Groups set stage for action on audits

WASHINGTON - Even though the American Hospital Association (AHA) lost its bid to get a court to intervene in a huge backlog of appeals of Medicare claims, the lawsuit keeps the controversial program in the spotlight, industry stakeholders say.

The U.S. District Court for the District of Columbia ruled in December not to require the Department of Health and Human Services (HHS) to meet statutory deadlines for timely review of claim denials. The judge said that Congress, not the court, should take up the issue.

“It's very disappointing, but it might give us more impetus with Congress to get audit legislation passed,” said Kim Brummett, senior director of regulatory affairs for AAHomecare.

While Medicare statute requires that appeals at the administrative law judge (ALJ) level be resolved within 90 days, it's currently taking more than 500 days, according to the Office of Medicare Hearings and Appeals (OMHA).

Both the AHA and AAHomecare succeeded in getting lawmakers to introduce bills to reform the audit program in 2014, but neither bill was passed. AAHomecare plans to reach out to the AHA in early 2015 to find out what its plans are for a new bill, Brummett says.

“If they go to Congress, it makes more sense for us to go to Congress, too,” she said.

The AHA will also likely continue exploring its legal options.

“We expect to appeal the decision,” said President and CEO Rich Umbdenstock in a statement.

Industry attorney Edward Vishnevetsky says the AHA is smart to stick with its lawsuit despite the district court's decision, because it can't rely on Congress.

“The legislative route would work if lawmakers had the time to understand the whole system,” said Vishnevetsky, an attorney with Munsch Hardt. “They're bombarded with reports that say the system has curbed millions and millions in fraud, and unless they have time to delve into the details, it's impossible to convince them otherwise.”

Vishnevetsky believes the AHA could very well get the district court's decision overturned on appeal.

“It's a constitutional issue, because there is no due process,” he said. “Yes, there's a way to go through a process and get a remedy, but the process is not working the way Congress approved. Justice delayed is justice denied.”

Whether relief comes by way of legislation or a legal decision, the timing could be just right “to get some action,” says industry attorney Steve Azia.

“This is an issue that applies to everyone,” he said. “Everyone is showing some interest, and everyone is moving in the right direction.”