Settlement Conference Facilitation
As part of the broader commitment by the Department of Health & Human Services to improving the Medicare claims appeals process, the Office of Medicare Hearings and Appeals (OMHA) will be expanding its current Settlement Conference Facilitation (SCF) program to reach additional providers and suppliers. SCF is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals.
OMHA expects to implement the expanded SCF program in April 2018.
Eligibility requirements will include the following:
- The appellant must be a Medicare provider or supplier (for the purposes of SCF, "appellant" is defined as a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI));
- The appeals involve request(s) for Administrative Law Judge (ALJ) hearing or Medicare Appeals Council (Council) review at the Departmental Appeals Board filed on or before November 3, 2017 by appellants:
- With a total of 500 or more appeals pending at OMHA and the Council combined; or
- With any number of appeals pending at OMHA and the Council that each have more than $9,000 in billed charges;
- Note: For appellants with fewer than 500 appeals, individual appeals with $9,000 or less in billed charges may potentially be resolved under the CMS LVA Settlement Option.
- The request(s) for ALJ hearing and/or Council review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision;
- All jurisdictional requirements for OMHA or Council review were met for the eligible appeals;
- The amount of each individual claim in an appeal must be $100,000 or less (for the purposes of an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less);
- The appellant cannot have filed for bankruptcy and/or expect to file for bankruptcy in the future; and
- Certain appellants that have or have had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations will be ineligible.
The following appeals will be ineligible for the expanded SCF program:
- Appeals that are eligible for resolution under a CMS settlement option made available on or after November 3, 2017 (for example, CMS LVA settlement option);
- Note: Appeals that were eligible for, but not settled under, the CMS Hospital Appeals Settlement Process (HASP) may be eligible for resolution in the expanded SCF program.
- Appeals in which the beneficiary was found liable after the initial determination or participated in the reconsideration;
- Appeals of claims that involve services, drugs, or biologicals billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes (for example, CPT Code 38999 Unlisted procedure, hemic or lymphatic system; HCPCS Code J3490 Unclassified drugs);
- Exception: Equipment or items (excluding drugs or biologicals) billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes are eligible for resolution in the expanded SCF program.
- Appeals involving payment disputes (for example, the appellant is arguing a fee schedule or contractor price amount is not sufficient payment);
- Exception: Appeals arising from down coding of claims are eligible for resolution in the expanded SCF program.
- Appeals that have been scheduled for an ALJ hearing, or where an ALJ hearing has already been conducted;
- Appeals that are in OMHA's Statistical Sampling Initiative (that is, the appellant is participating in the OMHA Statistical Sampling initiative and the appeals are part of the universe of appeals that are being resolved in that initiative);
- Appeals seeking OMHA review of QIC dismissals or Council review of ALJ dismissals; and
- Beneficiary-initiated appeals of QIC reconsiderations and any appeals arising from 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).
Additional information about the expanded SCF process and instructions on how to request SCF under the expanded program will be posted on this website when the expanded SCF option becomes available in April 2018.
If you are interested in SCF for appeals filed at OMHA in 2015 or earlier under our current program, please see the appropriate SCF link below for more information: