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Deal or No Deal? The CMS 68% Offer

Four Hospitals have Accepted So Far – Will Yours Be Next?

To help break the log jam of appeals hung up across the country with Administrative Law Judges taking 24 months or longer to rule on them, CMS offers to make a deal with hospitals (excluded from the offer are cancer hospitals, children’s hospitals, inpatient rehabilitation facilities, psychiatric inpatient facilities).

If eligible hospitals file a settlement agreement request by Oct. 31, 2014, then CMS will provide those hospitals with a partial payment of 68% of the net allowable amount for those inpatient claims CMS announced Tuesday, September 9, 2014.

Hospitals may not file for the settlement of some claims and continue to appeal others.

CMS updated its FAQ on Sept. 9 to make the following key points:

  • No settlements are in the works for appeals of coding denials.
  • Providers not filing a settlement request will remain in the normal appeals process.
  • This is a one-time settlement offer. Participating in the settlement offer is completely voluntary.  
  • Claims that have already been reviewed are always excluded from future review by a MAC and Recovery Auditor. Because CERT chooses claims randomly, it is possible that a handful of these claims will be selected for CERT review. This settlement does not impact reviews being conducted under the false claims act, so ZPIC or OIG reviews of potentially fraudulent claims will continue. 

As of September 9, four providers had submitted settlement requests. CMS said, “All passed the “eligible hospital” test and have been forwarded to the appropriate Medicare contractor for validation.”

What are your feelings about this offer? Fair or unfair?

Will it really help resolve healthcare costs for the nation, or hurt the fiscal ability of hospitals to maintain the best facilities, physicians, staff and newest technologies to provide emergency and care service lines to their communities?

We’d love to hear from you.