Beneficiaries now also suing about long wait for Medicare appeals hearings

Earlier this year, the American Hospital Association and three hospital and healthcare systems sued the U.S. Department of Health and Human Services (HHS) over the long backlog in Medicare claim denial appeals. Now patients are joining in with a nationwide class action suit.

Lawyers for the Center for Medicare Advocacy filed the suit on August 26 in the U.S. District Court in Connecticut (Lessler et al. v. Burwell, 3:14-CV-1230, D. Conn.) on the behalf of five named plaintiffs. These Medicare beneficiaries from Connecticut, New York and Ohio had all waited more than three months for a hearing and decision by an Administrative Law Judge (ALJ) on their Medicare appeals, even though the law says an appeal decision must be issued within 90 days.

According to the Center for Medicare Advocacy, the current average wait time between when a request for a hearing is filed and when a decision is issued is on average 489 days, five times as long as the maximum amount of time it is supposed to take under the law.

Furthermore, beneficiaries’ appeals are supposed to be handled ahead of provider appeals because HHS and legislators have recognized that individual seniors have fewer financial resources to endure a long wait for a correction of a possibly erroneous claim denial. In March, Rep. Jim McDermott (D-Wash.), a ranking member of the powerful House Committee on Ways and Means Subcommittee on Health, wrote HHS urging an easing of the backlog and a continued effort to make sure beneficiaries’ appeals are handled first. The fact that it is still taking the ALJs this long to get to beneficiaries’ cases decided has concerned elected officials, particularly those hearing complaints from constituents.

“This lawsuit is necessary because of a broken Medicare appeals system. We’re suing to fix it for the Plaintiffs and the thousands of beneficiaries in similar circumstances who are struggling to pay health care bills, or going without needed care while stuck in bureaucratic limbo,” said Gill Deford, Director of Litigation for the Center for Medicare Advocacy in a press release announcing the suit.

While a wait of over a year is bad, the hospitals allege in their suit that most new requests for hearings by an ALJ filed by a provider are not even being taken for at least two years and that as of Feb. 12, about 480,000 appeals were awaiting assignment to an ALJ.

The Center for Medicare Advocacy complaint is available here.