on how the CMS implements them, they told Bloomberg Law. “The CMS hasn't really given many details on how they will be applying these, so I will be curious to know what limits, if any, they will place on them,” R. Ross Burris III, a health-care attorney with Polsinelli PC in Atlanta, told Bloomberg Law.

The Medicare appeals backlog has grown so much in recent years that a health-care provider challenging a reimbursement decision may have to wait as long as three years before its reimbursement appeal is finally adjudicated. The backlog has been the subject of multiple lawsuits, including one brought by the American Hospital Association that led a federal court to order the CMS to come up with ways to reduce the backlog.
In the face of this judicial pressure, the CMS Nov. 3 announced two new settlement initiatives aimed at reducing the number of pending appeals. The low-volume appeals settlement option allows providers with fewer than 500 pending appeals and a total billed amount of less than $9,000 per appeal to settle their claims for 62 percent of the net allowed amount. Additionally, the CMS has said it will expand the use of settlement conference facilitation, which is a type of mediation between the health-care providers and the CMS, to arrive at an acceptable settlement value for resolving claims.

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