High-profile consumer advocacy group sues over broken Medicare appeals process

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Long-term care providers have been outspoken in their criticism of the Medicare appeals process, which has all but ground to a halt. Now a class-action lawsuit says Medicare beneficiaries also are being harmed by the excessively long delays.

The Center for Medicare Advocacy filed in U.S. District Court in Connecticut on behalf of five named plaintiffs on Tuesday. Under the Medicare Act, administrative law judges have 90 days to issue a ruling on a disputed claim after a request for a hearing. The wait time currently averages nearly 500 days, according to the Center for Medicare Advocacy. The ALJs have been swamped in large part because it has become common practice to deny claims at the earlier levels of the appeals process, the consumer advocacy group contends.

“As a result of the extremely high denial rates at the Redetermination and Reconsideration levels, many beneficiaries must take their claims to the ALJ level,” said Judith Stein, executive director of the Center for Medicare Advocacy. “Those that ‘wait it out' for fair reviews with an ALJ are desperately in need of care; they can't wait an additional two years or more for a decision on their appeal.”

There currently is a freeze on ALJ hearings for appeals from providers, but a formal freeze has not been put in place for beneficiary appeals.

An alternative dispute resolution process for providers has been implemented, but the scale of the problem means there's no obvious way to speedily cut down the backlog, Chief Administrative Law Judge Nancy J. Griswold told a Congressional panel in July.

The plaintiffs are from Connecticut, Ohio and New York, and all have waited longer than 90 days for a decision on a Medicare appeal.

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