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HHS Announces a "Settlement Express" Option for Medicare Appeals

HHS's Office of Medicare Hearings and Appeals (OMHA) has long faced a backlog in Medicare appeals to Administrative Law Judges (ALJs). In an effort to address this backlog, OMHA established a Settlement Conference Facilitation (SCF) process. OMHA describes SCF as an alternative dispute resolution process that gives certain providers and suppliers the opportunity to resolve all eligible Part A and Part B appeals at once.

The SCF pilot began in June 2014 focusing on Medicare Part B appeals and has gradually been expanded, due in part to its success. Last week, OHMA announced a new plan to expand the SCF program even further and offer providers a quicker option to resolve eligible payment disputes: SCF Express.

Beginning in June, once accepted to SCF, CMS will provide appellants with a settlement offer (the “Express Settlement Notice”) based on the preliminary data available. The appellant must respond within seven calendar days of the date on the Express Settlement Notice by signing the settlement agreement or declining the SCF Express and proceeding to the actual settlement conference process. OMHA cites the benefits of SCF Express as: (1) no CMS medical review of appeals; and (2) faster resolution, as there are no conferences.

OHMA outlines the updated criteria for SCF-eligible appeals here. They also provide a detailed set of FAQs. Importantly, OMHA reminds stakeholders that the SCF process is a payment negotiation and it is not an opportunity to make arguments regarding medical necessity or Medicare coverage policies. Stakeholders are hopeful that the SCF Express will help clear the lengthy backlog of pending appeals. Stay tuned for updates related to this new initiative.

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Bridgette advises health care providers, ACOs, health plans, PBMs, and laboratories on regulatory, fraud and abuse, and business planning matters, applying her experience in health system administration and ethics in health care to her health law practice.