Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-15-05015/USCOURTS-caDC-15-05015-0/pdf.json

Nature of Suit Code: 890
Nature of Suit: Other Statutory Actions
Cause of Action: 

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United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued November 9, 2015 Decided February 9, 2016

No. 15-5015

AMERICAN HOSPITAL ASSOCIATION, ET AL.,

APPELLANTS

v.

SYLVIA MATHEWS BURWELL, IN HER OFFICIAL CAPACITY AS 

SECRETARY OF HEALTH AND HUMAN SERVICES,

APPELLEE

Appeal from the United States District Court

for the District of Columbia

(No. 1:14-cv-00851)

Catherine E. Stetson argued the cause for appellants. 

With her on the briefs was Jaclyn L. DiLauro. Adam K. Levin

entered an appearance.

Ronald S. Connelly was on the brief for amicus curiae 

Fund for Access to Inpatient Rehabilitation in support of 

appellants.

Joshua M. Salzman, Attorney, U.S. Department of 

Justice, argued the cause for appellee. With him on the brief 

were Benjamin C. Mizer, Principal Deputy Assistant Attorney 

General, Vincent H. Cohen Jr., Acting U.S. Attorney, Mark B. 

Stern, Attorney, William B. Schultz, General Counsel, U.S. 

Department of Health and Human Services, Janice L. 

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Hoffman, Associate General Counsel, and Susan Maxson 

Lyons, Deputy Associate General Counsel.

Before: TATEL, KAVANAUGH, and SRINIVASAN, Circuit 

Judges.

Opinion for the Court filed by Circuit Judge TATEL.

TATEL, Circuit Judge: At heart, this case is about an 

agency caught between two congressionally assigned tasks. 

Congress has prescribed specific time frames for the Secretary 

of Health and Human Services to reach decisions on various 

stages of administrative appeals of Medicare reimbursement 

claim denials. But Congress has also directed the Secretary to 

implement the Medicare Recovery Audit Program to detect 

waste, fraud, and abuse. Although the audit program has 

recovered billions of dollars in fraudulently or otherwise 

improperly paid funds, it has also contributed significantly to 

a volume of appeals that makes compliance with the statutory 

time frames impossible. Plaintiffs, including several hospitals 

with a significant amount of money tied up in the appeals 

process for far longer than the statute contemplates, seek a 

writ of mandamus compelling the Secretary to act within 

those time frames. Although Plaintiffs disclaim any desire or 

authority to force the Secretary to curtail the audit program or 

take any other particular action to meet the deadlines, the

record suggests that absent further congressional action, the 

Secretary would likely have to drastically curtail that program 

to comply with such an order. The district court concluded 

that mandamus relief was unwarranted, noting the political 

branches’ ongoing efforts to resolve this tension and the audit 

program’s success in detecting improper payments. For the 

reasons set forth in this opinion, we reverse and remand with 

instructions to the district court to consider the problem as it 

now stands—worse, not better.

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I.

After a hospital or other health-care provider performs

Medicare-eligible services, it submits a claim for 

reimbursement to a Medicare Administrative Contractor 

(MAC). 42 U.S.C. §§ 1395ff(a)(1)–(2), 1395kk-1(a); 42 

C.F.R. §§ 405.904(a)(2), 405.920–405.928. The MAC decides 

whether to pay or deny the claim. If a claim is denied, the 

Medicare Act provides a four-level administrative appeal 

process, followed by judicial review. At the first level, the 

health care provider presents its claim again to the MAC for 

“redetermination.” 42 U.S.C. § 1395ff(a)(3)(A), (a)(3)(C)(ii). 

The second level involves “reconsideration” by a Qualified 

Independent Contractor (QIC). Id. § 1395ff(c). The Centers 

for Medicare and Medicaid Services (CMS) oversees initial 

determinations and redeterminations by the MACs, as well as 

reconsiderations by the QICs.

If the provider remains unsatisfied, and if its claim 

exceeds $150, it may continue to the third stage: de novo 

review by an administrative law judge, including a hearing.

Id. § 1395ff(b)(1)(E)(i), (b)(1)(E)(iii), (d)(1)(A); 42 C.F.R. 

§ 405.1006(b); 80 Fed. Reg. 57,827, 57,827 (2015). This 

stage of the process is overseen by the Office of Medicare 

Hearings and Appeals (OMHA), which houses ALJs and their 

support staff, and which is funded by a separate appropriation. 

See Medicare Prescription Drug, Improvement, and 

Modernization Act of 2003, Pub. L. No. 108-173, § 931, 117 

Stat. 2066 (requiring the Secretary to create an 

“administrative office that is organizationally and functionally 

separate from [CMS]” to “assure the independence of 

administrative law judges”). The fourth and final 

administrative stage involves de novo review by the Medicare 

Appeals Council, a division of the Departmental Appeals 

Board (DAB). Although the DAB has authority to hold a 

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hearing, it does so only if “there is an extraordinary question 

of law/policy/fact.” Mot. for Summ. J. Ex. 2, at 118. Finally, 

after completing the administrative appeal process, providers 

may seek review in district court of claim denials worth at 

least $1,500. 42 U.S.C. § 1395ff(b)(1)(E)(i), (b)(1)(E)(iii); 42 

C.F.R. § 405.1006(c); 80 Fed. Reg. at 57,827. We apologize 

to our readers for all of the acronyms, but this is, after all, a 

Medicare case, and acronyms seem integral to the parties’ 

native language.

To prevent appeals from lingering unresolved, the statute 

includes specific time frames for each step of the process. In 

particular, redetermination by the MACs “shall be concluded” 

within sixty days, 42 U.S.C. § 1395ff(a)(3)(C)(ii), and, with 

exceptions not relevant here, QICs “shall conduct and 

conclude” reconsiderations within sixty days, id.

§ 1395ff(c)(3)(C)(i). Similarly, ALJs “shall conduct and 

conclude a hearing . . . and render a decision” within ninety 

days, id. § 1395ff(d)(1)(A), although the appealing provider 

may “waive” this “deadline,” id. § 1395ff(d)(1)(B). And 

finally, the DAB “shall conduct and conclude a 

review . . . and make a decision or remand the case to the 

administrative law judge for reconsideration” within ninety 

days. Id. § 1395ff(d)(2)(A). If all these time periods are met, 

appeals will work their way through the administrative 

process within about a year.

The statute also prescribes “consequences of failure to 

meet” several of the statutory “deadlines.” In a process 

commonly referred to as “escalation,” a provider that has been 

waiting for longer than the statutory time limit may advance

its appeal to the next stage. Thus, a provider may “escalate” 

its appeal to the ALJ stage if the QIC fails to act within the 

required sixty days, id. § 1395ff(c)(3)(C)(ii), to the DAB 

stage if the ALJ fails to act within the required ninety days, id.

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§ 1395ff(d)(3)(A), and to district court review if the DAB 

fails to act within the required ninety days, id.

§ 1395ff(d)(3)(B).

For years, the administrative appeal process functioned 

largely as anticipated, with its various stages typically 

completed within the statutory time frames. American 

Hospital Ass’n v. Burwell, 76 F. Supp. 3d 43, 46 (D.D.C. 

2014). Then, in 2010, the Secretary fully implemented the 

Medicare Recovery Audit Program, which Congress had 

required the Secretary to set up “for the purpose of identifying 

underpayments and overpayments and recouping 

overpayments.” 42 U.S.C. § 1395ddd(h)(1). Specifically, 

Congress directed that the Secretary “shall enter into contracts

with recovery audit contractors” (RACs), who must be paid 

“on a contingent basis for collecting overpayments” and “in 

such amounts as the Secretary may specify for identifying 

underpayments.” Id. § 1395ddd(h)(1)(B). Although Congress 

also specified certain other features of the program, such as 

that it must have “[n]ationwide coverage,” id.

§ 1395ddd(h)(3), it left the Secretary broad discretion to 

determine many other program details.

The RAC program has had two primary effects. First, the 

government has recovered a great deal of improperly paid 

money. According to the Secretary, “[i]n 2012, the program 

identified $2.3 billion in overpayments, and in fiscal year 

2013, the recovery auditors identified and corrected $3.65 

billion in overpayments.” Appellee’s Br. 8–9 (footnotes 

omitted). In 2012, the Secretary adds, “only 7% of claims 

identified by audit contractors as overpayments were 

challenged and overturned on appeal,” and only 9.3% were in 

2013. Id. at 9.

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But because RAC denials are appealable through the 

same administrative process as initial denials, the RAC 

program has contributed to a drastic increase in the number of 

administrative appeals. Thus, the number of appeals filed 

ballooned from 59,600 in fiscal year 2011 to more than 

384,000 in fiscal year 2013. Mot. for Summ. J. Ex. 7, at 4. 

Although the Secretary explains that other factors, such as 

“increased utilization of Medicare-covered services,” have 

played a role in increasing the number of appeals filed,

Appellee’s Br. 9, the government acknowledged at oral 

argument that 46% of the appeals currently pending before 

OMHA originated from the RAC program. Oral Arg. Tr. 35.

Between RAC and non-RAC appeals, OMHA currently 

receives many more cases than it can process in a timely 

fashion. Indeed, every two months or less, it receives as many 

appeals as it can process in a full year. Appellants’ Br. 12. As 

of February 2015, the decisions ALJs were releasing had been 

pending for an average of 572 days. Appellee’s Br. 10. This 

number will almost certainly continue to grow as the backlog 

worsens. 

The Secretary has worked to address the backlog and 

corresponding delays. As a result of various reforms, the 

number of appeals the average ALJ resolves each year has 

more than doubled since 2009. Mot. for Summ. J. Ex. 7, at 4. 

Moreover, the agency secured funding for seven additional 

ALJs and associated staff in fiscal year 2014—an increase of 

about 10% over previous staffing levels. Id. at 5.

Despite these additional resources and significant 

improvements, the Secretary and OMHA find themselves in 

an untenable position. OMHA still has the capacity to process 

only about 72,000 appeals per year, a far cry from the almost 

400,000 appeals it received in fiscal year 2013, or from the 

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over 800,000 appeals that composed its backlog in July 2014.

Id. These figures suggest that at current rates, some alreadyfiled claims could take a decade or more to resolve. Bowing 

to this reality, in December 2013, OMHA’s Chief ALJ sent a 

memorandum informing various hospitals that OMHA had 

temporarily suspended assigning appeals to ALJ dockets, that 

the suspension would last “at least 24 months,” and that the 

agency “expect[ed] post-assignment hearing wait times 

[would] continue to exceed 6 months.” Mot. for Summ. J. Ex. 

3, at 1. The DAB stage is also plagued by delays, although not 

quite to the same degree. E.g., Mot. for Summ. J. Ex. 7, at 

107, 111.

Congress is fully aware of both the backlog and its 

connection to the RAC program. The Senate Finance 

Committee has held multiple hearings on the issue, dating 

back to at least July 2013. Indeed, although at a 2015 hearing,

Senator Orrin Hatch, the committee chairman, expressed 

concern over the lengthy delays, he recognized that OMHA

“has also taken steps to address its backlog, but there is only 

so much the agency can do with their current authorities and 

staffing.” See Hatch Statement at Finance Hearing on 

Medicare Audit and Appeals (Apr. 28, 2015),

http://www.finance.senate.gov/chairmans-news/hatch

-statement-at-finance-hearing-on-medicare-audit-and-appeals.

Moreover, the Senate is considering a bill known as the 

“AFIRM Act,” which would provide $125,000,000 in 

additional annual funding for OMHA, as well as make other 

reforms to the appeal process designed to address the backlog.

AFIRM Act, S. 2368, 114th Cong. (2015). If enacted, this 

legislation might go some way toward resolving the problems. 

As of yet, however, the bill remains only a bill, and the delays 

continue.

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If the vast majority of these delayed appeals were 

ultimately denied, they might amount to little more than an 

unfortunate nuisance. The record suggests, however, that 

many have merit. Hospitals responding to a survey conducted 

in 2014 by one of the plaintiffs in this case, the American 

Hospital Association, reported that they had appealed 52% of 

RAC denials, and that 66% of these appeals that had been 

completed were successful. Mot. for Summ. J. Ex. 5, at 55. 

The Secretary quibbles with the details of this statistic—and 

we acknowledge the obvious self-selection and bias 

problems—but even government counsel conceded at oral 

argument that 43% of ALJ appeals (including from RAC and 

non-RAC denials) succeed. Oral Arg. Tr. 37. This reversal 

rate is hardly negligible.

The delays at the ALJ stage are especially harmful to 

hospitals because HHS recoups funds after the QIC stage. 42 

U.S.C. § 1395ddd(f)(2)(A). Given hospitals’ frequent success 

at the ALJ level, this means that they are often deprived of 

access to significant funds to which they are entitled. This 

problem takes a particular toll on hospitals with a large share 

of patients who rely on Medicare.

Plaintiffs in this case, three such hospitals or hospital 

systems and the American Hospital Association (collectively, 

the “Association”), filed suit in United States district court 

seeking relief in the nature of mandamus under 28 U.S.C. 

§ 1361 (which, for ease of reference, we refer to simply as 

“mandamus”) to “compel the Secretary . . . to meet the 

statutory deadlines for administrative review of denials of 

claims for Medicare reimbursement.” Compl. at 1. The three 

hospitals or hospital systems are (1) Baxter Regional Medical 

Center, a 268-bed regional hospital in Arkansas that derives 

65% of its gross revenue from Medicare, Holleman Decl. 

¶¶ 5–7; (2) Covenant Health, a community-owned health 

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system of hospitals in Tennessee that derives 55% of its gross 

revenue from Medicare, Geppi Decl. ¶¶ 5, 8; and (3) Rutland 

Regional Medical Center, a community-owned 188-bed 

hospital in Vermont that derives 47% of its revenues from 

Medicare, Wallace Decl. ¶¶ 6, 10. All three allege that they 

have significant funds tied up in the Medicare appeals 

process—including in appeals that have already exceeded the 

statutory time frames—and that their inability to access these 

funds makes a number of essential activities, such as 

replacing ICU beds, difficult or impossible. All three report

that the inability to access the money makes it more difficult 

to provide adequate care, and at least Baxter and Covenant 

say they may stop offering certain services if the system is not 

fixed.

The Association sought summary judgment in the district 

court, and the Secretary moved to dismiss for lack of 

jurisdiction. The district court concluded that the 

jurisdictional and merits questions merged, and thus resolved 

both motions at once. The district court denied the 

Association’s motion for summary judgment and granted the 

Secretary’s motion to dismiss for lack of jurisdiction, 

concluding that the agency’s delay was not so unreasonable as 

to justify mandamus. In doing so, the district court concluded 

as follows: “The Court hopes that the Secretary and Congress 

will continue working together toward a solution and that 

OMHA will receive the resources necessary to fulfill its 

obligations. Hospitals that are owed reimbursement should 

not be indefinitely deprived of funds. The Court cannot 

predict whether, over time, if HHS and Congress cannot 

adequately address the overflow of appeals, the [analysis]

might shift toward Plaintiffs.” American Hospital Ass’n, 76 F. 

Supp. 3d at 56.

This appeal followed.

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II.

“The remedy of mandamus is a drastic one, to be invoked 

only in extraordinary circumstances.” Power v. Barnhart, 292 

F.3d 781, 784 (D.C. Cir. 2002) (internal quotation marks 

omitted). To show entitlement to mandamus, plaintiffs must 

demonstrate (1) a clear and indisputable right to relief, (2) that 

the government agency or official is violating a clear duty to

act, and (3) that no adequate alternative remedy exists. United 

States v. Monzel, 641 F.3d 528, 534 (D.C. Cir. 2011). These 

three threshold requirements are jurisdictional; unless all are 

met, a court must dismiss the case for lack of jurisdiction. See 

In re Medicare Reimbursement Litigation, 414 F.3d 7, 10 

(D.C. Cir. 2005) (internal quotation marks and alteration 

omitted). “Even when the legal requirements for mandamus 

jurisdiction have been satisfied, however, a court may grant 

relief only when it finds compelling equitable grounds.” Id.

“The party seeking mandamus has the burden of showing that 

its right to issuance of the writ is clear and indisputable.” 

Power, 292 F.3d at 784 (internal quotation marks omitted).

Mandamus claims that, like this one, target agency delay, 

turn on “whether the agency’s delay is so egregious as to 

warrant mandamus.” In re Core Communications, Inc., 531 

F.3d 849, 855 (D.C. Cir. 2008) (internal quotation marks

omitted). In such cases, courts are guided by the “TRAC

factors,” so named because they come from our decision in 

Telecommunications Research & Action Center v. FCC. 

These factors are as follows:

(1) the time agencies take to make decisions must be 

governed by a rule of reason; (2) where Congress has 

provided a timetable or other indication of the speed 

with which it expects the agency to proceed in the 

enabling statute, that statutory scheme may supply 

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content for this rule of reason; (3) delays that might 

be reasonable in the sphere of economic regulation 

are less tolerable when human health and welfare are 

at stake; (4) the court should consider the effect of 

expediting delayed action on agency activities of a 

higher or competing priority; (5) the court should 

also take into account the nature and extent of the 

interests prejudiced by delay; and (6) the court need 

not find any impropriety lurking behind agency 

lassitude in order to hold that agency action is 

unreasonably delayed.

Telecommunications Research & Action Center v. FCC 

(TRAC), 750 F.2d 70, 80 (D.C. Cir. 1984) (internal quotation 

marks and citations omitted). Although these factors provide 

guidance by setting out “the hexagonal contours of a 

standard,” we have been careful to emphasize that they are 

“hardly ironclad,” id., and that “[e]ach case must be analyzed 

according to its own unique circumstances,” Air Line Pilots 

Ass’n v. Civil Aeronautics Board, 750 F.2d 81, 86 (D.C. Cir. 

1984).

We have never squarely addressed the interplay of the 

three threshold mandamus requirements—clear duty, clear 

right to relief, and absence of an adequate alternative 

remedy—and the six TRAC factors. Because these factors

function not as a hard and fast set of required elements, but 

rather as useful guidance as to whether a delay is “so 

egregious as to warrant mandamus,” TRAC, 750 F.2d at 79, 

their roles may differ depending on the circumstances. For 

example, in situations where plaintiffs allege that agency

delay is unreasonable despite the absence of a specific 

statutory deadline, the entire TRAC factor analysis may go to 

the threshold jurisdictional question: does the agency’s delay 

violate a clear duty? By contrast, in situations where the 

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statute imposes a deadline or other clear duty to act, the bulk 

of the TRAC factor analysis may go to the equitable question 

of whether mandamus should issue, rather than the 

jurisdictional question of whether it could.

Here, the district court recognized the unsettled 

relationship between jurisdictional and merits questions in 

mandamus suits. American Hospital Ass’n, 76 F. Supp. 3d at 

49–50. Guided in part by our precedent outside of the agencydelay context, the district court concluded that the 

jurisdictional and merits inquiries “merge[d],” and that “the 

dual nature of the inquiry” allowed it to “resolve Plaintiffs’ 

Motion for Summary Judgment together with Defendant’s 

Motion to Dismiss for Lack of Jurisdiction.” Id. at 50 (internal 

quotation marks omitted). Accordingly, after analyzing the 

TRAC factors, the district court denied Plaintiffs’ summary 

judgment motion and granted the Secretary’s motion to 

dismiss for lack of jurisdiction. 

In our view, however, the distinction between the 

jurisdictional inquiry and the equitable merits inquiry matters, 

especially because it affects our standard of review. We 

review the threshold requirements for mandamus jurisdiction 

de novo. In re Medicare Reimbursement Litigation, 414 F.3d 

at 10. But we review “the equities” for abuse of discretion. Id.

Accordingly, we first consider the threshold jurisdictional 

question, and then turn to the equities.

A.

At the outset, we must determine whether, as the 

Association argues, the statutory time frames are mandatory 

deadlines. According to the Association, the statute imposes 

mandatory duties by providing that certain actions “shall” 

occur within specified time frames. As the Secretary sees it, 

however, the opportunity for providers to escalate appeals 

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deprives the district court of jurisdiction to issue mandamus, 

either because escalation demonstrates the lack of a statutory 

duty or because it provides an adequate alternative remedy. In 

the unique circumstances of this case, we agree with the 

Association.

To begin with, as to clear duty, the statute uses the 

typically mandatory “shall.” E.g., 42 U.S.C. § 1395ff(d)(1)(A) 

(“[A]n administrative law judge shall conduct and conclude a 

hearing . . . and render a decision on such hearing” within 

ninety days. (emphasis added)). To be sure, as the Secretary 

points out, context can dictate that “shall” take a directory 

rather than a mandatory meaning. But here, context only 

reinforces a mandatory reading. The statute itself repeatedly 

refers to the time frames as “deadlines.” E.g., id.

§ 1395ff(d)(1)(B). And the provision permitting “[w]aiver of 

deadline by party seeking hearing,” id., would lack meaning if 

the agency had no obligation to comply with the deadline in 

the first place.

The Secretary argues that by permitting escalation, 

Congress acknowledged that the time frames would 

sometimes remain unmet, thus suggesting that Congress did 

not view them as mandatory. Appellee’s Br. 19–20. The 

Secretary’s premise fails to support her conclusion. Merely 

providing a consequence for noncompliance does not 

necessarily undermine the force of a command.

The argument that escalation provides an adequate 

alternative remedy is somewhat stronger. If delays occurred 

only in isolated or occasional cases, escalation might suffice. 

Indeed, we agree with the Secretary that Congress’s inclusion 

of the remedy in the statutory scheme indicates that Congress 

anticipated that violations might occur with some measure of 

regularity. That said, nothing suggests that Congress intended 

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escalation to serve as an adequate or exclusive remedy where, 

as here, a systemic failure causes virtually all appeals to be 

decided well after the statutory deadlines.

In some circumstances, of course, distinguishing between 

violations that escalation can adequately address and those it 

cannot might be difficult. The systemic failure at issue in this 

case, however, presents no such line-drawing dilemma. 

Escalation from the ALJ stage to the DAB stage is unlikely to

provide a timely hearing. Not only does the DAB itself have a 

backlog, but it holds hearings only where an “extraordinary 

question” is involved.

Nor does further escalation to district court suffice. As 

the government acknowledged at oral argument, district court 

review would be deferential, Oral Arg. Tr. 28, hardly an 

adequate substitute for a de novo hearing before an 

administrative law judge.

Alternatively, the Secretary argues that she has no clear 

duty because the action the Association seeks mandamus to 

compel is discretionary rather than ministerial. As the 

Association points out, however, although both the content of 

the administrative appeal decisions and the means the 

Secretary uses to ensure they are reached in a timely fashion 

are discretionary, the Association formally seeks to compel 

neither. Rather, it simply seeks to compel the Secretary to 

make decisions within the statutory time frames. Appellants’ 

Reply Br. 6. The Secretary insists that the Association’s 

request constitutes a “programmatic attack” on the way her 

department manages its resources, that the department lacks 

the resources to render decisions within the statutory time

frames, and that even if it had the necessary resources, we

should hesitate to reorder agency priorities in such a manner. 

The Supreme Court, however, has distinguished 

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impermissible “programmatic attack[s]” from “the failure

to . . . take some decision by a statutory deadline,” Norton v. 

Southern Utah Wilderness Alliance, 542 U.S. 55, 63–64

(2004), the very failure the Association challenges here.

In making her “programmatic attack” argument, the 

Secretary emphasizes that many agency delay cases involve

one or a small number of decisions, rather than the countless 

administrative appeals at issue in this case. Appellee’s Br. 27.

In the presence of a clear statutory deadline, however, the 

scope of the program involved goes to “the equities” of 

granting mandamus rather than to the threshold jurisdictional 

question of whether a clear duty exists. Indeed, this court has 

made clear—albeit in a case denying mandamus relief—that 

“[h]owever many priorities the agency may have, and 

however modest its personnel and budgetary resources may 

be, there is a limit to how long it may use these justifications 

to excuse inaction in the face of” a statutory deadline. In re 

United Mine Workers of America International Union, 190 

F.3d 545, 554 (D.C. Cir. 1999). And in another case, we 

strongly suggested that we would have granted mandamus to 

require an agency to make over a dozen delayed decisions had 

the agency not convinced us that it had resolved the 

underlying issues and was quickly working through its 

backlog. In re American Federation of Government 

Employees, AFL-CIO, 790 F.2d 116 (D.C. Cir. 1986).

Finally, our decisions in In re Barr Laboratories, Inc., 

930 F.2d 72 (D.C. Cir. 1991), and Mashpee Wampanoag 

Tribal Council, Inc. v. Norton, 336 F.3d 1094 (D.C. Cir. 

2003)—both relied on by the Secretary—are not to the 

contrary. In these cases, we rejected mandamus claims that 

would have had the effect of allowing the plaintiffs to jump 

the line, functionally solving their delay problem at the 

expense of other similarly situated applicants. To be sure, the 

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complaint in this case does seek this type of relief, see Compl. 

Prayer for Relief (b)(i), (b)(ii), which we agree our precedent 

forecloses. But the complaint also requests the broader relief 

of “requiring HHS to otherwise comply with its statutory 

obligations in administering the appeals process for all 

hospitals.” Id. (b)(iii). The line-jumping cases of Barr Labs

and Mashpee Wampanoag Tribal Council neither speak to nor 

preclude such relief.

We thus conclude that the statute imposes a clear duty on 

the Secretary to comply with the statutory deadlines, that the 

statute gives the Association a corresponding right to demand 

that compliance, and that escalation—the only proposed 

alternative remedy—is inadequate in the circumstances of this 

case. Because the Association has demonstrated that the 

threshold requirements for mandamus jurisdiction are met, 

and because the Secretary’s other jurisdictional arguments 

fail, we reverse the district court’s dismissal for lack of 

jurisdiction.

B.

On remand, the district court should determine whether 

“compelling equitable grounds” now exist to issue a writ of 

mandamus. The court appears to have considered this 

question as it stood in late 2014 as part of its merged 

jurisdictional and merits inquiry, but the record on appeal 

makes clear that the situation has worsened—something the 

district court will need to account for as it applies the TRAC

factors. Although the difficult decision of when to issue the 

extraordinary writ rests in the first instance with the district 

court, given the large number of federal agencies within our 

jurisdiction and the importance of ensuring the application of 

uniform mandamus standards, we think it helpful to set out 

the factors that weigh most strongly for and against 

mandamus in this case.

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Perhaps counseling most heavily against mandamus is the 

writ’s extraordinary and intrusive nature, which risks 

infringing on the authority and discretion of the executive 

branch. These risks are especially salient here because

mandamus would, in effect, probably require the agency to 

make major changes to its operations and priorities, including 

drastically limiting the scope of a statutorily mandated 

program that has recovered billions of dollars in incorrectly 

paid funds. Moreover, as the district court properly noted, 

Congress’s awareness of and attention to the situation counsel 

against issuance of the writ. American Hospital Ass’n, 76 F. 

Supp. 3d at 56. So too, we think, does the fact that Congress 

has provided escalation as a remedy, even though that remedy 

may offer less than full relief. Escalation might inform the 

district court’s analysis of whether the delay is egregious 

enough to warrant the grant of mandamus relief, even if it 

does not preclude mandamus jurisdiction altogether. Finally, 

the district court also correctly concluded that the Secretary’s 

good faith efforts to reduce the delays within the constraints 

she faces—such as by implementing reforms that have 

doubled ALJ efficiency—push in the same direction. Id. at 

55–56. The backlog and delays have their origin in the 

political branches, and ideally the political branches should

resolve them.

On the other hand, several significant factors counsel in 

favor of mandamus. To begin with, the record demonstrates

that the delays are having a real impact on “human health and 

welfare.” TRAC, 750 F.2d at 80. For example, one plaintiff, 

Baxter Regional Medical Center, submitted a declaration

explaining that having money tied up in the appeals process 

beyond the statutory deadlines makes it much more difficult 

to purchase replacement ICU beds, replace (rather than patch) 

a roof over its surgery department, and replace a twenty-yearUSCA Case #15-5015 Document #1597907 Filed: 02/09/2016 Page 17 of 19
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old catheterization lab which will “soon need to be shut 

down.” Holleman Decl. ¶¶ 14–15. Likewise, amicus the Fund 

for Access to Inpatient Rehabilitation reports that the delays 

have led at least one rehabilitation hospital to “avoid 

admitting certain types of patients, regardless of whether its 

staff believes the patients meet the coverage criteria for 

rehabilitation hospital care, if those patients have indicia 

within their medical records that are likely to trigger an 

audit.” Amicus Br. 28. These consequences—none of which 

the government challenges—are unsurprising; common sense 

suggests that lengthy payment delays will affect hospitals’ 

willingness and ability to provide care.

Moreover, and critically to our thinking about this case, 

although Congress directed the Secretary to establish the RAC 

program, it has left her with substantial discretion to 

implement it and determine its scope. 42 U.S.C. 

§ 1395ddd(h). True, Congress seems to approve of the way 

the Secretary has implemented the program, and the agency is 

entitled to some leeway to resolve the tension between 

competing priorities. If it fails to do so, however, and if 

Congress fails to act, either by providing the Secretary 

sufficient resources to comply with the clear statutory 

deadlines it has already enacted or by relieving her of the

obligation to do so, these deadlines dictate that the Secretary 

will have to curtail the RAC program or find some other way 

to meet them. Federal agencies must obey the law, and 

congressionally imposed mandates and prohibitions trump 

discretionary decisions.

All that said, we reiterate that the district court has broad 

discretion in weighing the equities and deciding “whether the 

agency’s delay is so egregious as to warrant mandamus.”

Taking the above factors into account, the district court—

more than a year after its first denial and with the problem 

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only worsening—might find it appropriate to issue a writ of 

mandamus ordering the Secretary to cure the systemic failure 

to comply with the deadlines. On the other hand, if the district 

court determines on remand that Congress and the Secretary 

are making significant progress toward a solution, it might 

conclude that issuing the writ is premature. If so, it could

consider such action as ordering the agency to submit status 

reports updating the court on the level of appropriations, the 

progress of the AFIRM Act, and any other relevant 

information.

In the end, although courts must respect the political 

branches and hesitate to intrude on their resolution of 

conflicting priorities, our ultimate obligation is to enforce the 

law as Congress has written it. Given this, and given the 

unique circumstances of this case, the clarity of the statutory 

duty likely will require issuance of the writ if the political 

branches have failed to make meaningful progress within a 

reasonable period of time—say, the close of the next full 

appropriations cycle. Cf. In re Aiken County, 725 F.3d 255, 

258–59 (D.C. Cir. 2013) (granting mandamus after Congress 

failed to take advantage of a previous order holding the case 

in abeyance to give Congress the chance to “clarify” 

potentially conflicting signals on whether it wanted the 

Nuclear Regulatory Commission to expend appropriated 

funds on activities related to storing nuclear waste at Yucca 

Mountain).

III.

We reverse the district court’s dismissal for lack of 

jurisdiction and remand for further proceedings consistent 

with this opinion.

So ordered.

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