Tuesday, May 27, 2014

AHA Sues HHS to End ALJ Appeals Backlog

Dan Ciolek

On May 22, the American Hospital Association (AHA) issued a press release announcing that they had filed a lawsuit against the U.S. Department of Health and Human Services (HHS) to assure that its Administrative Law Judges (ALJs) meet the statutory 90-day timeline requirement for deciding Medicare claim appeals. The ALJ represents level 3 of the 5-step Medicare claims appeals process. The AHA is joined in its suit by hospital plaintiffs in Arkansas, Tennessee, and Vermont.

According to the Office of Medicare Appeals and Hearings (OMHA) website:
“Due to the overwhelming number of receipts and the existing workload within the Agency, OMHA implemented a program that defers the assignment of most requests for hearing received after April 1, 2013. Under this new docketing process, new requests for hearing will be entered into our case processing system, then held until they can be accommodated on an Administrative Law Judge's docket for adjudication.”
On February 12, OMHA conducted an all-day public forum to discuss agency initiatives to help mitigate the growing backlog, hear provider concerns, and to examine the causes and various ways providers can cope with the enormously lengthy delay for a provider’s appeal to be adjudicated ALJ level. After the OMHA public forum, AHCA issued a press release urging government action to resolve this growing issue. An updated May 20, 2014 table on the OMHA website indicates that the average ALJ appeal processing time continues to grow and, as of April 2014, increased to 418.7 days.

Per the AHA press release, the plaintiffs allege that “excessive inappropriate denials by Recovery Audit Contractors (RACs) are the direct cause of the current backlog.” That AHA also alleges that the “perverse incentive” of the RAC contingency-based payments leads to excessive inappropriate denials that are typically overturned at the ALJ level according to the HHS Office of Inspector General (OIG). The AHA lawsuit seeks that the Court issue a “declaratory judgment that HHS’s delay in adjudication of Medicare appeals violates federal law” and to also compel HHS to comply with providing timely ALJ reviews within the statutory limit.

AHCA continues to monitor this situation and develop strategies to support our members and the beneficiaries we serve as RAC denials have also increased the Part A SNF and Part B therapy claim appeals backlog.

For further information, contact Dianne De La Mere at ddmare@AHCA.org.

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