• Text Resize A A A
  • Print Print
  • Share Share on facebook Share on twitter Share

Settlement Conference Facilitation

Settlement Conference Facilitation (SCF) is an alternative 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 Office of Medicare Hearings and Appeals (OMHA) level or the Medicare Appeals Council (Council) level of the Medicare claims appeals process.  If a resolution is reached, a settlement document is drafted to reflect the agreement.  As part of the agreement, the requests for hearing or review for the appeals covered by the settlement will be dismissed.

A 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 facilitator is an employee of OMHA, which is a component of the Department of Health and Human Services (HHS) Office of the Secretary, and is organizationally and functionally separate from CMS.  Mediation within this program is centered on facilitating payment negotiations. 

All Medicare Part A and Medicare Part B providers and suppliers who have OMHA or Council appeals pending are encouraged to read the materials on this website to familiarize themselves with the SCF process and eligibility requirements.

Note: SCF is separate and distinct from the Centers for Medicare & Medicaid Services' (CMS) Low Volume Appeals (LVA) Settlement Option.  For more information about LVA, please visit https://go.cms.gov/LVA or contact CMS with questions at MedicareSettlementFAQ@cms.hhs.gov.

SCF Eligibility

SCF Appellant Eligibility Criteria includes the following:

  • The appellant must be a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI);
  • The appellant must have 25 or more SCF eligible appeals pending at OMHA and the Council combined; or, less than 25 SCF eligible appeals pending at OMHA or the Council and at least one appeal has more than $9,000 in billed charges;
  • The appellant cannot have filed for bankruptcy and/or expect to file for bankruptcy;
  • The appellant may be excluded from participation if he or she has or has had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations. 

SCF Appeals Eligibility Criteria includes the following:

  • The appeals must involve request(s) for Administrative Law Judge (ALJ) hearing or Council review filed on or before November 3, 2017;
  • 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 must be met for the eligible appeals;
  • All pending OMHA and Council appeals associated with a single NPI and corresponding Provider Transaction Access Number (PTAN) must be included in SCF;
  • Appeals must not be scheduled for an ALJ hearing or an ALJ hearing must not have been conducted;
  • The billed amount of each individual claim must be $1,000,000 (one million) or less. For the purposes of a statistical sample,  the extrapolated overpayment amount stated in the initial demand notice must be $1,000,000 or less.
    • Settlement agreements with individual claims, or extrapolated overpayments, of $100,000 or less will be fully executed when CMS and the appellant sign the settlement agreement.
    • Settlement agreements with any individual claims, or extrapolated overpayments, in excess of $100,000 (and up to $1,000,000) will be subject to U.S. Department of Justice (DOJ) approval prior to full execution by CMS and the appellant.
  • Appeals must not be involved in OMHA's Statistical Sampling Initiative;
  • Appeals must not be actively engaged in a CMS Medicare appeals initiative that was available on or after November 3, 2017 (i.e., CMS Low Volume Appeals settlement option, the QIC Demonstration Project, or the CMS Serial Claims Initiative);
  • The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration;
  • Appeals must not involve items, services, drugs, or biologicals billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes (e.g., CPT Code 38999 Unlisted procedure, hemic or lymphatic system; K0108 Wheelchair component or accessory, not otherwise specified);
  • Appeals must not involve payment disputes (e.g., the appellant was paid as billed, in full, by the contractor, but the appellant believes the fee schedule or contractor price amount is insufficient payment);
    • Appeals arising from down coding of claims are eligible for SCF.
  • Appeals must not arise from a QIC or ALJ dismissal order; and
  • Appeals must not be beneficiary-initiated appeals of QIC reconsiderations or any appeals arising from Medicare Part C, Medicare Part D, or 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). 

Please note all appeals eligible for SCF must be included in SCF.  Appellants may not select some SCF eligible appeals for settlement and others for ALJ hearing or Council review.

SCF Process

  1. An appellant will submit a Request for SCF to OMHA_SCFAppeals@cms.hhs.gov for all pending OMHA and Council appeals associated with an NPI/PTAN.
    1. The request is an OMHA document available in the Downloads section of this website.
  1. CMS will be informed the appellant has requested SCF.  CMS will have 15 calendar days to determine whether CMS will participate in SCF with the appellant.    

Please note:  Any party may decline to participate at any time during the settlement conference process.   Participation is not mandatory for any party.

  1. After CMS indicates it will participate, an SCF Request Spreadsheet (Spreadsheet) of the appeals eligible for SCF will be created.  The spreadsheet will contain all OMHA and Council appeals believed to be eligible for SCF.
  2. The appellant will receive a Preliminary Notification Package.
  1. The appellant must respond to the Preliminary Notification by submitting the SCF Agreement of Participation within 20 calendar days of the date on the Preliminary Notification.
    1. The SCF Agreement of Participation must be e-mailed, and only handwritten signatures will be accepted (e-signatures using Adobe Acrobat are unacceptable).
  1. Once the appellant’s complete SCF Agreement of Participation is received, an SCF Confirmation Notice will be issued.
    1. The SCF Confirmation Notice includes the following information:
      1. The Confirmation Notice
      2. The final Spreadsheet
  1. SCF Express:  CMS provides a settlement offer to the appellant based on preliminary data available to CMS (e.g., ALJ overturn rates, type of claim or service, etc.).  The appellant can choose to take the SCF Express offer or proceed to the actual settlement conference process.

    Only appellants with appealed claims that have billed amount(s) of $100,000 or less or appeal(s) of an extrapolated overpayment that is $100,000 or less are eligible for SCF Express.  If an appellant has any appealed claims or extrapolated overpayment appeal(s) in excess of $100,000, the appellant is ineligible for SCF Express.
    1. Within 30 calendar days of the date of the SCF Confirmation Notice, an SCF Express Offer Package will be issued to the appellant. 
    2. The appellant must respond (within 7 calendar days of the date on the SCF Express Offer Package) by signing and emailing the proposed  settlement agreement or stating that it declines CMS’ offer and wishes to proceed to a settlement conference.
    3. The proposed settlement agreement signed by the appellant will be forwarded directly to the CMS representative for signature and effectuation.
  1. For those appellants who decline SCF Express and wish to proceed to a settlement conference (or those appellants who do not qualify for SCF Express because they have individual claims, or extrapolated overpayment appeals, in excess of $100,000 (and up to $1,000,000)), OMHA will begin the Pre-Settlement Conference Scheduling Process:
    1. OMHA will send an email to all parties and assigned facilitators providing potential pre-settlement conference dates.  OMHA will select a pre-settlement conference date that accommodates both parties.
    2. OMHA will randomly select a few appeals that will be the focus of CMS and the appellant’s review.  These selected appeals ensure that both parties are considering similar material when determining negotiation posture. This is not a statistical sample.
  1. Pre-Settlement Conference
    1. The settlement conference and position paper submission, if applicable, will be discussed and finalized at the pre-settlement conference.
  1. Settlement Conference (where all appealed claims subject to the conference have billed amount(s) of $100,000 or less or the appeal of an extrapolated overpayment is $100,000 or less):
    1. If an agreement is reached, both parties will sign the agreement the day of the conference.
      1. If the settlement conference session concludes after 2:00pm Eastern Time, or the appellant returns its signed portion of the agreement after 2:00pm Eastern Time, the agreement will be fully executed the next business day.
      2. Settlement discussions will not continue the next business day.
    2. If an agreement is not reached, the appeals subject to the conference will return to the previously assigned adjudicator, if applicable, or to the OMHA and Council docket for future assignment in the order in which the request for review was received.
  1. Settlement Conference (where an appealed claim(s) subject to the conference has a billed amount in excess of $100,000 or an appeal of an extrapolated overpayment in excess of $100,000):
    1. If an agreement is reached, both parties state firmly to the facilitators their agreed percentage.  The facilitator will end the settlement conference.  There will be no further negotiations once the settlement conference has ended.  The facilitator will draft the proposed settlement agreement; however, the parties will not sign the agreement at this time. 
    2. The DOJ will be informed of the proposed agreement.  If the DOJ approves the proposed agreement, the facilitators will notify the appellant and send the draft agreement to the appellant. 
    3. The appellant will have one business day to return their portion of the proposed agreement to the facilitators.  If the appellant does not return the proposed agreement within one business day, the appellant’s SCF request will be cancelled and the appeals will be returned to OMHA and/or Council docket (if the appeal(s) were previously assigned to an adjudicator, the appeals will return to that adjudicator’s docket). 
    4. The facilitators will forward the appellant signed, proposed settlement agreement to CMS.  CMS will have one business day to return its signed portion of the settlement agreement. 
    5. The settlement agreement will be fully executed only after all of the actions above have occurred.

SCF Downloads

Contact Us

If you have any questions regarding Settlement Conference Facilitation, you can submit your questions via email to OMHA.SCF@hhs.gov

Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on June 15, 2018