CMS Offers 68% for Your Appeals:
How will it work and is it a good deal ?
Late on Friday August 29, 2014, CMS issued proposed settlement terms to acute care hospitals with pending appeals of denials for inpatient claims, in an evident attempt to appease pressure from Congress and the provider community about the huge backlog of appeals waiting to be adjudicated. So now, CMS wants to settle all “qualifying” claims at 68 percent of the “net paid amount” of the claims.
The big question for providers is – is 68% enough?
This new program *might* clean up hundreds of millions of dollars in appeals now held by CMS and literally stuck at the ALJ level of appeal. However, one must still be prudent… how do you calculate what you might be giving up, if you take the offer?
LOTS of questions arise, so here’s what we discussed on the show:
- Who qualifies for the offer?
- Which claims qualify for settlement?
- How are Settlement Requests made?
- How are Settlement Requests paid to the provider?
- When will these payments made to the provider?
- What is the actual amount of the settlement? How is it calculated?
- Are there other reimbursement considerations and implications?
Ultimately, I’ll let you cheat, here’s what my panel’s consensus was: Yes, it’s worth looking into, but there is no “right answer” – every hospital must decide for themselves about the costs of staying in the untenable appeals process as it exists, or taking the 68% and moving on.
Is it “right” for CMS to insist that you take 68%? NO, but it might be the most practical thing for some hospitals to do. So listen to the discussion, use the downloads and decide for yourself.
Today’s Handouts include:
Text of Settlement Offer page from CMS.gov [PDF]
Administrative Agreement [PDF]
Eligible Claim Spreadsheet [XLS]
Spreadsheet Field Definitions [PDF and DOCX]
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