Hospital Appeals Settlement Process
11/03/2017 - As part of the broader Department of Health & Human Services commitment to improving the Medicare appeals process, CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined, as of November 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met. CMS will settle eligible appeals at 62% of the net allowed amount.
Separately, OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA option. More information will be available on the OMHA website at https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlement-conference-facilitation/index.html.
Please continue to monitor these websites for specific details about these options in the coming weeks.
- 1/17/17 – As a reminder, the 2016 Hospital Appeals Settlement Process is open until January 31, 2017. Interested providers should submit an Expression of Interest between December 1, 2016 through January 31, 2017. Details about the process, including a fillable Expression of Interest Form, are available in the downloads section below.
- 12/12/16 – Updated FAQs posted.
- 12/1/16 – The Hospital Appeals Settlement Process 2016 is now open. Interested providers should submit an Expression of Interest between December 1, 2016 through January 31, 2017. Details about the process, including a fillable Expression of Interest Form, are available in the downloads section below.
- 11/30/16 – Join CMS on December 12, 2016 at 1:30 PM EST for a MLN Connects National Provider Call on the 2016 Hospital Appeals Settlement. To register or for more information, visit MLN Connects® Event Registration. Space may be limited, register early.
- 11/14/16 – Slides for the November 16, 2016 MLN Connects National Provider Call are available in the "Downloads" section below.
- 11/3/16 – Details regarding the Hospital Appeals Settlement are now available below.
- 10/28/16 – Join CMS on November 16, 2016 at 1:30 PM EST for a MLN Connects National Provider Call on the 2016 Hospital Appeals Settlement. To register or for more information, visit MLN Connects® Event Registration. Space may be limited, register early.
- 09/28/16 – CMS has decided to once again allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Specific details of the settlement will be released in the near future. Please continue to monitor CMS’ website for additional information.
Beginning December 1, 2016, CMS will make available an administrative settlement process for inpatient status claims. This process will be open to eligible hospitals willing to withdraw certain pending appeals in exchange for timely partial payment (66% of the net allowable amount).
Under the 2014 Hospital Appeals Settlement Process, CMS executed settlements with 2,022 hospitals, representing approximately 346,000 claims. CMS paid approximately $1.47 billion to hospital providers that agreed to the settlement process.
Some providers, however, did not take advantage of this process the first time. CMS encourages hospitals with inpatient status claims currently in the appeals process at the Administrative Law Judge level or the Departmental Appeals Board level to consider this process. The deadline for hospitals to submit an Expression of Interest is January 31, 2017. CMS believes this process will ease the administrative burden of current appeals, and the associated litigation risk, for both the hospital and Medicare program.
The following facility types are ELIGIBLE to submit a settlement request:
- Acute Care Hospitals, including those paid via Prospective Payment System (PPS), Periodic Interim Payments (PIP), and Maryland waiver; and
- Critical Access Hospitals.
The following facility types are NOT eligible to submit a settlement request:
- Psychiatric Hospitals paid under the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS);
- Inpatient Rehabilitation Facilities (IRFs);
- Long-Term Care Hospitals (LTCHs);
- Cancer Hospitals; and
- Children’s Hospitals.
A full definition of each of these facility types can be found at §1886(d) or §1820(c) of the Social Security Act. If a hospital is approved for participation in this process, the resulting settlement will apply to all eligible claims from that provider. Eligible claims are those denied by a Medicare contractor on the basis that services may have been reasonable and necessary but treatment on an inpatient basis was not, that are either under appeal at Level 3 or Level 4 or within their administrative timeframe to request an appeal review, with dates of admissions prior to October 1, 2013, and where the patient was not a Part C enrollee. The hospital cannot choose to settle some claims and continue to appeal others. Certain hospitals will be excluded from this settlement opportunity based on pending False Claims Act litigation or investigations.
To request participation in the process, hospitals must complete the Expression of Interest and submit it to MedicareAppealsSettlement@cms.hhs.gov
The settlement process is initiated by the hospital submitting their Expression of Interest to CMS at MedicareAppealsSettlement@cms.hhs.gov. If the hospital is approved for participation, CMS then generates a proposed spreadsheet of eligible claims/appeals for the hospital’s review, along with the Administrative Agreement for the hospital to sign. The hospital will validate the information and notifies CMS if there are any discrepancies on the eligible claims list by submitting an Eligibility Determination Request to CMS at MedicareAppealsSettlement@cms.hhs.gov within 15 calendar days of receiving the Agreement. CMS and the hospital have 30 days to resolve any discrepancies. If discrepancies are resolved, the hospital will sign the Administrative Agreement, then CMS will sign the agreement. At any time prior to the hospital signing the agreement, they may withdraw its interest and will retain its full appeal rights. Proceedings on all eligible pending appeals will be stayed during this process. See process document in the downloads section below for additional details.
See the downloads section below for the most recent frequently asked questions. Please email any questions to MedicareSettlementFAQs@cms.hhs.gov. CMS may post and periodically update a list of Frequently Asked Questions about this settlement process.