Health Information Management

News: Hospital system appeal for mandamus order on HHS denied

CDI Strategies, March 31, 2016

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Another hospital lost its attempt to push through the backlog of denied claims appeals recently. Despite calling the Administrative Law Judge (ALJ) bottleneck “grotesque,” the Fourth Circuit Court of Appeals denied a Cumberland County (North Carolina) hospital system’s request to force the Department of Health and Human Services to provide it with an ALJ hearing.

The Fourth Circuit Court of Appeals affirmed a lower court decision on March 7, denying Cumberland County Hospital System’s request for a mandamus order. The order would have forced the Department of Health and Human Services to provide the facility with a hearing before an administrative law judge (ALJ) on its appeals of denied claims.
More than 750 of the hospital’s appeals, amounting to $12.3 million, have been pending for more than 90 days, which the hospital argues is a violation to the congressional mandate in the Medicare Act that its appeals be heard and decided by ALJs within 90 days.
The court disagreed, ruling that the hospital does not have a “clear and indisputable right” to an ALJ hearing within a 90-day time frame, and it had not demonstrated that HHS had “a clear duty to provide such a hearing.” Further, the court stated that the 90-day deadline was just one element of the four-step appeals process, which, if not met, allowed the provider to appeal to the Departmental Appeals Board (DAB).
The court concluded, “the political branches, rather than the courts, are best suited to address the backlog in the administrative process.”
Click here to read the court’s March 7 decision. 

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