Summary of AHA v.价格,2017 U.S.App.LEXIS 14887 (D.C.环八月。11,2017)

On August 11,2017,D.C.Circuit reversed the district court and held that the district court abused its discretion by ordering the Secretary of HHS to clear the backlog of administrative appeals of denied Medicare reimbursement claims within four years,因为它没有认真地检验秘书关于这个结果是不可能的断言。The underlying action demanded relief to address the Secretary's inability to keep up with"在这一过程中,意外而戏剧性的上诉上升引起了一场混乱。”starting in fiscal year 2011.

In the initial proceedings,一组医院寻求司法命令,迫使部长提供救济,使其免于在行政上诉级别解决医疗保险索赔上诉时被认为是不合理的拖延。哥伦比亚特区联邦地方法院批准了部长因缺乏管辖权而提出的解雇动议,但是D.C.电路颠倒。The Circuit Court remanded the case back to the district court,with instructions to consider the merits of appeal,即。,whether relief should be granted and if so the form of the relief.

The Four-Year Plan to Reduce the Backlog

在处理原告关于还押的指控时,the district court adopted the hospitals' so-called four-year plan and ordered the Secretary to reduce the current backlog of cases pending at the Administrative Law Judge level by 30% by the end of 2017;60% by the end of  2018;90% by the end of 2019;and 100% by the end of 2020.  The Secretary then appealed the district court's order to the D.C.巡回法院。在上诉时,秘书认为不可能遵守时间表,because the only means of meeting the timetable would be to pay claims through mass settlements regardless of their merits,which (according to the Secretary) would be in violation of the Medicare statute.

在没有发现秘书实际上是否无法合法地遵守地区法院的命令的情况下,D.C.巡回法院认为,由于秘书表示不可能合法遵守地方法院的命令,地方法院犯了可逆转的错误,命令秘书遵守时间表,而没有首先发现合法遵守确实是可能的。The Circuit Court also held that it was an error for the district court not to evaluate the Secretary's assertion that the timetable would increase,不减少,the number of backlogged appeals,because the timetable would generate an incentive for claimants to file additional appeals and hold out for big payouts.

The Case is Remanded to District Court to Determine Feasibility of Compliance Timetable

华盛顿特区因此,巡回法院再次将案件发回地方法院,并命令地方法院决定秘书是否不可能遵守时间表。然而,the Circuit Court noted that the Secretary will bears a"heavy burden to demonstrate the existence of an impossibility."The Court further noted that if the district court finds on remand that the Secretary failed to carry his burden of demonstrating impossibility,它可能不经修改就重新发布订单。


许多医疗保险覆盖上诉都涉及一家医院,该医院呼吁拒绝短期住院,理由是入院不是医疗上必需的,病人可以作为门诊病人来治疗。然而,因为CMS不允许医院根据B部分重新住院(出院后一年内除外,在大多数情况下,在RAC重新开放并否认住院索赔之前,这些索赔将早已过期)。医院认为他们别无选择,只能上诉。It is important to keep in mind that although the D.C.Circuit faulted the district court for not considering the issue of whether the Secretary could legally comply with the prescribed timetable,the fact that the Secretary will bear the burden of proof on this issue may mean that the district court may end up issuing the same type of relief as it did before.