Home Health & Hospice Week

A lawsuit from the American Hospital Association aims to shorten wait times for appeals.

Background: At the beginning of the year, the HHS Office of Medicare Hearings and Ap-peals warned that “based on our current workload and volume of new requests, we anticipate that assignment of your request for hearing to an Administrative Law Judge may be delayed for up to 28 months.” The extraordinary backlog of appeals is largely due to Recovery Audit Contractor denials that providers are contesting.

Now the AHA and three plaintiff hospitals want the Department of Health and Human Ser-vices to adhere to statutory deadlines for appeals, particularly to the ALJ. “Lengthy, systemic delays in the Medicare appeals process, which far exceed statutory timeframes, are causing severe harm to providers of Medicare services,” the complaint contends.

Providers “will likely have to wait up to five years, and possibly longer, to have their claims proceed through a four-level administrative appeals process that could otherwise conclude in less than a year according to statute,” AHA argues. “The stakes … are high — billions of dollars in Medicare reimbursement hang in the balance.”

The ALJ backlog may be especially detrimental to HHAs as they seek to have face-to-face physician encounter-based denials overturned in the appeals system.