On February 9, 2016, the U.S. District Court of Appeals for the District of Columbia Circuit determined that a District Court has jurisdiction to order HHS to address the significant backlog in the Medicare appeals process.  This decision follows an appeal to the U.S. District Court of Appeals by the American Hospital Association, which brought suit against HHS for its failure to properly manage Medicare appeals.

More specifically, the American Hospital Association and three private hospitals filed suit against HHS for failing to comply with statutory deadlines in processing and deciding claims appeals.  Following oral argument on November 9, 2015, the U.S. District Court of Appeals concluded that “the statute imposes a clear duty on the Secretary to comply with the statutory deadlines, that the statute gives the Association a corresponding right to demand that compliance, and that escalation–the only proposed alternative remedy–is inadequate in the circumstances of this case.”  In short, the district court must “determine whether compelling equitable grounds now exist to issue a writ of mandamus.”

Although it is ultimately up to the District Court judge to determine whether mandamus is appropriate, the U.S. District Court of Appeals predicted that “given the unique circumstances of this case, the clarity of the statutory duty likely will require issuance of the writ if the political branches have failed to make meaningful progress within a reasonable period of time–say, the close of the next full appropriations cycle.”

The Florida health care law firm of Nicholson & Eastin, LLP regularly represents health care providers with Medicare and Medicaid claim audits and appeals, as well as prepayment review defense. If you have a Medicare, Medicaid or commercial insurance payment dispute or appeal, please contact us for a consultation.