On February 9, 2016, the D.C. Circuit, in American Hospital Association v. Burwell, No. 1:14-cv-00851 , held that a district court has jurisdiction to compel the Department of Health & Human Services (“HHS”) to address the substantial backlog of disputed Medicare claims and to make decisions within the statutory deadlines in the face of complaints by the American Hospital Association (“AHA”) and several hospitals.  Not only did the D.C. Circuit find that the suit met the threshold requirements for mandamus jurisdiction, it also opined that the circumstances of the case and the clarity of HHS’ duty to meet statutory deadlines will “likely require” issuance of the writ if HHS has not made meaningful progress in addressing the backlog by the close of the next full appropriations cycle.

After a Medicare claim is denied, the Medicare Act provides a four-level administrative appeal process, followed by judicial review. The statute includes specific time frames for each step of the process.  At the first level, the provider presents its claim to the Medicare Administrative Contractor for “redetermination,” to take place within 60 days.  The second level involves “reconsideration” by a Qualified Independent Contractor, also to be completed within 60 days.  The third level constitutes de novo review by an administrative law judge (“ALJ”) within 90 days.  The fourth and final administrative stage involves de novo review by the Medicare Appeals Council within 90 days.  Appeals should work their way through the administrative process within about a year if all of the respective time frames are met.

Continue Reading DC Circuit Breathes New Life into AHA’s Suit over Medicare Appeals Backlog