HOSPITAL APPEALS SETTLEMENT INFORMATION Presenter: Leanne Layne

INTRODUCTION - Presentation Purpose: Relay information - CMS response to recent increase in claim appeals

SETTLEMENTPARAMETERS - Acute Care and Critical Access Hospitals are eligible - Claims must be patient status determinations - Claims must be pending appeal - Claims must be within the timeframe to request an appeal review - Claim Date of Admission prior to Not previously withdrawn/billed for Part B payment

SETTLEMENT DETAILS - Settlement amount will be 68% of net payable amount of denied inpatient - Hospital (Provider) agrees to the dismissal of all associated claim appeals. - Provider: Entity identified by the 6 digit PTAN - All or None

REQUIRED PROCESS - Hospital must go to for the 2 required documents - Hospital Signed Administrative Agreement - Spreadsheet of Claims/Appeals Number - Hospital must submit required documents to: - Hospital must stay appeals during validation process - Requests must be submitted to CMS on or before October 31, 2014

VALIDATION - CMS will review the hospital provided data against their records*** - MAC will send agreement list to hospitals for final review - Hospital will respond with either - Confirmation to proceed - Notice of abandonment - CMS signs Agreement - MAC will effectuate the payment - Appeal entities will dismiss associated appeals (***Discrepancies process on following slide)

VALIDATION: DISCREPANCY PROCESS - CMS may add eligible claims - MAC will send additions/deletions to hospital for review - If hospital agrees: resubmit revised spreadsheet and administrative agreement - If hospital disagrees: MAC and the hospitals will discuss - MAC effectuates a second payment based on Round 2 - Appeal entities will dismiss associated appeals

SETTLEMENT PAYMENT - Single payment (A second payment will be made if discrepancy process is initiated) - Payment made within 60 days of date of Agreement - Provider can NOT seek additional payment from Medicare beneficiary (coinsurance & deductible) - Amounts already paid can be retained - Payment plans/agreement in place can stay in place

ADDITIONAL INFORMATION FROM Q & A - These claim are still considered denied for cost reporting or PS&Rs - No auditors can come back and review settled claims at a later date - CMS would not answer any questions about billing secondary - Pre or post payment reviews can be included - Interest is only applicable if settlement not paid within 60 days of Agreement - If facility decides to abandon settlement, your appeal picks up where you left off - Payment will be made on remit, but no location determined

CONTACT FOR CMS Website: Questions:

QUESTIONS?