Settlement Conference Facilitation Pilot
Settlement Conference Facilitation is a pilot alternate dispute resolution process designed to bring the appellant and the Centers for Medicare & Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the Administrative Law Judge hearing level of the Medicare claim appeals process. If a resolution is reached, a settlement document is drafted by the settlement conference facilitator to reflect the agreement and the document is signed by the appellant and CMS at the settlement conference session. As part of the agreement, the requests for an Administrative Law Judge hearing for the claims covered by the settlement will be dismissed.
The settlement conference facilitator uses mediation principles to assist the appellant and CMS in working toward a mutually agreeable resolution. The facilitator does not make official determinations on the merits of the claims at issue and does not serve as a fact finder, but may help the appellant and CMS see the relative strengths and weaknesses of their positions. The settlement conference facilitator is an employee of the Office of Medicare Hearings and Appeals, which is a component of the HHS Office of the Secretary, and is organizationally and functionally separate from CMS.
The OMHA Settlement Conference Facilitation program is different and separate from the CMS Part A option for resolving Part A inpatient admission denials that was announced August 29, 2014. If you are a hospital seeking to resolve Part A claims denied on the basis that an inpatient admission should have been billed as Part B outpatient services, please refer to http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html for information on the CMS resolution option and how to request an Administrative Agreement to exercise the option.
To be eligible for the Settlement Conference Facilitation (SCF) process:
- A request for hearing must appeal a Medicare Part B Qualified Independent Contractor (QIC) reconsideration decision;
- The appellant must be a Medicare provider or supplier. For the purposes of this pilot, “appellant” is defined as a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI) number (see the Settlement Conference Facilitation Pilot Fact Sheet for more information on this eligibility requirement).
- The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration;
- All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims;
- The request for hearing must have been filed in 2013 and not be currently assigned to an Administrative Law Judge;
- The amount of each individual claim must be less than $100,000. For the purposes of an extrapolated statistical sample, the extrapolated amount must be less than $100,000.
- At least 20 claims must be at issue, or at least $10,000 must be in controversy if fewer than 20 claims are involved;
- There cannot be an outstanding request for OMHA statistical sampling for the same claims; and
- The request must include all of the appellant’s pending appeals for the same item or service at issue that meet the SCF criteria. For example, if an appellant has 50 wheelchair appeals pending that meet the requirements above, the appellant must submit a request for SCF for all 50 wheelchair appeals.
- Appellants may submit an SCF request for appeals involving multiple items or services, provided the appellant has included all of the appeals that meet the above eligibility requirements in its SCF request, for all of the items or services involved in the appeals.
- Appellants may not request an SCF for some but not all of the items or services included in a single appeal. For example, if an individual appeal has at issue 10 diagnostic tests and 10 drugs/biologicals, an appellant may not request that the diagnostic tests go to SCF and the drugs/biologicals go to hearing.
Beneficiary-initiated appeals of QIC reconsiderations are not included in this pilot because those appeals are being prioritized for a hearing before an Administrative Law Judge. Medicare Part A, Medicare Part C, Medicare Part D, and appeals of Social Security Administration decisions regarding entitlement, Part B late enrollment penalties, and Part B and Part D income related monthly adjustment amounts (IRMAAs) are not eligible for the Settlement Conference Facilitation process at this time. In addition, requests for reviews of QIC dismissals are not eligible for the Settlement Conference Facilitation process.
We encourage you to read the entire Settlement Conference Facilitation Pilot Fact Sheet and process flowchart linked in the Downloads section before requesting a settlement conference. Please continue to visit this site for the most up-to-date instructions and helpful templates for requesting a settlement conference.
You must complete a written request for SCF and a spreadsheet providing detailed information on the claims in your request for SCF. While use of the pre-formatted templates (see Downloads section) is not mandatory, all of the information requested in the templates must be provided. If any information is missing or information is not easily identifiable or discernable by the settlement conference processing team, you will receive notice of the deficiency in your request and will be given 10 calendar days from receipt of the notice to resolve the deficiency. Failure to resolve identified deficiencies will result in rejection of your request and your appeals will be returned to the standard hearing process for adjudication.
In addition to submitting a written request for SCF and a claim spreadsheet, you must complete the Settlement Conference Facilitation Agreement of Participation. Failure to complete the agreement will result in a rejection of your request for a settlement conference.
Rejection of a request for SCF is not appealable. Prior to requesting SCF, please read the Settlement Conference Facilitation Pilot Fact Sheet, Process Flowchart, Request for Settlement Conference Facilitation Template, Settlement Conference Facilitation Request Spreadsheet, Settlement Conference Facilitation Agreement of Participation, and the Settlement Conference Facilitation Standard Settlement Terms. This will ensure you understand the requirements and procedures of the pilot program and your responsibility as a potential participant in the process.
If you have any questions regarding the Settlement Conference Facilitation pilot, you can submit your questions via email to OMHA.SCF@hhs.gov.
- Settlement Conference Facilitation Pilot Fact Sheet
- Settlement Conference Facilitation Process Flowchart
- Request for Settlement Conference Facilitation Template
- Settlement Conference Facilitation Agreement of Participation
- Addendum to Settlement Conference Facilitation Agreement to Participate
- Settlement Conference Facilitation Request Spreadsheet
- Settlement Conference Facilitation Standard Settlement Terms