RAC Appeals Settlement

Transcription

1 RAC Appeals Settlement A webinar for Missouri Hospital Association Stacy Harper (913) sharper@lathropgage.com September 25, 2014 Presented by Donn Herring (314) dherring@lathropgage.com 1

2 Overview CMS Appeals Backlog Related Disputes and Other Resolution Attempts Requirements of the Settlement Offer Response to the Settlement Offer Factors to Consider 2

3 CMS Appeals Process and Timeline Level One- MAC Redetermination Must be in writing or on CMS approved form File within 120 days (30 days to toll recoupment) MAC has 60 days to respond Level Two- Qualified Independent Contractor Reconsideration Must be in writing or on CMS approved form File within 180 days Last opportunity to introduce new evidence QIC has 60 days to respond Level Three- ALJ Hearing File within 60 days Recoupment is no longer tolled ALJ has 90 days to issue decision Level Four- Review by Medicare Appeals Council File within 60 days 90 days until adjudication Level Five- Judicial Review in Federal District Court File within 60 days 3

4 CMS Appeals Backlog From 2010 to 2013 the appeal requests to the Office of Medicare Hearings and Appeals (OMHA) grew by 184% As of December 2013, OMHA had a backlog of over 460,000 claims and the number of claims filed had increased to 15,000 per week. Assignment of all new appeals was suspended in December Delays in assignment are anticipated to be up to 28 months. Post assignment wait times are anticipated to exceed 6 months. Priority is given to Part D prescription drug denials and beneficiary initiated claims. 4

5 Related Disputes and Other Resolution Attempts CMS Ruling 1455-R March 13, 2013 Allows billing for some Part B services Requires dismissal/waiver of any Part A appeals RAC audits of these claims were suspended October 1, 2013 to March 31, 2015 American Hospital Association Litigation Originally filed in November 2012 Amended following the ruling to challenge the timely rebilling requirements Dismissed by the District Court on September 17, 2014 Pilot Program July 2014 Part B alternative dispute resolution process for claims in excess of $10,000 Statistical sampling pilot for Part A 5

6 The Settlement Offer- Eligibility Acute Care and Critical Access Hospitals With appeals pending at any level of appeal or within the administrative timeframe to request an appeal Related to a denial based on inappropriate patient status (billed as inpatient but was reasonable and necessary as an outpatient) For claims with an admission date before October 1,

7 The Settlement Offer- Details CMS will pay 68% of the net payable amount of the denied inpatient claim Does not include co-payment or deductible amounts Does include add-on payments Settled claims will remain denied for cost report purposes, which may impact GME, IME, or DSH payments Co-payments Do not have to refund patient co-payments and deductibles Cannot collect on unpaid co-payments and deductibles unless a payment arrangement is already in place with the patient Cannot include write offs in bad debt No interest will be paid on settled claims Any interest previously paid by the hospital will be refunded CMS will not pay interest on the claims 7

8 The Settlement Offer- Requirements Must accept by October 31, 2014 Must include all claims pending appeals before OMHA Sign Administrative Agreement Provide Eligible Claim Spreadsheet Filed electronically to 8

9 The Settlement Offer- Process Once the offer is accepted, CMS will reconcile the hospital s spreadsheet with CMS pending appeals. If all claims are verified, CMS will issue payment If there are discrepancies, CMS will notify the hospital and provide option for discussion period to finalize the list of claims During the validation process, the hospital will have the option to abandon the settlement agreement if they disagree with the list of claims and/or pricing Payment will be in one or two lump sum payments. A PDF listing the claims included will be provided to the hospital in advance of the payment CMS anticipates the process will take approximately 60 days from a signed agreement 9

10 Response to the Settlement Offer As of September 22, 2014, four hospitals had accepted the settlement Rep. Kevin Brady issued a letter urging CMS to scrap the settlement offer, primarily related to concerns regarding how the 68% was determined CMS has not responded to Rep. Brady, but continues with the settlement offer 10

11 Factors to Consider The Money The amount pending appeal X The Anticipated Settlement Amount Expected success rate (based on historic appeals + Interest due on claims expected to prevail - Cost of continued appeal 11

12 Factors to Consider The Other Stuff Cash flow and timing of payment Hospital resources to continue the appeals Net present value of the payment Impact on patient collections 12

13 Questions?? Stacy Harper (913) Donn Herring (314)