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A nationwide class action lawsuit was filed in Connecticut federal court on Tuesday alleging that the Obama administration has failed to clear the backlog of Medicare appeals that take over 500 days to resolve, which is more than five times longer than permitted under law.
Lead plaintiffs, five Medicare beneficiaries, allege in their class action lawsuit that administrative judges who resolve appeals have been delayed by the increased scrutiny on billing in recent years. “The Medicare program’s system of administrative review has four levels of appeal,” their class action lawsuit says. “Only the third level, the administrative law judge (ALJ) level, provides the right to an oral hearing before the adjudicator, including witness testimony, allows a beneficiary to present his or her case with more than written evidence and argument, and provides the only opportunity for meaningful review.”
“Because of the crucial role of the ALJ in the review process,” the class action lawsuit continues, “Congress has directed that a decision must issue from the ALJ no more than 90 days from the date that the request for an ALJ hearing is received. As of July 2014, the average length of time in which ALJ decisions were issued after the hearing request was received was over five times that statutory limit, 488.8 days.” The plaintiffs claim that they were denied for various claims including ambulance rides, physical therapy, and oral surgery due to delays in the administrative appeals process.
In their class action lawsuit, plaintiffs argue that administrative law judges or “ALJs” are integral to providing an appropriate process to appeal denials of Medicare claims because ALJs are not Medicare contractors. The plaintiffs point out in their complaint that although a relatively small number of Medicare claim denials are appealed, many of the appeals are successful, including 28 percent of Medicare beneficiary appeals and 61 percent of Medicare provider appeals in 2010,. according to a report by the U.S. Department of Health and Human Services.
The plaintiffs request in their class action lawsuit that the delays caused by the backlog be determined to violate the Medicare Act and due process afforded under the Constitution. “Plaintiffs challenge this defective administrative review process as in violation of the Medicare statute and the Due Process Clause of the Fifth Amendment,” says the class action lawsuit. “On behalf of themselves and the nationwide class consisting of all other Medicare beneficiaries harmed by this systemic denial of a timely, meaningful, and statutorily mandated review process, plaintiffs seek declaratory, injunctive, and mandamus relief to correct the system of administrative review for the beneficiaries of Medicare.”
The proposed Class includes: “All Medicare beneficiaries who have pending a timely request, or will have pending a timely request, for an administrative law judge hearing, and for whom an administrative law judge has not rendered, or will not render, a decision on such hearing by the end of the 90-day period beginning on the date the request for hearing was filed.”
The lead plaintiffs are represented by Alice Bers, Gill Deford, Judith A. Stein and Margaret M. Murphy of the Center for Medicare Advocacy.
The Delayed Medicare Appeals Class Action Lawsuit is Lessler, et al. v. Burwell, Case No. 3:14-cv-01230, in the U.S. District Court for the District of Connecticut.
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