Medicare Reimbursement: CMS Launches New LVA Process for Settling Payment Appeals

While Part B lab reimbursements may be going down, the good news is that it just became easier to challenge Medicare payment denials. Here is an overview of the new CMS Low Volume Appeals settlement process and how to take advantage of it with regard to both Part A and Part B claims. Here is an overview of the LVA process and how to take advantage of it.

Potential Recovery

The LVA settlement process, which officially began on February 5, 2018, offers timely partial payment of 62% of the net Medicare approved amount.

Eligible Providers

LVA settlement is open to Medicare Part A and Part B providers, including labs, as well as physicians and suppliers (referred to collectively as “appellants”) with fewer than 500 combined pending appeals with the Office of Medicare and Appeals and Medicare Appeals Council (Council) at the Departmental Appeals Board as of November 3, 2017. Your lab is not eligible to file LVA settlement appeals if it is currently involved in False Claims Act (FCA) litigation or is subject of a pending criminal, civil or administrative investigation for FCA or other program integrity concerns. Other ineligible appellants include:

• Beneficiaries, enrollees, their family members or estates;
• State Medicaid Agencies;
• Medicare Advantage Organizations (Medicare Part C); and
• Those that have filed for or expect to file for bankruptcy.

Eligible Appeals

Appeals must meet all seven of the following criteria to be eligible for LVA settlement:

• [_] The appeal was pending before the Office of Medicare Hearing and Appeals (OMHA) and/or Council level as of Nov. 3, 2017;
• [_] It was properly and timely at the OMHA or Council levels as of Nov. 3, 2017;
• [_] The appeal is still pending as of the date the LMV agreement is signed (as explained in the Settlement Process section below);
• [_] The appeal’s total billed amount is $9,000 or less;
• [_] The claims in the appeal were denied by a Medicare contractor and remain in a fully denied status within the Medicare system;
• [_] The claims were submitted under either Medicare Part A or B; and
• [_] The claims are not part of an extrapolation.

The All-or-Nothing Condition

If an your NPI is approved for participation in the LVA process, the resulting settlement covers all eligible appeals from you. In other words, the appellant is not allowed to choose to settle some eligible appeals but not others.

The Settlement Process

There are detailed procedural rules you must follow to use the LVA process.

Step 1: EOI Submission

It is up to you, the appellant, to initiate the process by filing a form called a Low Volume Appeals Settlement Expression of Interest (EOI) to CMS at MedicareAppealsSettlement@cms.hhs.gov during the appropriate window, based on your NPI.

EOI Submissions Windows

Labs with multiple NPIs must submit one EOI per NPI with eligible appeals during the appropriate window depending on whether the NPI ends in an odd or even number.

Step 2: Determination of Participation Eligibility

CMS must review the EOI to determine if you are eligible to participate in the LVA process. If so, it will send you:

• A Spreadsheet of potentially eligible appeals and associated claims; and
• An Administrative Agreement.

Step 3: Validation & Signing

You must next review the Spreadsheet and either validate it or notify CMS of any discrepancies you identify by submitting an Eligibility Determination Request (EDR) form to MedicareAppealsSettlement@cms.hhs.gov within 15 days of receiving the Spreadsheet. If there are no discrepancies, you must also sign the Agreement and send it to CMS for counter signing; if there are discrepancies, Step 4 comes into play.

Step 4: Reconciliation

You have 30 days to resolve any identified Spreadsheet discrepancies with CMS. When and if that happens, you must sign the Agreement and send it to CMS for counter signature. Once CMS counter signs, whether via Step 3 or 4, it will send you a copy of the fully executed Agreement.

The Withdrawal Right

If you get cold feet about using the LVA to settle your pending appeals, you may withdraw from the process and retain full appeal rights, as long as you have not yet returned the signed Agreement to CMS. But once CMS gets the signed Agreement from you, it will “stay,” i.e., freeze proceedings on all of your pending appeals and there will be no turning back.