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Hospital Appeals Settlement information
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  1. Hospital Appeals Settlement information Presenter: Leanne Layne

  2. Introduction Presentation Purpose: Relay information CMS response to recent increase in claim appeals

  3. Settlement parameters Acute Care and Critical Access Hospitals are eligible Claims must be patient status determinations Claims must be pending appeal Claims must be within the timeframe to request an appeal review Claim Date of Admission prior to 10.01.13 Not previously withdrawn/billed for Part B payment

  4. Settlement details Settlement amount will be 68% of net payable amount of denied inpatient Hospital (Provider) agrees to the dismissal of all associated claim appeals. Provider: Entity identified by the 6 digit PTAN All or None

  5. Required process Hospital must go to http://go.cms.gov/InpatientHospitalReviewfor the 2 required documents Hospital Signed Administrative Agreement Spreadsheet of Claims/Appeals Number Hospital must submit required documents to: MedicareAppealsSettlement@cms.hhs.gov Hospital must stay appeals during validation process Requests must be submitted to CMS on or before October 31, 2014

  6. validation CMS will review the hospital provided data against their records*** MAC will send agreement list to hospitals for final review Hospital will respond with either Confirmation to proceed Notice of abandonment CMS signs Agreement MAC will effectuate the payment Appeal entities will dismiss associated appeals (***Discrepancies process on following slide)

  7. Validation: discrepancy process CMS may add eligible claims MAC will send additions/deletions to hospital for review If hospital agrees: resubmit revised spreadsheet and administrative agreement If hospital disagrees: MAC and the hospitals will discuss MAC effectuates a second payment based on Round 2 Appeal entities will dismiss associated appeals

  8. Settlement payment Single payment (A second payment will be made if discrepancy process is initiated) Payment made within 60 days of date of Agreement Provider can NOT seek additional payment from Medicare beneficiary (coinsurance & deductible) Amounts already paid can be retained Payment plans/agreement in place can stay in place

  9. Additional information from q & a These claim are still considered denied for cost reporting or PS&Rs No auditors can come back and review settled claims at a later date CMS would not answer any questions about billing secondary Pre or post payment reviews can be included Interest is only applicable if settlement not paid within 60 days of Agreement If facility decides to abandon settlement, your appeal picks up where you left off Payment will be made on remit, but no location determined

  10. Contact for cms Website: http://go.cms.gov/InpatientHospitalReview Questions: MedicareSettlementFAQs@cms.hhs.gov

  11. Questions?