Background on Consent Settlement

8.2.3.3.1 - Background on Consent Settlement (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 defines consent settlement as an agreement between the Secretary and a provider of services or supplier whereby both parties agree to settle a projected overpayment based on less than a statistically valid sample of claims and the provider of services or supplier agrees not to appeal the claims involved. The UPICs and the contractor medical review units shall submit via secure email the consent settlement to the Primary and Associate GTLs before offering a consent settlement to the provider or supplier. If the UPICs or the contractor medical review units do not have secure email, the consent settlement shall be sent to the Primary GTL and the Associate GTL via hard copy. Upon receipt, GTLs will forward the consent settlement to the Director of the Division of Benefit Integrity Management Operations. The UPICs and the contractor medical review units may contact the provider upon approval of the consent settlement. Consent settlement documents carefully explain, in a neutral tone, what rights a provider waives by accepting a consent settlement. The documents shall also explain in a neutral tone the consequences of not accepting a consent settlement. A key feature of a consent settlement is a binding statement that the provider agrees to waive any rights to appeal the decision regarding the potential overpayment. The consent settlement agreement shall carefully explain this, to ensure that the provider is knowingly and intentionally agreeing to a waiver of rights. Consent settlement correspondence shall contain: 1. A complete explanation of the review and the review findings; 2. A thorough discussion of §1879 and §1870 determinations, where applicable; 3. The consequences of deciding to accept or decline the consent settlement offer; and 4. It is rare that a UPIC will offer and develop a consent settlement. However, when the UPIC offers and develops a consent settlement, the AC or MAC shall administer the settlement.