In a victory for the American Hospital Association (AHA), not to mention the industry as a whole, a federal District Court in the District of Columbia recently denied the U.S. Secretary of Health and Human Services (HHS) request for a stay of proceedings. The AHA is seeking judicial relief that would force the Secretary to handle Medicare appeals in accordance with statutorily designated timeframes. And most recently the Secretary called for a proverbial “Time Out” citing a few initiatives they have deployed but mostly touting several “proposed” changes that necessitate congressional approval. The Court found that even if all of the proposed changes were approved by Congress (which is extremely unlikely as prior petitions to increase funding have been defeated on Capitol Hill), it simply does not do enough to materially reduce the burden on providers. Therefore, the Court denied the time out petition and effectively announced their verdict to “play on!”
To be clear, the backlog has no chance of improvement without dramatic changes. And the Court effectively states that they do not have a magic wand to make the backlog go away. However, in our opinion, this is not a problem to be fixed with more money. We must look to the genesis of appeals and reduce the sheer volume of claims that necessitate an appeal for proper payment. Contractors need to make policies clearer and medical record assessment more intuitive. The restriction on clinical interference has further created an unnecessary ripple effect on the volume of appeals we must pursue. This chronic drain on provider resources to pursue these escalations is simply not sustainable. This recent ruling validates the basis of the AHA claim and underscores the need for substantive change. Now that the case is once again moving forward, we will continue to report on developments as the case advances through the Federal Court and the American Hospital Association begins making their case to the judge.