In an effort to reduce the amount of time that it takes to appeal Medicare claims, the Centers for Medicare and Medicaid Services (CMS) recently announced that long-term care providers will be allowed to appeal some claims decisions without going through the traditional administrative law judge hearing process. Instead of using this process, CMS is allowing some claims to be appealed through an alternative dispute resolution pilot program that it has just implemented. Long-term care providers immediately cheered this news as the administrative law judge process can be extremely lengthy and has contributed to a significant backlog that is taking CMS a long time to work its way through. CMS’ hope is that its new pilot program will be more effective in adjudicating appeals, and long-term care providers are also hoping that this turns out to be the case so that they can obtain disputed Medicare funds that they are entitled to more quickly.
The pilot program is called settlement conference facilitation (SCF). Under SCF, representatives from providers will meet with representatives from CMS and a third party to settle claim disputes. This third party is the “settlement conference facilitator” and is an employee of the Office of Medicare Hearings and Appeals. Facilitators do not have the power to make official determinations on the merits of the claims that are being disputed; instead, their role is to use mediation principles to help the appealing provider and CMS come to a resolution that they can both agree on. Initially, the SCF program will be limited to appealing Medicare Part B claims because of the sizeable backlog that currently exists with these claims. Long-term care providers believe that this backlog is primarily due to overeager auditors who deny claims for small reasons, such as a signature being on the wrong line or small typographical errors. In addition to the program being limited to Medicare Part B, providers must also meet additional criteria in order to use it. For example, the party filing the appeal has to be a Medicare provider or supplier, the amount of each individual claim must be less than $100,000, and finally, at least $10,000 must be at issue if fewer than 20 claims are being disputed. These are just a few of the criteria that must be satisfied in order to use the SCF process. A complete list can be found on the Department of Health and Human Services website. Furthermore, if the appealing party is not satisfied with the outcome of the SCF negotiations, it still has the right to request an administrative law judge hearing and can pursue that course if it would like to.
Long-term care providers are optimistic that the settlement conference facilitation program will be successful and enable them to obtain disputed Medicare funds more quickly than they would have under the traditional appeals process that uses administrative law judges. These funds can then be used for a variety of purposes such as general operations, maintenance, or for employee compensation. Long-term care providers who are interested in obtaining additional financing in today’s low interest environment for growth, acquisitions, or other reasons should also continue to look to the successful financing firm Cambridge Realty Capital and the many different financing options that it offers for these and other purposes.