Center for Medicare Advocacy Sues to Fix Broken Medicare Appeals System

August 26, 2014 – The Center for Medicare Advocacy filed a nationwide class action lawsuit in United States District Court in Connecticut today (Lessler et al. v. Burwell, 3:14-CV-1230, D. Conn.). The five named plaintiffs, from Connecticut, New York and Ohio, have all waited longer than the statutory 90-day limit for a decision on their Medicare appeals. The current average wait time is over five times the congressionally mandated time limit.  The complaint is available here. 

The Medicare Act requires Administrative Law Judges (ALJs) to issue decisions within 90 days after a request for a hearing. Yet, as of July 2014, the current wait time for a decision averaged 489 days. Due to an unjust and time-consuming Medicare appeals process that essentially “rubber stamps” denials at the first two levels of appeal, the ALJ hearing is the third level of appeal, and represents the first chance for a meaningful review of a beneficiary’s appeal – which can include the chance to provide oral and witness testimony.  

“This lawsuit is necessary because of a broken Medicare appeals system. We’re suing to fix it for the Plaintiffs and the thousands of beneficiaries in similar circumstances who are struggling to pay health care bills, or going without needed care while stuck in bureaucratic limbo,” said Gill Deford, Director of Litigation for the Center for Medicare Advocacy.

ALJ wait times have dramatically increased since 2009 in part because of increasing rates of denial at the lower levels of appeal.  

“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. This system needs to be fixed.” 

Secretary Sylvia Burwell should ensure that the Medicare appeals system provides legitimate reviews at the earliest levels – and timely, fair hearings and decisions for beneficiaries who must seek Administrative Law Judge hearings.

To speak with a representative of the Center for Medicare Advocacy about this case, please contact Lauren Weybrew atlweybrew@douglasgould.com or 646-214-0514.