Regulations

LTC providers will be able to appeal Medicare claims without ALJ

Long-term care providers will be able to appeal certain Medicare claims decisions without utilizing an administrative law judge, the Centers for Medicare & Medicaid Services announced Thursday.

Settlement Conference Facilitation is an alternate dispute resolution process that would bring providers and CMS representatives together to negotiate and settle Medicare disputes with the help of a third party. This settlement conference facilitator would be an employee of the Office of Medicare Hearings and Appeals, which is a separate agency from CMS, according to a fact sheet on the pilot program.

The fact sheet states that, “The facilitator does not make official determinations on the merits of the claims at issue and does not serve as a fact finder, but may help the appellant and CMS see the relative strengths and weaknesses of their positions.”

The pilot program is meant for Medicare Part B claims appealed to at the administrative law judge level. An association of RACs supports the new pilot program. Providers cannot, at this time, use the alternate method to pursue claims appeals under Medicare Part A, C or D. Certain other eligibility criteria apply, such as that the claim cannot have already been assigned to an ALJ.

Click here for more details about eligibility and the process to request settlement conference facilitation.