Low-Volume Appeals (LVA) and expansion of its Settlement Conference Facilitation (SCF) program are two new offerings by the Office of Medicare Hearings and Appeals (OMHA) to improve the appeal process.
In an effort to improve the Medicare appeal process, hospitals are being offered two new programs – one designed for hospitals with a low volume of pending Part A and B claims at the administrative law judge (ALJ) level and the expansion of the federal Settlement Conference Facilitation (SCF) program.
The two programs were announced on Nov. 3 and posted today by the Centers for Medicare & Medicaid Services (CMS) and the Office of Medicare Hearings and Appeals (OMHA).
“In a surprise move, CMS announced that they are offering a third settlement offer to hospitals (that) have outstanding cases awaiting hearings at the ALJ or Medicare Appeals Council level,” wrote Ronald Hirsch, MD, in a statement to RACmonitor. “But unlike previous offers, this offer only applies to hospitals with fewer than 500 Part A and B claims awaiting adjudication where no single claim exceeds $9,000. CMS is now offering a settlement of 62 percent of the net allowed amount.”
As of today, there are still no available details on how hospitals can apply for the settlement or the time frame for applying for participation. CMS has indicated that it will post updates on its Hospital Appeal Settlement Process page at https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Hospital-Appeals-Settlement-Process-2016.html.
“This offer has a couple of interesting points,” said Hirsch. “First, it appears from the $9,000 limit that they are targeting a reduction the number of appeals that remain after the hundreds of thousands of appeals that resulted from the many Recovery Audit Contractor (RAC) denials of short-stay inpatient admissions.”
Hirsch, vice president of physician advisory services at R1, said that while CMS had what he described as “many takers” of its 68 percent and 67 percent offers, the number of remaining claims still is taxing the ALJs handling an overwhelming number of appeals.
Hirsch also described the offer of 62 percent as interesting because in most negotiations, the first offer is a starting point and subsequent offers are higher.
“By offering only 62 percent in this third round, it seems they (CMS) are hoping more providers have become tired of waiting for their hearings and will accept this lower payment,” Hirsch said. “Anecdotally, I find most hospitals that did not accept the first two offers declined the offers on the principal that they were right and the RAC wrong. Offering them now a lower percentage is likely to be viewed as an insult rather than a legitimate offer to consider. Time will tell how well this is accepted.”
CMS also noted that there will be an expansion of the SCF process, but gave no details.
The 30th Annual Compliance Institute for the Health Care Compliance Association (HCCA) is scheduled to take place in Orlando next week. If you are there,
Last summer’s Loper Bright decision was supposed to be a watershed moment for administrative law. By overturning Chevron deference, the U.S. Supreme Court declared that
Please log in to your account to comment on this article.
Breast biopsy procedures may be clinically straightforward but accurately translating them into compliant billing can be anything but. In this focused webcast, Shawn Blackburn, CPC, CPMA, CIC, CRC, CCS-P breaks down how imaging guidance, lesion count, laterality, and payer expectations all impact how these procedures should be reported. Through clear explanations and real-world scenarios, you’ll gain practical insight into aligning clinical workflows with billing requirements, avoiding common pitfalls, and ensuring your documentation supports accurate reimbursement and compliance.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Sherri L. Clayton, RHIT, CSS. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →
Have a Medicare regulation question you’d love Dr. Hirsch to answer? Now is your chance! CLICK HERE to learn more→
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
