HHS Continues to Face Pressure over Inability to Clear Administrative Appeals

HHS Continues to Face Pressure over Inability to Clear Administrative Appeals


Healthcare providers who have to deal with administrative audits and recoupment requests are well aware that attempts to contest or challenge them can result in protracted wait times to reach a level of appeal where complaints will be taken seriously and addressed by a (hopefully) impartial administrative law judge (ALJ).  As we covered in this blog entry, the American Hospital Association (AHA) took issue with the delays related to challenges of Recovery Audit Contractor (RAC) reviews commissioned by the Centers for Medicare and Medicaid Services (CMS). 

The AHA sued the Department of Health and Human Services (HHS) in 2012, and  in the latest installment of this litigation, HHS has been ordered to clear the backlog of more 800,000 appeals by 2020, with at least 30% of them being cleared by the end of 2017.  This is yet another significant victory for the AHA in this long-running litigation, even as the judge overseeing the litigation commended the AHA for its willingness to compromise in agreeing to give HHS over three years to clear the backlog. 

HHS’s willingness to reach this settlement, coupled with other efforts to compromise and resolve outstanding RAC appeals indicates that the government’s recognizes its inability to provide timely adjudication of these issues.  This can be significant for providers since many times the findings of administrative contractors, like RACs, are incorrect or faulty on their face.  While this most recent settlement does nothing to fix the ongoing and protracted delays faced by non-hospital providers, there are two takeaways that all healthcare providers should keep in mind when facing these issues:  First, this recent action demonstrates that HHS realizes these delays are a problem, and is looking for solutions to clear the backlog.  Second, and more importantly, providers facing delays for administrative hearings related to large dollar recoupment requests should not ignore the possibility of seeking judicial relief, either to leverage a more favorable resolution with CMS and HHS, or to gain quicker access to review by an ALJ. 

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