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.
When to apply for Low Volume Appeals Settlement
The dates to apply for this new CMS initiative are here!
Based on whether your agency has an odd or even NPI:
- For appellants with National Provider Identifiers (NPIs) ending in an even number (0, 2, 4, 6, 8), Expression of Interests (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.
So if your agency has an EVEN number NPI, your window to express an interest in the LVA process has opened.
If your agency has an ODD number NPI, your opportunity will begin in just over a month.
As I have noted in prior blogs and discussions with agencies: I highly recommend that home health agencies consider participating in the LVA Settlement Process.
Clarifying the Low Volume Appeals Process
Based on some questions received from earlier posts, here are some clarifications on the process:
- While your agency may have appointed QIRT as a representative of your agency for the appeal and any Administrative Law Judge Hearings, QIRT is NOT representative for the agency in the LVA process. For example, I am not the representative for any organization I assisted with filing ALJ hearing requests.
- While the two time periods to express interest in the LVA process are open, it is recommended that any previously scheduled ALJ hearings request a “Continuance” to allow the appeal (if the claims are fully-denied) to be part of the LVA Settlement. Find instructions for this on the LVA FAQ, posted on the CMS website.
- The agency does not have to identify the claims they are seeking LVA Settlement on. CMS will generate the list once the Expression of Interest (EoI) is received via email in the respective time period.
- All eligible claims must be part of the settlement agreement: once CMS generates the list, it is shared with the agency to check for accuracy. However, the agency cannot remove eligible claims if they choose to sign the settlement agreement.
- The “Appellant” in this process is the home health agency. Not any beneficiary. Not QIRT. Not me.
- Appellants who are currently in bankruptcy or who expect to file for bankruptcy are not eligible for settlement. Certain appellants that have or have had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations may not be eligible for settlement.
A Quick Review of Low Volume Appeals
Low Volume Appeals Settlements 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. Those types of claims 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 must 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 LVA Settlement Option applies to:
- Cases waiting for an Administrative Law Judge Hearing (ALJ) filed BEFORE November 3, 2017.
- Cases that 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.
Implementation of LVA Settlement Option (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).
- EOIs will be accepted:
- February 5, 2018, through March 9, 2018 – appellants with National Provider Identifiers (NPIs) ending in an even number (0, 2, 4, 6, 8)
- March 12, 2018, through April 11, 2018 – appellants with NPIs ending in an odd number (1, 3, 5, 7, 9)
- The EOI is emailed 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
- A Medicare contractor denied the claims included in the appeal and 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 the 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, appeals and associated claims may be removed from a settlement for not meeting eligibility criteria; the 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.
Further information is available on the CMS website.
Based on all of these factors, I strongly recommend that agencies consider 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