More on Reimbursement

Court sets 2020 deadline for HHS to resolve Medicare claims backlog

Hospitals win in court-ordered, four-year timetable for HHS to clear hundreds of thousands of appealed claims.

Susan Morse, Managing Editor

Hospitals on Monday won their two-year court battle to have hundreds of thousands of backlogged appeals on Medicare claims settled.

A federal court agreed with the four-year timetable requested by the American Hospital Association.

By the end of 2017, Health and Human Services must have a 30 percent reduction of the current backlog of cases; by Dec. 31, 2018,  a 60 percent reduction; and by the end of 2019, a 90 percent reduction, with an elimination of the backlogged cases by Dec. 31, 2020.

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Health and Human Services Secretary Sylvia Burwell opposed another AHA request, that the court on Jan. 2, 2021 grant default judgement in favor of all claims pending at the level of Administrative Law Judges that had not had a hearing for more than a year.

Administrative Law Judge is the third of four levels in the administrative-appeal process. Here backlog and delays are especially significant, according to court records.

"Defendant nonetheless argues that imposing such a timetable would require her to 'make payment on Medicare claims regardless of the merit of those claims'" which conflicts with the Medicare statute, HHS said.

The court agreed and said it would not automatically enter default judgements in all qualifying appeals as of Jan. 2, 2021. Instead, if HHS fails to meet the deadlines set forth in the timetable, AHA may move for default judgement.

The court also ordered HHS to file status reports every 90 days.

AHA v. Sylvia Burwell, as secretary of Health and Human Services, has been ongoing in the courts since 2014, when the American Hospital Association asked the court to compel the federal agency to adjudicate pending Medicare reimbursement appeals by statutory-imposed deadlines.

Hundreds of thousands of appeals were languishing in a backlogged administrative process, according to court documents.

Motions were filed on both sides, there was an appeal and a remand order. Originally the court was reluctant to intervene, U.S. District Court Judge James E. Boasberg said.

[Also: House v. Burwell court order one more way for Trump to end ACA]

Burwell moved to stay proceedings until Sept. 30, 2017, the close of the next full appropriations cycle, to allow HHS time to pursue administrative and legislative efforts to tackle the backlog. Her motion was denied.

HHS said efforts to reduce the backlog were moving along faster than originally estimated. HHS continued to promise elimination of backlog only with legislative action.

The court said the backlog was still unacceptably high.

Twitter: @SusanJMorse