The Center for Medicare Advocacy has filed a class-action lawsuit on behalf of plaintiffs who have been denied a meaningful review of their Medicare claims for home health care coverage at the first two levels of appeal. The four named plaintiffs in the suit, which was filed in United States District Court in Connecticut, represent thousands of Medicare beneficiaries in Connecticut who receive an initial denial of home health care coverage that the Center charges is essentially “rubber stamped” at both the Redetermination and Reconsideration levels. The problem persists throughout the country, the Center says.
The combined denial rate for home health care coverage at the first two levels of review is about 98 percent, according to the Center. However, beneficiaries must complete those levels before they can get a hearing with an Administrative Law Judge (ALJ), which provides the first real opportunity for a meaningful evaluation of a claim. The Center tells ElderLawAnswers that ALJs generally reverse between 40 and 60 percent of the time in such cases.
“Older people and people with disabilities are going without necessary care because they’re being wrongly denied coverage and either drop out of the years-long appeals process, waiting for a hearing, or impoverish themselves to pay for care,” said Gill Deford, Litigation Director at the Center. “The sheer number of beneficiaries who are forced to deal with this time-consuming, meaningless appeals structure compelled us to take action to seek meaningful reviews earlier in the appeals process.”
The Center says that the denial rate at Redetermination and Reconsideration has been increasing in recent years, coinciding with the implementation of a new administrative review process for “traditional” Medicare (Parts A and B). While the new system was intended to make the process more efficient and user-friendly, the actual effect has been to deny beneficiaries an efficient and meaningful review of their claims, requiring them to take claims to the third level of review, an ALJ hearing.
“Most beneficiaries don’t have the resources, time or support to take their claims all the way to an Administrative Law Judge, making the first two levels of review vitally important,” said Judith Stein, Executive Director of the Center for Medicare Advocacy. “ ‘Rubber-stamping’ appeals deprives a huge number of people a legitimate review process and harms those who depend on Medicare coverage for critical health care and to maintain their quality of life.”
To read the complaint, filed as Hull v. Sebelius, click here.
For the class brief in the case, click here.
For more from the Center on the suit, click here.
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