On June 17, 2019, the Centers for Medicare & Medicaid Services (CMS) announced a settlement option for certain IRF appeals pending at any of the four fee-for-service Medicare administrative appeals levels: the Medicare Administrative Contractor (MAC), qualified independent contractor (QIC), the Office of Medicare Hearings and Appeals (OMHA) Administrative Law Judge (ALJ), and/or the Medicare Appeals Council (Council) stage.
The settlement option is limited to IRF appellants that filed appeals at the MAC for redetermination on or before August 31, 2018 that are pending or eligible for appeal at the MAC, QIC, OMHA or Council stages of appeal.
Under the IRF settlement initiative, CMS will pay 69 percent of the net payable amount for most claims associated with pending IRF appeals. However, CMS will pay 100 percent of the net payable amount for the following:
- Claims denied solely based on the threshold of therapy time not being met (where the claim did not undergo a medical necessity review for the IRF services); and
- Claims denied solely because the justification for group therapy was not documented in the medical record.
Expressions of Interest must be filed between June 17, 2019 and September 17, 2019.