The Low Volume Appeals Settlement Process, also known as LVA, is a new option for agencies who are waiting for ALJ hearings or MAC/DAB reviews. Take advantage of this opportunity to settle fully-denied claims.
The dates to apply for this new CMS initiative are fast approaching. As noted in my first comments on Low Volume Appeals (published 1/17/18): I highly recommend home health agency participation in the LVA Settlement.
The Low Volume Appeals Settlement Process will obtain a 62% recovery of the billed amount for fully-denied claims in a much shorter period than waiting for the hearing. Claims with partial denials (historically these have most frequently partial therapy denials) are not part of this option; these will remain in the hearing process. However, claims fully denied for an invalid face-to-face encounter, not homebound, or incomplete plan of care would most likely be eligible, and thus these can be removed from the appeal process.
While all eligible claims for your agency would have to be part of the review (you cannot choose to hold back some full denials if they otherwise would qualify) LVA still offers a reasonable return on denied monies in a reasonable time.
The Low Volume Appeals (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.
How the LVA Settlement Option is implemented (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 National Provider Identifiers (NPIs) ending in an even number (0, 2, 4, 6, 8), EOIs will be accepted on February 5, 2018, through March 9, 2018.
- For appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), EOIs will be accepted on March 12, 2018, through April 11, 2018.
- Email the 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.
- The appeal has a total billed amount of $9,000 or less.
- The appeal was properly and timely filed at the OMHA or Council level as of November 3, 2017.
- Medicare contractor denied the claims included in the appeal and the claims remain in a fully-denied status in the Medicare system.
- The claims included in the appeal were submitted for payment under Medicare Part A or Part B.
- The claims included in the appeal were not part of an extrapolation.
- As of the date that 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: The appellant will be notified 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 Agreement.
Step 7. A copy of the executed Agreement will be sent to the appellant once signed by CMS, and 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: There is a possibility that during the effectuation process, the MAC will remove appeals and associated claims from the settlement for not meeting eligibility criteria; the MAC will notify the appellant 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.
Nearly all agencies will qualify to use LVA (500 claims, $9000 per claim limit) and thus smaller organizations may benefit even more. NPI number (odd or even) indicates application window and the period to express interest begins in February so this will come up quickly.
For agencies waiting years for a hearing, this may offer a viable resolution to their fully-denied claims.
Further information is available at:
Note that for this process, the agency burden is low since CMS will be generating the list of requested hearings and MAC filings and providing that to the agency for review and editing. Also note that even after CMS makes and reviews this list, the company is allowed to not proceed with the settlement, leaving the cases as pending for hearing — unchanged from before participating in this process.
Based on all of these factors, I recommend that agencies look into the Low Volume Appeals Initiative.
By: Joe Osentoski, RN-BC, QIRT Reimbursement Recovery & Appeals Director
Have questions? QIRT can help.
Contact us: Compliance@QIRT.com