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Update on American Hospital Association v. Burwell

ALJ Appeals(February 23, 2016):  The U.S. Court of Appeals for the District of Columbia Circuit recently issued a decision the Administrative Law Judge (ALJ) level of the administrative appeals process that breathes new life into efforts to resolve the backlog of ALJ appeals cases currently pending around the country.  The case, American Hospital Association v. Burwell, was originally filed by the American Hospital Association (AHA) to obtain a court order to force ALJs in the Office of Medicare Hearings and Appeals (OMHA) to adjudicate ALJ appeals within the 90 days mandated by law. The lower court initially refused AHA’s request and dismissed the case. On appeal, the D.C. Circuit reversed the lower court’s decision and remanded the case for further consideration. The appellate court instructed the district court to weigh all of the facts in favor of and against the AHA’s request and to issue a new decision. Although the case has now been returned to the lower court for further review, the D.C. Circuit appeared to suggest in its own decision how the district court should decide the case. The appellate court wrote, “…the clarity of the statutory duty [for Medicare ALJs to hear and decide cases within 90 days] likely will require issuance of the writ [ordering ALJs to timely adjudicate appeals] if the political branches have failed to make meaningful progress within a reasonable period of time – say, the close of the next full appropriations cycle.”

The importance of this decision for Medicare providers whose claim appeals are or may be stuck in “limbo” at OMHA cannot be overstated. The D.C. Circuit has clearly acknowledged the mandatory duty of ALJs to hear and decide claim appeals within 90 days. The court also strongly implied that the order sought by the AHA should be issued in the relatively near future unless Congress acts in the interim.

Meanwhile, the logjam at OMHA has continued to grow even since the AHA first filed suit. According to the agency’s own statistics, the average processing time for ALJ appeals hearing requests increased from 661 days in 2015 to 791 days in the first quarter of 2016. This fact may contribute to the court’s decision as to whether to order the ALJs to begin timely processing of cases.

It is likely that industry and trade groups representing other types of Medicare providers will take action to capitalize on the AHA’s success. CMS will also almost certainly step up efforts to lobby Congress to help fix the issue and to resolve the backlog of pending ALJ appeals. Ultimately, whether the ALJ appeala backlog is resolved by court order or through meaningful efforts by Congress and CMS, this is spectacular news for Medicare providers across the country.

ALJ AppealsLiles Parker attorneys assist providers across the country with all matters related to claim appeals, reimbursement, enrollment, compliance, and corporate formation / transactions. If you have questions or concerns about a pending Medicare claim appeal, please contact Adam Bird for a free consultation.  He can be reached at:  1 (800) 475-1906.

 

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