On August 29, 2014, CMS issued notice that it will provide a process for resolving claims denied based on patient status with admission dates before October 1, 2013. For cases denied during postpayment review, CMS will pay 68% of the net paid amount of the denied claim; for cases denied during prepayment review, CMS will pay 68% of the approximate amount that would have been paid to the provider. CMS will pay the full settlement amount within 60 days of the provider entering into a fully executed Administrative Agreement, which constitutes the settlement agreement between CMS and the provider. Hospitals must submit their requests by October 31, 2014, or otherwise request an extension from CMS.
The following conditions must be met for claims to be eligible for settlement:
There are three important caveats to settlement, however. First, CMS notes that a hospital “may not choose to settle some claims and continue to appeal others.” This language suggests that a hospital must include all eligible claims within its settlement spreadsheet, including both prepayment and postpayment denials. Second, CMS will not pay any interest that has accrued on the claim. Third, and noted only within the Administrative Agreement itself, providers will not be allowed to seek additional payment from a beneficiary or collect any deductible or coinsurance amount for any claim resolved through the settlement. The only exceptions are if the provider has a repayment plan existing with a beneficiary as of the effective date of the settlement, or if the hospital has already retained any deductible or coinsurance amount before the effective date of the settlement.
CMS will conduct a National Provider Call on September 9, 2014 at 12:00pm CST regarding the settlement offer. We have provided a link below to the registration page for the call, along with links to other notable publications regarding the settlement offer.
For additional information related to the contents of this alert, please contact Larry McCarty at email@example.com or Jeff Moore at firstname.lastname@example.org.