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Whitmer Faces Uphill Grind On Healthcare Agenda

By PAUL NATINSKY
Governor-elect Gretchen Whitmer has her work cut out for her. Despite historic gains for Democrats and women in Michigan and national midterm elections, Michigan’s legislature retains its Republican majority, and thus presents the new governor with an uphill challenge on all of her initiatives, including her healthcare plan, titled, “Get It Done: Healthy Michigan, Healthy Economy.”

The 19-page document covers a full range of issues facing a state that has low to middling marks on health status, access to care and the cost of healthcare services.

“The state of Michigan has invested very little in public health—just enough to meet what is needed to draw down federal funding,” stated Whitmer in ‘Get It Done.’”

To remedy that state of affairs, Whitmer pledges to “protect Healthy Michigan gains,” from 2014, when then-Gov. Rick Snyder expanded the state’s Medicaid program and helped cut Michigan’s uninsured rate from 18 percent in 2011 to just over 5 percent in 2017. Whitmer made her legislative cooperation with Snyder on this issue one of the focal points of her campaign.

Overall, Whitmer’s plan addresses four main points:
-Making healthcare more affordable
-Expanding access to healthcare
-Improving quality
-Investing in public health

Whitmer looks to reinsurance to better provide for the financial risk of treating Michigan’s high-risk, low-health-status population. Borrowing from other states’ approaches to keeping coverage affordable for “super utilizers of healthcare,” Whitmer proposes “a Michigan reinsurance program (that) would lower costs here as well by preventing insurance premiums from being driven up by over-utilization of our state healthcare system and should be examined in conjunction with a 1332 innovation waiver to pull down federal pass-through savings.”

She cites examples from Alaska, Maryland, Minnesota and Oregon, which she states have had positive results lowering health insurance costs resulting from super utilizers of healthcare and leveraged federal dollars to pay for it. “Oregon brought in $30 million in federal funding for its reinsurance program.16 Alaska drew down $300 million in federal funding over five years to fund its reinsurance program.17 Minnesota has brought in $271 million in federal funding per year. After years of double-digit increases, premiums fell by an average of 15 percent following the implementation of Minnesota’s reinsurance program. In Maryland, average individual market premiums for 2019 are expected to decrease by nearly 14 percent after the state received federal approval to implement a reinsurance program. Without reinsurance, 2019 premiums would have increased by 30 percent.”

Reducing prescription drug costs has been another bellwether issue for candidates on both sides of the aisle. Whitmer quotes National Council on State Governments. ““Prescription drugs account for almost 10 percent of overall health spending in the United States, totaling $263 billion annually.” She added that “prescription spending is the fast growing cost of the health care dollar; in 2015, prescription drugs had the largest price increases in 24 years”
“As governor I will implement transparency standards and strong consumer protections that facilitate better price negotiations between hospitals and the pharmaceutical industry,” stated Whitmer. She cites other states that have adopted transparency laws on prescription drug costs: California requires advance notice of price increases over 16 percent; Oregon requires a pharmaceutical company to disclose corporate profits if a drug’s price increases over 10 percent, and Nevada requires insulin makers to justify price increases. In Vermont, the law requires the pharmaceutical industry to justify price increases on the top 15 drugs that account for the most state spending on prescription medicines.

Whitmer also made extensive use of access issues during her campaign, as did Democrats nationwide. The national flagship issue here is access to healthcare for those with pre-existing conditions, including asthma, cancer, diabetes and other conditions that have made it difficult for sufferers to buy health insurance.

“If protections for pre-existing conditions are repealed by Congress or overturned by a conservative majority on the U.S. Supreme Court, my administration will work to pass legislation here in Michigan that guarantees coverage for people with preexisting health conditions,” she stated in “Get It Done.”

The governor-elect also outlined a nursing scholarship program aimed at addressing a nursing shortage in Michigan.

The new governor is prepared to put her money where her mouth is, pledging significant efforts toward resources for mental health, research, telemedicine and safe drinking water, in part through federal funds and as part of an infrastructure improvement plan.

Of course, funding and support for measures, state and federal, will be an uphill grind for the new governor, who will be working against Republican majorities at home and in Washington. Still, issues such as pre-existing condition protection and drug cost control are rapidly becoming bi-partisan issues, at least rhetorically. Whitmer’s term runs through the 2020 election cycle, so it will be interesting to see what materializes during the second half of her first term.

House Dems Will Steer Health Policy

By EMMARIE HUETTEMAN
For the first time since passing the Affordable Care Act, Democrats will soon control the House of Representatives and its powerful health committees. But Republicans’ tightened grip on the Senate means those hoping for another round of dramatic, progressive reforms may be disappointed.

Empowered by voters outraged over Republican attempts to chip away at the law’s protections for the sick, Democrats owe much of their midterm takeback to health care issues. And Democratic leaders say they are ready to get back to work, this time training their sights on skyrocketing drug prices, among other policy conundrums, with a majority of House votes and a slate of new committee chairmanships in hand.

In a few weeks, House Democrats will meet to elect their leaders, including several committee chairs who will be responsible for the nation’s health care policy and spending in the coming years. Hill denizens expect those currently serving as the top Democrat on most House committees to ascend to the chairmanships, with few if any members mounting serious challenges.

Those basking in a post-“blue wave” glow would do well to temper their expectations, recalling that the Republican-controlled House had already voted 54 times to unravel some or all of the Affordable Care Act by its fourth birthday in 2014. In most cases, Democrats in the Senate and White House stopped those efforts in their tracks.

With the Senate (and the presidency) remaining under Republican control and even fewer moderate Republicans left in the House after this election, Democrats will struggle to move legislation without Republican support. What they can do is hold hearings, launch investigations and generally unnerve the pharmaceutical industry, among other likely adversaries.

And there’s a chance they could strike a deal with President Donald Trump, whose administration is moving to crack down on drug companies.

Who are the members most likely to wield the gavels? And what will they do with that power? Here’s a look at some of the major committees that influence health policy — and the people who may lead them.

The Committee on Energy and Commerce: Rep. Frank Pallone, New Jersey
Pallone, who has served in the House for 30 years, became the top Democrat on this influential committee in 2015. Should he become chairman, he would be responsible for the broadest health portfolio in the House, which includes Medicaid, public health, insurance and drug safety. This is the committee that marked up the Affordable Care Act in 2009 (when Pallone chaired the health subcommittee) and the House Republican repeal effort in 2017.

Under the Trump administration, Pallone has touted his stewardship of bipartisan legislation reauthorizing the fees charged to manufacturers to review the safety of prescription drugs and medical devices. He has also called for hearings on “mega-mergers” like the proposed merger between CVS and Aetna and worked with other Democrats to counter Republican attempts to undermine the Affordable Care Act.

Unsurprisingly, his influence over health care issues has attracted a lot of money from pharmaceutical companies, health professionals, HMOs and other industry players. By mid-October, Pallone had received more than $945,000 in campaign contributions from the health sector for this election, according to the Center for Responsive Politics. According to a KHN analysis, nearly $170,000 came from political action committees associated with pharmaceutical companies.

The Committee on Oversight and Government Reform: Rep. Elijah Cummings, Maryland
Cummings could prove the pharmaceutical industry’s biggest headache come next year. Having served as the committee’s ranking member since 2011 — a post that lacks the chairman’s subpoena power — he has been champing at the bit to hold drugmakers accountable.

Shortly after Trump’s inauguration, Cummings approached him about working together to lower the cost of prescription drugs (to no immediate avail), and he has partnered with other lawmakers to demand information from pharmaceutical companies about their drug pricing strategies. Previewing what a Cummings-led committee might look like, he has even launched his own investigations into drug costs, releasing reports with his findings.

Drugmakers have wasted few campaign contributions on Cummings: He has received just $1,000 from their PACs this election, according to data analysis by KHN.

In a statement to Kaiser Health News, Cummings said Democrats would conduct “credible, responsible oversight” of the Trump administration, adding: “For healthcare, that means investigating skyrocketing prescription drug prices, actions that would threaten protections for people with preexisting health conditions, and efforts to undermine the Medicaid program.”

The Committee on Ways and Means: Rep. Richard Neal, Massachusetts
Ways and Means oversees Medicare and influences health policy through its jurisdiction over taxes. Though Neal became the top Democrat on this committee in 2017, he has been involved in health care much longer, having played a part in the crafting of both the Affordable Care Act and the failed reform effort under the Clinton administration in 1993.

Facing a primary challenger who touted her support for “Medicare-for-all” in his deep-blue district, Neal denied that he opposes the progressive single-payer proposal. But he also said Democrats should focus on shoring up the Affordable Care Act, particularly its protections for those with preexisting conditions and caps on out-of-pocket expenses. (He won handily.)

The health sector was by far one of the top contributors to Neal’s re-election campaign this year, giving more than $765,000, according to the Center for Responsive Politics. Neal’s district includes the headquarters of several health insurers and other medical companies, which makes him a prime target for campaign contributions.

The Committee on Appropriations: Rep. Nita Lowey, New York
If chosen, Lowey would become the first woman to chair the powerful House Committee on Appropriations, holding the nation’s purse strings.

Like Neal and Pallone, Lowey was first elected to Congress in 1988, and she became the committee’s top Democrat in 2013. She has been a dedicated and effective advocate for investing in biomedical research into major diseases like diabetes and Alzheimer’s, as well as public health programs like pandemic preparedness.

She has also long championed women’s health issues, proving a vocal critic of the Trump administration’s proposed gag rule on Title X funding, among other policies. Watch for her to continue to push back on the administration’s efforts to restrict access to abortion rights.

And on the Senate side, the Committee on Finance: Sen. Chuck Grassley, Iowa?

The rumor mill favors Grassley, the Republican who has served most recently as the chairman of the Senate Committee on the Judiciary, to replace retiring Sen. Orrin Hatch (R-Utah).

Senate Republican leaders have signaled that entitlement programs like Medicare and Medicaid could use trimming and, with Republicans emerging from the midterms with a slightly bigger majority, this committee could have its hands full.

Hatch proved a friend to the pharmaceutical industry, and his war chest reflected that, taking in more than $850,000 in campaign contributions from drugmaker PACs in the past decade alone, according to a Kaiser Health News analysis. But Grassley has taken a more adversarial approach to the industry, working with a Democratic colleague last summer to pressure drug companies to list their prices in direct-to-consumer ads, for instance.

Grassley held the chairmanship from 2003 to 2006, leaving him two more years at the top, should he want it. (Senate Republican chairs may serve for only six years.) But he might choose to stay on as head of the Judiciary Committee, in which case the next chairman may be the next-most-senior Republican: Sen. Mike Crapo of Idaho.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. http://www.kaiserhealthnews.com

ON POINT WITH POs: Strategic Partnerships

By EWA MATUSZEWSKI
At this risk of entertaining numerous strategic partnership requests following the publication of this blog, I want to explore the benefits of partnerships that may or may not have financial benefits, yet bring the strengths of two or more parties together for the greater good.

What has me thinking of partnerships in general is the soon-to-be launched integrated primary care clinic our PO is opening at the Warren location of the Judson Center. Judson Center provides autism programs, behavioral health services, child and family services including foster care and adoption, and disability support services throughout Southeast Michigan. With the opening of the clinic, they can add primary care to these services, switching up the converse trend of bringing behavioral health into primary care and at the same time supporting the State’s Section 298 initiative to better coordinate physical and behavioral health services.

We first became acquainted with Judson’s work through collective efforts to expand the PCMH neighborhood. At the same time, we were getting to know each other as participants in Oakland County’s ECHO program, one of the best regional examples of a community health-based strategic alliance I have ever experienced. Judson approached us to jointly apply for a health and well-being grant. While the first grant request was not accepted, a second joint grant application request for the integrated behavior health clinic model was approved by the Michigan Health Endowment Fund; the clinic is slated for opening in January 2019.

Healthcare organizations are uniquely positioned to enter into strategic partnerships with each other as well as community-based organizations that comprise the PCMH-N. When vital prevention program knowledge is available through healthcare organizations, it’s often critical to partner with a group that is already in the community trenches. The YMCA of Metropolitan Detroit, for example, offers rehabilitation services through the DMC’s Rehabilitation Institute of Michigan to facilitate the rehabilitation process for those recovering from a serious illness or injury. Our organization has a partnership with (Detroit) Central City Integrated Health to provide diabetes prevention programs. The Michigan Osteopathic Association is working with Michigan Health Information Network to help physician practices update their technology and data and information sharing. It’s not a moneymaker, it’s an effort to capture information that can be shared to improve patient outcomes and cost efficiencies through avoidance of duplicate testing and access to the tech tools physicians need to practice the 21st century model of medicine.

In 2017, several Michigan POs, including MedNetOne, created an independent physician organization alliance, Michigan Providers of Healthcare Services (MiPHCS) to not only share best practices but to create economies of scale in dealing with some of the large payors. While the fledgling partnership may be greeted with skepticism by some, it’s a new day in healthcare and organizations who continue to go it alone in all their initiatives may find themselves redundant, eclipsed by progressive organizations that see strategic partnerships as the best means to meet both patient-centric and community goals and sustain financial viability as well.

MiPHCS also responds to gripes that Michigan insurers are going out of state to select vendors for Michigan-based health programming. Complaining without offering solutions is a sign of weak leadership. MiPHCS offers just one example of a local solution that can impact Michigan patient populations through program offerings including diabetes self-management, care management and other training and hands-on activities that enhance health and well-being.

When we enter and support strategic partnerships, we make it easier for Michigan payors and community-based organizations to reach their goal of a healthier Michigan. It is incumbent on us to consider what strategic partnerships may be best suited to our own organizations as we seek collaborative solutions for issues the healthcare community deeply cares about.

COMPLIANCE CORNER: PRRB Appeals Rules Change

By SARAH HILLEGONDS
In August, the Provider Reimbursement Review Board released 90 pages of updated rules governing its appeals process. The rules were issued with immediate effect and apply to all pending and future appeals. If a provider fails to comply with these new rules, the PRRB has discretion to dismiss the appeal.1 Because appeals before the PRRB are typically high-value cases, it is critical that attorneys and providers that have cases before the PRRB understand the rule changes.

As background, the PRRB is an independent adjudicating body of the United States Department of Health and Human Services to which a Medicare Part A provider may appeal if dissatisfied with a “final determination” by a Medicare contractor of the Center for Medicare & Medicaid Services. A “final determination” for purposes of a Part A appeal include, but are not limited to, notices of program reimbursement, exception determinations, and other determinations issued by CMS or its contractors with regard to the amount of total reimbursement due to the provider.2 In order to appeal a final determination to the PRRB, the amount in controversy for a single provider must be at least $10,000.3 For two or more providers, the amount in controversy must be $50,000 or more.4 Part A providers that most often utilize the PRRB process to challenge program reimbursement decisions are hospitals.

Noteworthy rule changes include, but are not limited to, the requirement that the parties file a preliminary position paper with corresponding exhibits with the PRRB. Previously, parties were required to exchange preliminary position papers, but were only required to file a cover sheet, list of exhibits, and a good faith statement with the PRRB.5 Under the new rules, arguments and documents not included in the preliminary position paper may be excluded at the hearing except for good cause. As such, providers will need to fully develop their positions and include all available relevant documentation in a preliminary position paper. The case will be dismissed if a provider fails to timely file a preliminary position paper or, alternatively, a proposed joint scheduling order indicating that the parties believe the case may be resolved without briefing.6

In addition, the new rules reflect the CY 2015 Outpatient Prospective Payment System Final Rule, as incorporated in 42 C.F.R. § 413.24, which requires providers to either claim or protest an item on the cost report as a condition of payment. For cost reporting periods before January 1, 2016, a provider has a right to a PRRB hearing notwithstanding its failure to comply with the disallowance regulation, so long as the Medicare contractor was bound by the regulation or other payment policy being appealed. For appeals of costing reporting periods after July 1, 2016, the PRRB is required to give the parties an opportunity to submit factual evidence and legal arguments regarding the question of whether the provider’s cost report included an appropriate claim for the specific item under appeal.7

Other rule changes include the requirement that appeals of the same issue from different determinations be brought in a single appeal. For new appeals, if a provider believes their claims can be resolved through a reopening by the Medicare Administrative Contractor, the provider can withdraw their appeal.8 If no resolution is reached with the MAC, providers can reinstate their appeals with the PRRB by filing a motion for reinstatement that includes a copy of the reopening request and the MAC’s decision denying the reopening.9

The new rules described in this article are not intended to be an exhaustive list of the changes to the PRRB appeals process. Medicare Part A providers should familiarize themselves with the new rules, as failure to comply with the rules could have severe consequences. For additional information or assistance, please contact Sarah Hillegonds of Wachler and Associates, P.C., at (248) 544-0888.

1. 42 C.F.R. § 405.1868.
2. PRRB Rules, Version 2.0, Rule 4.3.1 (August 29, 2018).
3. 42 C.F.R. § 405.1837
4. Id.
5. PRRB Rules, Version 2.0, Rule 23 (August 29, 2018).
6. PRRB Rules, Version 2.0, Rule 23.2-23.4 (August 29, 2018).
7. PRRB Rules, Version 2.0, Rule 7.4 (August 29, 2018).
8. PRRB Rules, Version 2.0, Rule 47.2 (August 29, 2018).
9. Id.

LEGAL LEANINGS: Taming The Opioid Epidemic

By GREGORY W. MOORE & ALEXANDRA A. HALL
Forty-eight thousand Americans were lost to opioid overdoses in 2017. Michigan opioid-related deaths and overdoses rank 18th-highest in the nation. Over the last year, significant attention was dedicated toward combating this widespread issue on both a federal and state level.

Michigan

Recently enacted Michigan opioid laws were executed with the intent to save lives and decrease misuse of controlled substances. In effect, the laws have imposed significant administrative hurdles and led to some confusion among prescribers, pharmacists, and patients.

The new laws impose substantial obstacles for prescribers prior to writing a prescription for opioids. Among such obstacles include the requirement that when a prescriber issues the first prescription for a controlled substance containing an opioid to a minor, he or she must discuss various risks of addiction and overdose with the minor and the minor’s parent or guardian and obtain the signature of the minor’s guardian on a form issued by the state. Certain exceptions to this general rule include treatment associated with a medical emergency or surgery, if compliance would be detrimental to the minor, or if consent of the minor’s guardian is not required for the treatment. To complicate it more, if the individual signing the form is authorized to consent but is not a parent or guardian, the prescriber may not prescribe more than a single 72-hour supply of a controlled substance containing an opioid. The laws also require that all prescribers register with the Michigan Automated Prescription System (MAPS) prior to prescribing or dispensing any controlled substance and obtain and review a MAPS report before prescribing or dispensing more than a three-day supply of any controlled substance. Perhaps the most confusion surrounds a seven-day supply limitation for providers treating a patient for acute pain, leading pharmacists to question whether to allow partial refills and whether the prescription was for acute or chronic pain.
The initial effect of Michigan’s recent changes are that providers are often deterred from prescribing opioids for fear of liability, which has made it difficult for individuals who need these medications to get them.

Federal

On October 24, 2018, President Trump signed a 660-page opioid bill which aims to help curb the crisis on several fronts. The legislation directs funding to federal agencies and states to increase treatment for addiction and places interventions such as increased training of law enforcement to intercept shipments. Notable progress in the realm of treatment includes increased Medicaid funding for addiction treatment and the removal of the Institute for Mental Disease (IMD) exclusion that prohibited federal Medicare dollars from going to inpatient treatment centers for substance use disorders with more than 16 beds. This allows states to provide access to residential treatment for Medicaid enrollees in need of substance abuse treatment who were previously treated with frequent visits to the Emergency Room. This is a change that has been long advocated by those who are battling a lack of funding and treatment options for addiction.

On a more molecular level, to assist states in the identification of high risk patients, the Office of Inspector General, U.S. Department of Health and Human Services, has issued a “toolkit” for use by State Medicaid Fraud Control Units, Private Health Plans and others to assist in analyzing prescription drug claims data. The release of this toolkit arose out of the OIG’s recent analysis of Medicare Part D data wherein it identified 71,000 beneficiaries which it described as individuals at serious risk of misuse or overdose of opioids. The toolkit provides steps to calculate a patient’s average daily morphine equivalent (MED) which converts opioids and strengths into a standard value. The CDC recommends that physicians consider a patient’s MED level when prescribing opioids and patients with chronic pain should avoid daily dosages at 90 mg MED or more. The toolkit includes a Programming Code along with instructions to use the Code and analyze the data output.1 It is anticipated that Medicare Part D plan sponsors, private health plans, and Medicaid Fraud Control Units will immediately begin to utilize this Code to analyze claims data and begin notifying providers in an effort to improve care coordination and case management, and alert providers to increased risk of overdose and possible diversion.

Despite recent efforts, all parties agree that significant work on both federal and state levels remains in order to accomplish the universal goals: save lives and decrease abuse.

1. A download of the SAS programming code can be found here: https://oig.hhs.gov/oei/reports/oei-02-17-00560.asp

LANSING LINES

Enviro Groups Call Out Schuette For PFAS Response
Environmental groups took Attorney General Bill Schuette to task last month for “dragging his feet” on per- and polyfluoralkyl substances (PFAS) contamination in Michigan—behavior they compare to his response to the Flint water crisis.

Sierra Club Michigan Chapter Chair David Holtz said Schuette “is failing communities all across Michigan” and Bob Allison, deputy director at the Michigan League of Conservation Voters, called it “yet another example of inaction from our government—despite multiple warnings.”

“He’s sitting on PFAS contamination complaints just like he chose not to act on reports of lead in Flint’s drinking water,” Holtz said. “Attorney General Schuette had the authority to take legal action, but instead he chose to delay holding the Air Force accountable for their toxic mess.”

Allison added: “We learned earlier this year that the state ignored and shelved a report six years ago that raised alarms about this crisis. The state House, led by Tom Leonard, who now wants to be the next Attorney General, has shirked its responsibility for nearly a year in passing a tough, safe PFAS drinking water standard.”

The reaction came after the Detroit Free Press published an article quoting Troy attorney Anthony Spaniola, who owns property near the former Wurtsmith Air Force Base in Oscoda Township.

Bob Delaney, an environmental quality specialist with the Department of Environmental Quality (DEQ), said in 2014 that contaminants known as perfluorinated compounds were first discovered at the shuttered Air Force post in 2010.

The chemicals have been linked to cancers and other health-related issues.

Spaniola told MIRS that despite Delaney warning state officials about the contamination, “for the better part of eight years all levels of state government has sat on their hands.”

Spaniola said there was a dispute about whether the Air Force or state was responsible for the plumes of groundwater contamination entering the adjacent Van Etten Lake, Van Etten Creek and the Au Sable River, which pours into Lake Huron.

Spaniola and other residents had pushed to get action, but the Air Force claimed it didn’t need to comply with the regulation cited by the state and Schuette’s office, presumably, didn’t immediately respond to the Air Force.

“That dragged on for months and month and months,” he said, explaining that all the AG’s office had to do was point to the statute that said yes, the Air Force had to clean it up.

“For whatever reason, the AG’s office didn’t do it,” Spaniola continued. “We started seeing surface water foam, which was highly contaminated from PFAS. They let it escalate and fester.”

A message to Schuette’s office wasn’t returned today. In the past, the Department of Environmental Quality (DEQ) points to the $23.2 million the legislature passed before the end of 2017 to help address elevated PFAS levels.

“Michigan has moved faster than any other state in addressing PFAS contamination,” said DEQ’s Scott Dean in July. “We moved quickly to protect people from potentially unsafe drinking water in communities with known PFAS contamination from historical, industrial or military activities.”

According to the Detroit Free Press story, Base Realignment and Closure Cleanup Team meeting minutes show DEQ officials asked about the Air Force investigating the contamination in April 2017 and that the Air Force asked the request be put in writing. However, the newspaper noted, the DEQ letter was not sent until February.

Minutes from one meeting indicate the requested letter being “in the Attorney General’s Office” on Sept. 28, the Free Press reported.

Spaniola said the state also is “lagging” compared to other states because Michigan doesn’t have drinking water standards for PFAS.

“That’s a huge problem,” he noted.

MSMS: If You Graduate Med School, You’re A Doctor
The Michigan State Medical Society issued a statement today reading, “When a person graduates from medical school, that individual is entitled by law to call themselves a medical doctor, whether that individual works in a clinical or non-clinical setting.”
The statement from the professional association of more than 15,000 Michigan physicians comes as another entity airs a television ad criticizing 6th Congressional District candidate Matt Longjohn for calling himself a doctor with a PhD when he’s not registered to practice in Michigan or anywhere else.

Today’s ad comes from “Defending Main Street,” a pro-Republican SuperPAC, which promises a six-figure buy until Election Day on the issue of Longjohn calling himself a doctor on the campaign trail. The former YMCA’s former medical head did graduate from medical school, but isn’t licensed to practice.

“If Matt Longjohn is misleading voters on the campaign trail, how can Michigan families expect to trust him in Washington?” said Defending Main Street President Sarah Chamerlain.

The Department of Licensing and Regulatory Affairs opened a complaint file against Longjohn last month based on the allegation that was sent to the Michigan Board of Medicine for review.

The rub is more about Longjohn’s use of the “MD” and the clear impression he leaves in some campaign material that he sees patients. The Public Health Code forbids using titles that gives the public the impression you can practice medicine when you are not legally able to do so.

U.S. Rep. Fred Upton’s campaign and the Congressional Leadership Fund is also using this message on Longjohn in their ads, which Upton campaign manager called “another desperate and disgraceful smear” from Upton “and his Washington special interest friends.”

“They are lying about Dr. Longjohn because Upton has failed his constituents on health care,” said Ben Young. “The real story here is that Dr. Longjohn is a Southwest Michigan kid who worked his heart out to go to medical school, earned an MD as a single dad, and became one of the top health care innovators in the country who has improved care for millions. He is running to be part of a new generation of leadership, and that scares the hell out of career politicians like Fred Upton and his ilk.”

In related news, the race may be tightening, according to Sabato’s Crystal Ball which recently changed the MI-6 rating from “likely Republican” to “lean Republican.”

So What’s The Deal With Pre-Existing Conditions, Anyway?
If there’s anything Americans appear to agree on, it’s that people shouldn’t be denied health insurance coverage or have to pay more because of a medical condition they’ve had.
There’s so much support–from both sides of the political spectrum, polls show—for protecting coverage for people with pre-existing conditions that both Democrats and Republicans are going to great lengths to demonstrate how much they support what’s been heralded as the most popular component of former President Barack Obama’s Affordable Care Act.

Here in Michigan, both Democrats Gretchen Whitmer and Elissa Slotkin have had mothers who had cancer. Both said they struggled to get the healthcare their moms needed.

And both candidates have used those stories in their campaign ads to attack their Republican opponents, Bill Schuette and Mike Bishop, for their efforts to allegedly undermine protections for people with pre-existing conditions.

But both Republicans have said they support protecting coverage for people with pre-existing conditions. They said their records prove it, even if Schuette as Attorney General has supported nine lawsuits against the ACA, or that Bishop has voted for the repeal-and-replace bill in Congress.

Arielle Kane, director of health care at the Washington, D.C.-based Progressive Policy Institute, described pre-existing condition coverage as the “linchpin which kept the ACA alive.”

An August poll from the Kaiser Family Foundation found 75 percent believe it’s important to prevent insurance companies from denying coverage based on a person’s medical history and 72 percent believe it’s important to prevent those companies from charging sick people more. Republicans approve of those measures 58 percent and 56 percent, respectively.

Kaiser also reported recently that 71 percent of voters say health care is “very important” in their voting decisions for Congress this year, but the same poll found it means much more to Democrats (40 percent say it’s a top issue) than Republicans (17 percent).

Kane said playing up the pre-existing conditions piece is a winning issue for Democrats because of its aforementioned popularity, but also because it’s “really relatable” and “very personal.”

“It more feels like a fairness issue, and people just won’t stand for it,” she said.

Even Doug Badger, visiting fellow at the D.C.-based Heritage Foundation and a senior advisor to former President George W. Bush, acknowledged Republicans haven’t done a good job defending themselves on the issue.

Badger said it’s not a question of whether people with pre-existing conditions should have coverage, but how to make healthcare accessible and affordable for both people with pre-existing conditions and people who don’t have those.

“The Affordable Care Act solved the first part of the equation, unfortunately, at the expense of the second part,” he said.

Schuette has tried to argue his support for covering pre-existing conditions is separate from his repeated calls to repeal and replace Obamacare.

But that nuance may not matter to voters, said Arnold Weinfeld, interim director of MSU’s Institute for Public Policy and Research, who served a stint in the state House with the Democrats.

“It’s going to be seen as a flip,” Weinfeld said. “Because people are going to ask them, point-blank, then why did you vote for repeal . . . why did you look to . . . sue to overturn the Affordable Care Act.”

Weinfeld said Democrats have set the narrative, and Republicans “are going to have a very hard time nuance-ing their way around it.”

Either way, Republicans here have fought back aggressively – Schuette has fiercely refuted Whitmer’s claim that Schuette thinks insurance companies “should be allowed to deny coverage to people with pre-existing conditions,” as she says in her ad, which Bridge Magazine’s Truth Squad ultimately labeled misleading.

Bridge wrote, “Schuette may or may not think insurers should have that choice. But he certainly has never explicitly said it.”

Schuette staged a Lansing press conference soon after the Whitmer ad debuted to demonstrate examples of people with pre-existing conditions that he’s fought for (See “Schuette: Whitmer Did No `Heavy Lifting’ To Get Healthy Michigan OKed,” 10/8/18).

And he’s out with a new ad claiming he’s voted “6 times” to protect coverage of pre-existing conditions, with the ad citing “Michigan State Senate Voting Records.”

As for Bishop, he’s now calling Slotkin a liar for her attacks that he voted to “gut” coverage for that population.

“My opponent, her party and Nancy Pelosi have been doing this around the country. It’s in the bill itself,” Bishop said.

His campaign followed up with a press release detailing his “19-year record of votes” supporting protections for people with pre-existing conditions, both in the state Senate and the U.S. House.

Slotkin has highlighted the pre-existing condition issue in at least two campaign ads, including the one about detailing her mom’s story.

It’s a reference to Bishop’s support of congressional Republicans’ failed attempt to repeal and replace Obamacare.

Yet Badger said hanging an attack on lawmakers like Bishop over the U.S. House healthcare bill isn’t fair, because he said it didn’t eliminate those protections. However, it allowed states to set variations in premiums based on health status, so long as those premiums could be subsidized for the people affected, he said.

Politifact concluded the American Health Care Act – the U.S. House bill – would “weaken protections” for people with pre-existing conditions, while not ultimately nixing the insurers’ requirement to offer coverage.

In the WDIV Flashpoint debate between the MI-8 candidates, Bishop said the bill he voted for said health status cannot affect premiums, except if a state is approved for a waiver. Slotkin said the Republican bill would still price people with pre-existing conditions out of the market (See “Dem-Connected PAC Putting $1.4M Into MI-8, MI-11; Slotkin Releases New Ad,” 10/9/18).

When it comes to ensuring folks with pre-existing coverage get health insurance, that ACA-imposed requirement applies to the individual market, which isn’t where most Americans get their health insurance.

The Kaiser Family Foundation had the number at 14.4 million enrolled in early 2018 in the individual market, and the U.S.A. has about 328 million people. Data from 2016 show about 49 percent of Americans get coverage via their employer.

In fact, the Health Insurance Portability and Accountability Act, otherwise known as HIPAA, was approved by Congress in 1996 and was designed to protect people with pre-existing conditions who have employer-based coverage, according to this NPR article.

When asked about this, Kane said while it may be a smaller population affected by the pre-existing condition policy, we “all know someone in that situation.”

And when it comes to Michigan, before the ACA was ever around, there were certain conditions mandated for coverage in the public health code, like cancer, said Dominick Pallone, executive director of the Michigan Association of Health Plans.

So while people are “fired up” about the Texas case potentially eliminating protections for pre-existing conditions, Badger said, “it would have no practical effect in the state of Michigan” because insurers would still need to cover those conditions under state regulations.

Let’s Not Rush In Urgent Care Centers

By EWA MATUSZEWSKI
Did you hear my heart go thud? As I write this, I just read of Beaumont’s plan to open 30 urgent care centers in Metro Detroit by the end of 2019 with an out-of-state urgent care clinic operator. It’s not a new concept, just more of the same; yet I fear the proliferation of urgent care clinics may lead to the demise of the Patient Centered Medical Home and its focus on patent-centric, whole person coordinated care.

We want everything fast: our information, our food, our relationships… but should we slow down just a bit here and think about the patient/physician bond that is formed through the years, through primary care physicians who sometimes take care of entire families, even multi-generations of families? What’s the likelihood of replicating the health benefits of a primary care physician/patient relationship in an urgent care setting? How about the multi-disciplinary team efforts offered by many PCP practices as an effective means of controlling and or preventing chronic conditions? That’s not on the urgent care menu. (Or should I say “Immediate Care?” I see signs, literally, that this segment of the industry is morphing into a drive-through type healthcare approach.)

Interoperability, one of my crusading initiatives, (Yes, I have many), will prove extremely difficult if not impossible in an urgent care setting, with patients the losers when their PCPs or specialists are not able to access EHR data from the urgent care provider. Another challenge is the ability for PCPs to maintain solid financial footing relative to their urgent care physician peers. PCPs can’t charge a facility fee—but many health system urgent care clinics can. Even when providing the same exact service. Not only isn’t it fair, it’s not the appropriate use of our precious health care dollars. Did Beaumont or other health systems ask local PCPs if they wanted to be part of an urgent care type network? That could be an innovative and prudent approach to what is apparently a pressing need for the type of services/hours/care rendered by urgent care clinics.

This is not to say that urgent care clinics don’t have a place in keeping us healthy, especially over the weekend when a trip to the Emergency Department seems unnecessary, (not to mention costly and time consuming) yet our strep throat, sliced finger, eye infection or flu-like symptoms do merit medical attention. But they are complementary to our existing medical relationships, not replacements. Their focus is on episodic care, not forging relationships with patients. I’ve been to urgent care clinics many times over the years for myself and immediate family members. I’ll be darned if I can remember the name of any of the treating physicians, as kind and capable as they may have been. Such encounters simply don’t tend to produce relationships, unlike the physician/patient relationships that develop in primary care. On that note, I want to redirect the conversation to a group of physicians that are trying to rescue primary care in Michigan: osteopathic physicians (DOs).

A September 2018 JAMA article highlights the impact that DOs play in driving primary care, noting that among the osteopathic physicians in residency training programs in 2017, 50 percent were training in internal medicine, family medicine, pediatrics and ob/gyn, compared to 40 percent of MDs, with an additional 25 percent of family medicine residency programs filled by osteopathic physicians. In my own experience, I repeatedly witnessed DOs in action, steeped in community, stepping up to participate in new primary care initiatives and reaching out to the disadvantaged. As a child, I recall my immigrant father turned away from Highland Park General on Christmas Eve when he had no insurance and little cash to treat the open wound on his foot. He hobbled in the snow to Detroit Osteopathic Hospital on Glendale Avenue, where he was not only treated but given cab fare by the emergency room physician to ensure his safe travels home. That’s primary care at its finest.

Risky Business For Health Plans

By PAUL NATINSKY
This summer featured continued disruption in aspects of the Affordable Care Act. This time, the vehicle was suspended risk adjustment payments to health plans. The payments have since resumed, but the methodology used to determine them has come under question.

So-called “risk adjustment” payments were established in the ACA to stabilize the health insurance market by transferring money to plans serving higher risk patients from those serving lower risk patients. The total in transfers for 2017 is $10.4 billion.

Two lawsuits, one in Massachusetts and one in New Mexico, declared the methodology used to determine payments respectively legal and then illegal. These lawsuits prompted CMS to issue a final rule in late July intended to address concern about the methodology used for the payments.

“The final rule will restore the operation of the risk adjustment program and mitigate some of the uncertainty caused by the New Mexico litigation,” CMS Administrator Seema Verma said in a statement. “Issuers that had expressed concern about having to withdraw from markets or becoming insolvent should be assured by our actions.”

And some issuers were glad to see the payments resume. “The risk adjustment program is an important tool that ultimately protects consumers and helps lower costs for members,” said Andy Hetzel, vice president corporate communications, Blue Cross Blue Shield of Michigan. “Overall, Michigan’s market is more competitive than other states, and has a lower statewide average premium. BCBSM is the largest insurer, with rates extremely competitive to other insurers.

But other issuers are not so sanguine. “We were disappointed that the states and CMS didn’t take this opportunity to rethink the payment formula equation, which is flawed. We thought it was a really great opportunity to crack open the model and the payment calculations to make sure what they had intended to protect against was actually occurring in the model,” said Marti Lolli, Chief Marketing Officer and Senior Vice President of Consumer and Government Markets for Priority Health, a Michigan health plan.

Lolli said the current formula bases risk adjustment payments on a state average premium, moving money from those with low premiums to those with higher premiums, ostensibly to cover the added risk of high-needs patients that tend to drive premiums up. But Lolli said administrative costs and profit margins are used to calculate a health plan’s average premium. She said the premiumsshould be calculated based on medical
costs alone, and health plans that have low administrative costs and use management strategies such as narrow provider networks (which Lolli
said save 18 to 20 percent) to drive down costs should not be penalized with high risk adjustment payments.

Lolli said larger plans with higher average premiums penalize other plans operating in the state by driving up risk adjustment payments.

In 2017, Lolli said Priority Health paid $57 million in adjustment
payments. Blue Cross and Blue Shield of Michigan received $105
million.

“The statewide premium accomplishes the goal of the program, incentivizing insurers to set prices based on average risk, which creates a
more stable and less expensive risk pool,” said Hetzel.

“Frankly, the system would even better protect consumers if all carriers offered PPO plans. These plans have broader networks and typically attract people with more costly and complex health conditions. All other
carriers in Michigan have dropped this type of plan, leaving Blue Cross as the sole PPO option,” he added.

Lolli said there are a number of fixes that would make sense. In addition to removing administrative costs and profit margins from the state average
premium calculation, she said average premiums should be based on regions, rather than states to eliminate differences in costs between rural
and urban areas and to address market peculiarities within states.

Pursuing millennials and other young, healthy populations should not be penalized as enrolling healthy people who pay premiums was a major focus of the ACA, she said.

Another potential fix is limiting the exposure to risk payments for health plans that end up paying more in risk adjustment payments for their patients than they collect in premiums, a situation that affects about 20 percent of Priority Health’s enrollees, said Lolli.

“The risk of using a different formula, such as a calculation using a plan’s
own premium, is that the proposal would significantly increase volatility
in the market from year to year,” said Hetzel.

LETTER: Medicare For All Solves Many Problems

Editor:

Read your paper for the first time (Sept., 2018 issue), picked it up at U of M hospital.
Interesting letter to the editor by Allan Dobzyniak, MD. Apparently, he needs to research exactly what Medicare for all means. If he seriously thinks that doctors and other providers won’t be paid, he is mistaken. He also claims that socialized medicine, as he refers to it does not work and is akin to slavery. Funny, I don’t see any ofthe countries that have socialized medicine taking steps to get rid of it. Socialized medicine is a term some like to use to scare people and whether we admit it or not, we already have some types of socialized medicine in the United States.

His letter to the editor was quite clear concerning his thoughts. He thinks doctors will be giving away care for free, “That someone would expect a service from another without payment seems much like the scourge of slavery that was belatedly banished from this country in the mid-19th century. There seems a hypocrisy here as the loud screams of the
virtue signalers for social justice are joined by equally loud screams for physician services on demand for “free.” Medicare for all in no way would force physicians to provide services for free. They would continue to be paid, just through a different venue.

Britain started its universal healthcare in 1948 and ranks above the United States in many areas when it comes to healthcare. Its citizens have a longer life expectancy and lower infant mortality. The country has more acute care hospital beds per capita and fewer deaths related to surgical or medical mishaps. Britain achieves these results while spending a lot less on health care than we do. When it comes to funding, universal healthcare in Britain it is funded through a national healthcare tax. Which is basically the same plan some are pushing for here. Taxes would be used to fund Medicare for all. For 2017 my premiums alone totaled nearly $7,000 and that figure does not include my deductible or co-pays. What difference does it make if I pay our government several thousand dollars for healthcare coverage, rather than a private entity? HMOs and
PPOs limit which doctors and providers you can use and they put limits on what care or drugs you can receive under their plans.

Medicare for all would level the field for all of us. We would all be able to access the same care, which isn’t the way it is today. One of my children (my youngest) was severely injured in an auto accident in 2001. Recently, my son was an inpatient at U of M for testing (for seizures). Due to a mix-up at the hospital they sought prior approval through his Medicaid plan, the request was denied and his appointment was on the verge of being
canceled. Luckily, I was able to connect with them and let them know he was covered by our auto coverage for the testing he needs. His appointment wasn’t canceled. This experience shows that not all patients are treated equally. They receive care based on the insurance coverage they have. If we had UHC then everybody would be treated the same.

For Dr. Dobzyniak to insinuate that doctors and providers won’t be paid is just ridiculous. My husband has Medicare, his providers are paid. I have BCBS and my providers are paid. My son has Medicaid for routine care, his providers are paid and he has auto insurance for auto related injuries and his providers are paid. Medicare and Medicaid are both government-run health insurance programs. Our auto insurance coverage, while
purchased through private insurers, could also be considered government coverage, since it is mandated by law. And, coverage for catastrophic injuries is for life (MCCA fund) and must cover any care that is deemed medically necessary for injuries received in auto related accidents. Under any of these types of insurance we have the ability to appeal,
should they deny any service’ or the payment for any service. One thing that would change is the fee scale. Doctors and providers would no longer be able to collect different fees from different entities.

Medicare for all in Michigan should help lower the cost of auto insurance premiums, since we would no longer need to purchase separate coverage for auto related injuries. There is a fight in this state currently to gut our no-fault auto insurance law and those that are trying to gut it claim that high premiums are due to medical providers gouging the auto insurance industry. When, in actuality, it is because there is not a fee schedule in
place like there is for every other form of healthcare insurance. Some may not like the idea of universal healthcare, but if we are going to get a handle on exploding healthcare costs we have to do something.

Cheryl Botbyl

COMPLIANCE CORNER: Suggestion For Medicare Providers

Erin Diesel Roumayah, Esq.
Wachler & Associates, P.C.

In June, the Office of Medicare Hearings and Appeals (OMHA) publicly implemented an expanded Settlement Conference Facilitation program. SCF is an alternative dispute resolution process which provides appellants and the Center for Medicare and Medicaid Services an opportunity to discuss a mutually agreeable resolution for claims appealed to the Administrative Law Judge (ALJ) or Medicare Appeals Council levels of appeal. This program applies mediation principles to resolve eligible Medicare appeals in an expedient and efficient manner. Through this program, an OMHA senior attorney or program analyst trained in mediation techniques acts as a neutral facilitator between the appellant and CMS in a one-day mediation, to negotiate a lump-sum settlement on eligible appeals.

OMHA has significantly modified the eligibility criteria for appellants and appeals under the expanded program. This program was first released in the summer of 2014 and was restricted to Medicare Part B providers and suppliers. Nearly two years later, given wide support and interest in the program, it was expanded to Medicare Part A providers. As of December 31, 2017, OMHA resolved 70,785 appeals through the various phases of the SCF program. Notably, this is the equivalent of almost an entire year’s disposition capacity for all of OMHA. Resolving nearly an entire year’s worth of appeals from the ALJ level of the appeals process frees up considerable resources for OMHA to adjudicate claims that are not eligible for SCF or other resolution processes, or claims that appellants preferred to try at hearing.

In the most recent SCF expansion, OMHA has significantly expanded the program’s eligibility criteria for appellants and appeals. For appellants, any Medicare Part A or Part B provider or supplier (with an assigned National Provider Identifier number) is eligible for participation, so long as that provider or supplier has not filed for bankruptcy or expects to file for bankruptcy in the future; does not have past or current False Claims Act litigation or investigations against them or other program integrity concerns such as civil, criminal or administrative investigations; and has either: (1) 25 or more eligible appeals pending at OMHA and the Council combined, or (2) less than 25 eligible appeals pending at OMHA or the Council and at least one appeal has more than $9,000 in billed charges.

Appeal eligibility criteria are as follows:
• Appeals must involve requests for ALJ hearing or Council review filed on or before November 3, 2017;
• The request(s) for ALJ hearing or Council review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision;
• All jurisdictional requirements for OMHA or Council review must be met for the eligible appeals;
• All pending OMHA and Council appeals associated with a single NPI and corresponding Provider Transaction Access Number (PTAN) must be included in SCF;
• Appeals must not be scheduled for an ALJ hearing and an ALJ hearing must not have been conducted;
• The billed amount of each individual claim must be $1,000,000 or less. For the purposes of a statistical sample, the extrapolated overpayment amount stated in the initial demand notice must be $1,000,000 or less;
o Settlement agreements with individual claims, or extrapolated overpayments, of $100,000 or less will be fully executed when CMS and the appellant sign the settlement agreement.
o Settlement agreements with any individual claims, or extrapolated overpayments, in excess of $100,000 (and up to $1,000,000) will be subject to U.S. Department of Justice (DOJ) approval prior to full execution by CMS and the appellant.
• Appeals must not be involved in OMHA’s Statistical Sampling Initiative;
• Appeals must not be actively engaged in a CMS Medicare appeals initiative made available on or after November 3, 2017 (i.e. the Low Volume Appeals Settlement, the QIC Demonstration Project, or the CMS Serial Claims Initiative);
• The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration;
• Appeals must not involve items, services, drugs or biologicals billed under unlisted, unspecified, unclassified or miscellaneous healthcare codes;
• Appeals must not involve payment disputes (but appeals arising from down coding of claims can be eligible for SCF);
• Appeals must not arise from a QIC or ALJ dismissal order; and
• Appeals must not be beneficiary-initiated appeals of QIC reconsiderations or any appeals arising from Medicare Part C, Part D or appeals of Social Security Administration decisions regarding entitlement, Part B late enrollment penalties, and Part B and Part D income-related monthly adjustment amounts (IRMAA).

To initiate SCF under the expanded program, an appellant must submit a Request for SCF to OMHA. CMS will have 15 calendar days to accept or reject participation in the process. If CMS agrees to participate, OMHA will create a SCF Request Spreadsheet identifying all potentially eligible appeals for SCF resolution. OMHA will then send the spreadsheet to the appellant in a Preliminary Notification Package. An appellant will have 20 calendar days from receipt of the Preliminary Notification Package to accept or reject participation in the SCF process. Following OMHA’s receipt of the appellant’s Preliminary Notification Package the appellant will be issued an SCF Confirmation Notice.

In a significant departure from prior iterations of this program, certain eligible appellants may participate in a “fast track” resolution process. Specifically, appellants with appealed claims that have billed amounts of $100,000 or less or appeals of an extrapolated overpayment that is $100,000 or less are eligible to participate in the “fast track” process. These appellants will be offered an “SCF Express” settlement offer in the initial stages of the process. This offer is a non-negotiable settlement sum and OMHA clearly communicated that the SCF Express offer is not based on a medical review of an appellant’s eligible appeals. Appellants do not have the opportunity to submit initial information for CMS’ consideration as part of the SCF Express process. However, appellants should expect that the SCF Express settlement offer will be based on preliminary data available to CMS regarding the appellant and its claims, such as the appellant’s track record of favorable findings before ALJ hearing and the Council, or the number or scope of prior audits initiated by CMS regarding the appellant. If an appellant accepts the SCF Express settlement offer, the appellant and CMS will sign a settlement agreement memorializing the terms of the settlement and the covered claims will be dismissed from the Medicare appeals process.

If an appellant rejects the SCF Express settlement offer but wishes to proceed to the SCF conference, OMHA will coordinate a Pre-Settlement Conference between the appellant and CMS. At the Pre-Settlement Conference, the appellant, CMS and the OMHA facilitator will discuss the logistics for the settlement conference, schedule a date and time for the settlement conference, select sample claims for CMS’ and the appellant’s consideration, and schedule the timing of submission of supporting materials such as a position paper. At the day of the conference, if settlement is not reached, the appeals will return to the previous assigned adjudicator, if applicable, or to the OMHA and Council docket for future assignment in the order in which the request for review was received. If a settlement is reached, a settlement agreement is signed the day of the facilitation and the settled claims are dismissed from the Medicare appeals process.

There are recommended best practices and strategies for participation in SCF. For one, appellants should prepare a thorough evaluation of any sample claims identified during the Pre-Settlement Conference. The thorough evaluation should include a comprehensive position paper with supporting documentary evidence and testimonial support. Appellants should timely submit this information to CMS for CMS’ consideration in advance of the SCF conference. Appellants should also consider showcasing their major strengths, accolades and any unique considerations for CMS’ review. A thorough and strong posturing of the case prior to the conference can have a substantial impact on the success of the conference. Although at the conference there are no findings of fact or rulings of law, participants should be prepared to make an opening statement which highlights major issues and concepts for CMS’ consideration. Following opening statements, the SCF conference then proceeds through private sessions with the OMHA facilitator, who acts as a neutral intermediary in facilitating a resolution between the appellant and CMS.

The voluntary and expedited nature of the SCF process should be attractive to Medicare appellants seeking a cost-effective and efficient resolution of their pending appeals. If settlement is not reached, an appellant’s claims return to the ALJ appeals process in the order in which they were originally received. Although OMHA did not establish a firm time table for completion of the SCF process, a conservative estimate is that this process takes at least 10 weeks from the date an appellant receives OMHA’s spreadsheet identifying eligible claims until the date of the SCF conference. That is considerably faster than the Medicare traditional five-step appeals process that at recent estimates takes nearly 173 weeks at the ALJ level of appeal alone. As there currently is no deadline by which appellants must elect to participate in this program, providers and suppliers should review their potentially eligible claims and consider participation.

i . At a recent speech regarding the appeals process and new initiatives to combat the backlog and improve the appeals process, Chief Administrative Law Judge Nancy Griswold of OMHA estimated that in FY 2017 OMHA decided 84,729 appeals. “Latest Policy & Regulatory Changes to the Medicare Appeals Process,” American Health Lawyer’s Association Conference, March 21-23, 2018, presentation by Nancy J. Griswold, Chief Administrative Law Judge, OMHA and Erin Diesel Roumayah, Esq.