Plaintiffs are the American Hospital Association and three other regional hospitals and healthcare systems.
Providers with Medicare appeals pending may have their claims resolved sooner than expected. On Nov. 1, 2018, U.S. District Court Judge Boasberg ruled that the U.S. Dept. of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022.
Currently, there is a backlog of 426,594 appeals. Judge Boasberg’s ruling imposes a timetable for reducing the backlog of appeals. Specifically, HHS must clear 19 percent of the appeals by the end of fiscal year 2019; 49 percent of the appeals by the end of fiscal year 2020; 75 percent by the end of fiscal year 2021; and eliminate the backlog entirely by the end of 2022. Beginning on Dec. 31, 2018, HHS must file quarterly status reports on its progress.
This long-awaited ruling comes years after the American Hospital Association (AHA) filed the lawsuit alleging that HHS was violating federal law by failing to process appeals according to statutorily-mandated timeframes. Federal regulations require appeals at the Administrative Law Judge (ALJ) hearing level to be completed within 90 days following the date the request for hearing is received by the Office of Medicare Hearings and Appeals (OMHA).[1] The current average processing time, however, for a case pending at the ALJ level is more than three years.[2]
The Complaint, which was filed by the AHA in 2014, was initially dismissed by the District Court for lack of jurisdiction. In February 2016, the D.C. Circuit Court reversed the District Court’s dismissal and ordered the District Court to issue a decision on the merits. In December 2016, the District Court entered summary judgment in favor of the AHA and ordered HHS to comply with a timetable to eliminate the backlog of appeals by 2020. In August 2017, the D.C. Circuit again reversed the District Court and ordered the District Court to evaluate HHS’ claim that compliance with the timetable would be impossible.
In his recent decision, Judge Boasberg found that he could “easily conclude that it would be possible” for HHS to reduce and then eliminate the backlog as a result of increased funding from Congress to HHS.[3] In March 2018, Congress appropriated $182.3 million for the purpose of addressing the backlog and, by HHS’ own projections, the increased adjudication capacity as a result of the additional funding would allow HHS to “eliminate the backlog entirely in FY 2022.”[4] According to Judge Boasberg’s decision, HHS can request a modification of the order if Congress reduces HHS’ funding such that it would be impossible to comply with the timetable for reducing appeals.
Aside from the issue of whether it was possible for HHS to comply with the court-ordered timetable, Judge Boasberg found that the equities weighed in favor of the AHA as the lengthy Medicare appeals process impacts “hospitals’ willingness and ability” to provide care to patients.[5]
Judge Boasberg denied the AHA’s requests to reduce the interest charged on appeals, allow providers to rebill their claims for six months following issuance of the Court’s order, and require that HHS maintain its current settlement programs. Judge Boasberg concluded that “[w]here the agency is held to a set of deadlines, it is unnecessary – and unwise – to further specify the steps it must take.”[6]
If Judge Boasberg’s decision stands, it will significantly change the current Medicare audit timeline and the way that Medicare appeals are handled by providers and attorneys.
Program Note:
Listen to healthcare attorney Andrew Wachler report this story live on Monitor Monday, Nov. 12, 10-10:30 a.m.
[1] 42 C.F.R. 405.1016(a).
[2] Average Processing Time By Fiscal Year, https://www.hhs.gov/about/agencies/omha/about/current-workload/index.html
[3] AHA v. Azar, 2018 U.S. Dist. Lexis 186853, *8 (D.D.C. 2018) (emphasis in original).
[4] Id. at *7 (emphasis in original).
[5] Id. at *11.
[6] Id. at *13.
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
Please log in to your account to comment on this article.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Stacey Shillito, CDIP, CPMA, CCS, CCS‑P, CPEDC, COPC. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s third quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
BLOOM INTO SAVINGS! Get 25% OFF during our spring sale through March 27. Use code SPRING26 at checkout to claim this offer.
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
