Fresh from CMS: a Low Volume Appeals Initiative (LVA) extension. TCMS has extended the period to use this opportunity to settle claims.
What’s New in LVA?
3/29/2018- The deadline to submit an expression of interest (EOI) for the Low Volume Appeals (LVA) Initiative has been extended to June 8, 2018. Appellants that meet the eligibility criteria (and have either an odd or an even NPI) should submit an EOI between April 12 and June 8, 2018. Details about the process, including a fillable EOI, are available in the downloads section below.
From now until April 11, the current period is for appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), Expressions of Interest (EOI) will be accepted on March 12, 2018, through April 11, 2018. Then, both odd and even numbered NPI have a Low Volume Appeals Initiative extension to explore this settlement option.
I have noted in previous blogs and discussions with agencies that I highly recommend participation in the LVA Settlement. I stand by that assertion. At QIRT Compliance, we have assisted agencies who have had between 3 and more than 50 claims settled. This resulted in the recovery of monies that had been in limbo via appeals since 2013! The Low Volume Appeals Initiative extension offers you another opportunity to participate.
Full details are found at the CMS Low Volume Appeals website.
How Does an Agency Identify Claims for LVA?
Remember, an agency does not have to identify the claims they are seeking LVA Settlement on. CMS will generate the list after receiving the Expression of Interest (EoI) via email during the respective time period.
This will obtain a 62% recovery of the billed amount for fully denied claims in a much shorter period of time than waiting for the hearing. Claims with partial denials (historically these have most frequently partial therapy denials) are not part of this option, but instead remain in the hearing process. However, fully-denied claims (for an invalid face-to-face encounter, not homebound, or incomplete plan of care) are likely eligible and thus these can be removed from the appeal process.
You cannot choose to hold back some full denials if they otherwise would qualify. So while all eligible claims for your agency would have to be part of the review, LVA still offers a reasonable return on denied monies in a reasonable time.
The LVA Settlement Option applies to:
- Cases waiting for an Administrative Law Judge Hearing (ALJ) filed BEFORE November 3, 2017.
- Cases waiting for a Medicare Appeals Council ruling filed BEFORE November 3, 2017.
- Eligible cases must each be $9,000 or less.
- Total cases eligible from all agency NPI must be 500 or less.
- This 500 includes both pending ALJ hearings and MAC filings.
LVA Settlement Option Implementation (abbreviated version):
Step 1. The appellant (agency) submits an Expression of Interest (EOI) to MedicareAppealsSettlement@cms.hhs.gov during the appropriate timeframe.
- Agencies complete an Expression of Interest (EOI).
- For appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), CMS will accept EOIs on March 12 through April 11, 2018.
- The extended period is for both odd and even numbered NPIs from April 12, 2018, to June 8, 2018.
- Appellants email EOI to CMS.
Step 2. CMS receives EOI and verifies whether the appellant meets eligibility criteria.
Step 3. CMS will determine if the appellant has appeals that meet the following eligibility criteria:
- The appeal:
- was pending before the OMHA and/or Council level of appeal as of November 3, 2017;
- has a total billed amount of $9,000 or less;
- was properly and timely filed at the OMHA or Council level as of November 3, 2017;
- The claims included in the appeal were:
- denied by a Medicare contractor and remain in a fully denied status in the Medicare system;
- submitted for payment under Medicare Part A or Part B;
- not part of an extrapolation; and,
- As of the date this Agreement is fully executed, the appeal was still pending at the OMHA or Council level of review.
If the appellant has appeals that meet the eligibility criteria: The appellant will receive an email from CMS with an administrative agreement (Agreement) and an eligible appeal Spreadsheet (Spreadsheet) within 30 days of submitting their EOI.
If an appellant has no eligible appeals: CMS will notify the appellant within 30 days of submitting their EOI.
Step 4. Appellant reviews Spreadsheet and Agreement for completeness and accuracy.
Step 5. For up to 30 days, CMS, the appellant, and the appellant’s Medicare Administrative Contractor (MAC) will work on the EDR to reach a final consensus on the list of eligible appeals.
Step 6. CMS signs the Agreement.
Step 7. CMS will send a copy of the executed Agreement to the appellant once signed by CMS. All associated appeals are pended.
Step 8. The appellant’s applicable MAC receives the Spreadsheet. The MAC completes a final eligibility check and prices the associated claims.
Note: If appeals and associated claims do not meet eligibility criteria, the MAC may possibly remove them from the settlement. This would occur during the effectuation process and appellant will be notified if this occurs.
Step 9. The MAC makes payment to the appellant within 180 days of CMS’ signature on the settlement agreement.
Step 10. Settled appeals are dismissed, and appeals that contained claims that could not be settled, if any, are returned to their original position in the appeals queue to continue in the appeals process.
Step 11. CMS sends the appellant the fully executed agreement and final settled appeals list.
Contact QIRT with any questions or for more information: Compliance@QIRT.com.
Joe Osentoski, RN-BC
Reimbursement Recovery & Appeals Director; QIRT