Introducing the Low Volume Appeals Settlement Process, also known as LVA. This is a new option for agencies who are waiting for ALJ hearings or MAC/DAB reviews. QIRT highly recommends you take advantage of this opportunity to settle fully denied claims.
CMS has just provided a new avenue for agencies stuck waiting for Administrative Law Judge (ALJ) Hearings and Medicare Appeals Council Decisions. According to the rules, there must be an ALJ hearing within 90 days of the hearing request. In reality, this timeline has not been met for many years, and the wait is getting longer.
The QIRT team recently handled a home health hearing that highlights this issue:
- Received a Notice of Hearing for a home health claim.
- The hearing date is scheduled for April 19, 2018.
- ALJ hearing request was filed on July 15, 2014.
- This hearing is being held 1,374 days after the request, despite the 90-day statutory requirement.
- The service at issue is 4/19/12 – 6/17/12.
- The hearing is for service provided exactly 6 years prior.
Ultimately, agencies’ options are: continue waiting for a hearing, taking chances on which judge is assigned the appeal, and incur the additional cost in time and money to attend the hearing… or try this CMS settlement option. QIRT experts recommend most agencies consider the CMSLow Volume Appeals Settlement Process (LVA).
Why consider Low Volume Appeals Settlement?
Low Volume Appeals Settlement (LVA) will obtain a 62% recovery of the billed amount for fully denied claims in a much shorter period than waiting for the hearing. It only applies to fully denied home health and hospice claims that are not part of an extrapolation of the denial. There are also other eligibility exemptions. However, claims fully denied for an invalid face-to-face encounter, not homebound, or incomplete plan of care would most likely be eligible. Thus, the appeals process will remove these claims.
In addition, an agency can make an Expression of Interest to pursue but does not have to commit to pursuing. In this way, an agency can see which claims are eligible and weigh the benefits of continuing. While ALL eligible claims for the agency would have to be part of the settlement, LVA still offers a reasonable return on denied amounts to restore monies lost when the claims are denied. Note that partially denied claims cannot be part of the Low Volume Appeals Settlement option but will continue to hold their place in the appeals queue.
Who should consider LVA? When will LVA occur?
Nearly all agencies will qualify to use Low Volume Appeals Settlements (500 claims, $9000 per claim limit) and thus smaller agencies may benefit even more. The window to apply is based on NPI number (odd or even) and the period to express interest begins in February so this will come up quickly.
For agencies waiting years for a hearing, LVA may offer a viable resolution to getting their appeals.
By: Joe Osentoski, RN-BC, QIRT Reimbursement Recovery & Appeals Director
Have questions about Low Volume Appeals Settlements or the appeals process in general? Contact the QIRT experts today.