The US Department of Health & Human Services (HHS) says that it cannot meet the requirements of a federal court order to reduce the horrible backlog of Medicare appeals cases that for many years has plagued the United States and adversely impacted the ability of health care providers to be paid. The problem has been under scrutiny for some time, and the US General Accountability Office (GAO) has outlined in a report various inefficiencies to which the GAO attributes the problem. Health care providers in many instances are completely unable to, in a timely manner, vindicate their claims in Medicare appeals. Nevertheless, HHS contends that it needs more money from Congress to fix the problem.
In a case styled Am. Hosp.Assn v. Burwell, D.D.C., No. 14-cv-851, the United States District Court for the District of Columbia entered a recent Order wherein the Federal Court set annual backlog reduction targets of 30, 60, 90 and 100 percent over the next four years. In the case, the American Hospital Association and affiliated entities requested that the United States District Court compel HHS to adjudicate pending Medicare-reimbursement appeals in compliance with statutory deadlines. As explained in the Order, hundreds of thousands of appeals have languished in a terrible backlog. In the case, HHS contended that mandamus (i.e., a Court-ordered solution) was not necessary and that HHS would, eventually, resolve the issue. The Plaintiff, however, contended that a Court-ordered (and enforceable) time table for a solution was required in light of HHS’ failure thus far to fix the problem. The Plaintiff proposed the following timetable for reduction of the backlog:
- 30% by December 31, 2017
- 60% by December 31, 2018
- 90% by December 31, 2019
- 100% by December 31, 2020
- On January 1, 2021, default judgment in favor of all claimants whose appeals have been pending at the ALJ level without a hearing for more than one calendar year.
The Court agreed and adopted Plaintiff’s proposed backlog-reduction schedule, albeit without the default judgment provision. HHS has moved for reconsideration, arguing that it cannot hit those target dates without violating its “statutory obligation to protect the Medicare Trust Funds,” by paying Medicare claims that should not be paid under applicable law. The Court has already been dismissive of this argument and has noted that HHS has already violated the Medicare statute that imposes a 90-day deadline to issue rulings in ALJ appeals. The HHS has argued in that “[a]bsent substantial new resources and authorities from Congress,” HHS will have to settle backlogged Medicare claims “for the full value or nearly the full value of each appeal” regardless of merit, and still may not be able to comply with the Court-ordered deadlines. A ruling on HHS’ argument for reconsideration is expected to follow in the near future.
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