News: CMS to begin new round of settlements for inpatient appeals

CMS recently released details of its next round of settlements for hospitals with pending inpatient appeals to help clear a massive backlog that has been the subject of a long-running lawsuit.

With appeals waiting for adjudication before Administrative Law Judges (ALJ) continuing to languish, this is CMS’ second attempt at reducing the backlog by offering providers a portion of the appealed amount in return for ending the appeal. In 2014, the agency paid approximately $1.47 billion to 2,022 hospitals to settle approximately 346,000 claims. CMS also issued a proposed rule in June attempting to deal with its inability to complete reviews by its statutorily mandated deadline.

The second settlement process will pay providers 66% of the net allowable amount for claims denied by Medicare contractors for beneficiaries they determined were incorrectly placed in inpatient status. Claims must be under appeal at Level 3 or Level 4 (i.e., the ALJ or Departmental Appeals Board level) or within the timeframe to request an appeal review. Claims must also have a date of admission prior to October 1, 2013. Providers must choose to settle all applicable claims; they cannot continue to appeal any eligible denials that meet the settlement criteria.

Beginning December 1, providers can initiate the process by sending an expression of interest to CMS at MedicareAppealsSettlement@cms.hhs.gov. The agency must then approve the hospital’s participation and will work with the facility to determine eligible claims.

CMS will host a call November 16 at 1:30 p.m. with more details and has released an updated document with answers to frequently asked questions.

Editor’s note: This article was originally published in Medicare Compliance Watch.