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The 68-percent appeals settlement solution from the Centers for Medicare & Medicaid Services (CMS) came as breaking news back in early September 2014, RACmonitor Publisher Chuck Buck recalled.

“We posted our first story on the offer on Sept. 4, and followed up with a special webcast with healthcare attorney Andrew Wachler that took place on Sept. 17,” Buck said.

One month later, RACmonitor conducted a survey revealing that nearly a third of  respondents were choosing to tough it out and would not participate in either the settlement conference facilitation pilot nor the statistical sampling initiative – two of the three options put forth by CMS in an effort to reduce the volume of inpatient status claims pending in the appeals process. In explaining why they would not be participating, 3.7 percent reported that they felt that the 68-percent settlement offer was not a “fair settlement amount,” saying that they might have participated had the amount been higher. Interestingly, 5.5 percent declined to participate because they wanted to send “a message to CMS” that the Recovery Audit Contractor (RAC) system is unfair, and that agreeing to participate would be a recognition that they thought the RACs were doing “a good job.”

“The more we reported on the backlog of appeals at the Office of Medicare Hearings and Appeals (OMHA), the more of a rising chorus we heard from our readers,” Buck said. “That’s why in early July, Drew Wachler suggested that RACmonitor conduct another survey to determine the interest providers might have in reopening the 68-percent solution.”

“Actually, Drew told me recently that it was he who suggested to an official at OMHA that the agency reconsider opening discussions on this,” Buck said. “Drew said that the official told him that no one there at OMHA had considered the suggestion until he brought it to their attention.”

Buck said there was enough internal data from readers and listeners of Monitor Mondays to move forward with a special-edition town hall broadcast on the topic. The broadcast aired on Aug. 9, featuring Wachler and Steven Greenspan, vice president of regulatory affairs for Optum Executive Health Resources, which sponsored the broadcast.

During the 60-minute live town hall, Wachler and Greenspan polled audience members, seeking to determine from participants whether their organizations would consider participating in the 68-percent settlement if it were reopened. The poll results from more than 200 respondents were interesting: 48 percent indicated that their organization would consider it; another 48 percent were unsure of their organization’s position regarding participation; and only 4 percent indicated that their organization would not participate. 

These results demonstrate that there was considerable interest in the provider community. The information gathered should assist CMS in concluding that reopening the agreement would reduce the backlog of appeals, thus allowing other providers to move through the appeals process more easily. Furthermore, it would help CMS reduce the amount of interest that could have to be paid on the pending appeals.

The 68-percent settlement is consistent with the currently active settlement conference facilitation (SCF) pilot program, and it would help hospitals with pending appeals to resolve these claims in a more expedient matter, without waiting for an administrative law judge (ALJ) hearing.

“Last week, RACmonitor reported that CMS had in fact reopened what had until recently been known as the 68-percent settlement,” Buck said. “Wachler and an associate with his firm, Erin Diesel Roumayah, Esq., reported in detail the new process, which is called the 2016 Hospital Appeals Settlement Process.” Buck also reported that a Monitor Monday listener survey on Sept. 19 revealed that 83 percent of the broadcast’s audience were in favor of re-opening the 68-percent settlement program.

Moving forward, the new process allows eligible hospitals to enter into settlement agreements with CMS to resolve and withdraw eligible inpatient status claims. In contrast to the 2014 settlement, participating hospitals will now receive 66-percent payment of the net allowable amount of the settled claims.

“I really believe that all those who attended yesterday’s CMS open door forum on the new settlement owe a debt of gratitude to Drew Wachler for championing this cause,” Buck said. “I also want to thank Steven Greenspan for helping to bring this important issue to the attention of the RACmonitor audience by sponsoring the live broadcast in August.”

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Mark Spivey

Mark Spivey is a national correspondent for RACmonitor.com, ICD10monitor.com, and Auditor Monitor who has been writing and editing material about the federal oversight of American healthcare for more than a decade.

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