Audit and Compliance



A&C Nov 2017

In early November, the Centers for Medicare & Medicaid Services (CMS) and the Office of Medicare Hearings and Appeals (OMHA) announced two new appeals settlement programs in an attempt to reduce the tremendous backlog at the Administrative Law Judge (ALJ) appeals level. The ALJ appeals level is the third level in the five-step Medicare appeals process.

  • The Low-Volume Appeals settlement (LVA). The LVA settlement provides eligible appellants or providers an opportunity to settle eligible appeals at 62% of the net allowed amount.

    Eligibility: This is available to appellants with a low volume of appeals pending at OMHA and the Medicare Appeals Council (MAC), or the fifth appeals level. CMS defines low volume as fewer than a combined 500 Medicare Part A or Part B claim appeals pending at the ALJ and MAC as of November 3, 2017. Further eligibility includes a billed value of each claim of $9,000 or less. CMS mentions other conditions that need to be met in order to be eligible to participate in this program. Unfortunately, they do not outline these conditions. Instead, CMS recommends interested parties monitor its website for further details in the coming weeks.

    Recommendation: Providers interested in this program should develop a report in their audit management and tracking solution to determine how many claims are still in the third or fourth appeal level process and would be eligible for LVA. For TRACKER™ PRO clients, this report can be easily exported through the reporting functionality.

  • Expanded Settlement Conference Facilitation process (SCF). OMHA's website has information pertaining to the expansion of the SCF process. You can obtain that information and instructions here.

At this point, it is too early for providers to decide if they should take advantage of these new programs. Clearly, the first step would be to determine the volume of appeals held up with the ALJ and MACs. CMS may adopt the same detailed criteria they used on previous settlement offers. This will all be detailed in the coming weeks.

CMS Releases Its Annual esMD Program Report

The Electronic Submission of Medical Documentation (esMD) system, implemented by CMS, enables providers to electronically send medical records and supporting documentation to participating review contractors including Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RAs). Since the program's inception in September 2011, the esMD program has grown to process more than 2 million transactions annually.

CMS has added the following document types to the esMD system:

  • Prior Authorization of repetitive schedule non-emergent ambulance transports in certain MAC jurisdictions.
  • ASC X12N 278 HIPAA compliant requests/responses for prior authorizations.
  • First and second level appeal requests.
  • Recovery Auditor discussion requests, which allow providers to submit information to initiate a discussion request on a potential denial.
  • Advance determination of medical coverage. Under the DME program, providers may request prior approval and determine, in advance of delivery, if the purchase of a DME item would likely be covered by Medicare.

Bluemark is proud to be a CMS certified Health Information Handler and Review Contractor for the transmission of esMD documents.