Struggle to Balance Improper Payments & Medicare Appeals Claims Continues

On Wednesday, the Government Accountability Office provided testimony to Congress regarding improper payments. The report found that Medicare and Medicaid were two of the top five programs with the highest reported amounts of improper payments in 2013. Recent reports about improper payments had led to an increase in auditing by the government to recover funds, particularly RAC audits. Well, RAC audits were put on hold in February due to a huge backlog of claims and appeals from providers.

To assist with some of these Medicare disputes, CMS proposed a pilot program for an alternate form of dispute resolution earlier this week called Settlement Conference Facilitation. The reason that there is such a backlog is due to the lack of administrative judges available, so this new pilot seeks to provide a different way to alleviate the issue with the number of open claims. The Settlement Conference Facilitation, according to the HHS website, is “designed to bring the appellant and the Centers for Medicare and Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the Administrative Law Judge hearing level of the Medicare claim appeals process.” If an agreement is made, then the request for an Administrative Law Judge hearing will be dismissed, helping to reduce the number of these claims.

To be eligible for these types of claims, there are several criteria, a list of which can be found on the Settlement Conference Facilitation Pilot section of the HHS website.

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