Bello v. Azar (In re Bello)
Bello v. Azar (In re Bello)
Opinion of the Court
The Plaintiff, Josephine C. Bello, M.D., PLC ("Plaintiff"), filed this adversary proceeding seeking the turnover of funds held by Defendants, Alex Azar, the Secretary of the United States Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Wisconsin Physicians Service ("Defendants")
Factual Background
Plaintiff Josephine C. Bello, M.D., PLC ("Plaintiff" or "Debtor"), is a family medicine practice in Michigan. Dr. Josephine Bello is its owner and director. Under the Medicare Supplier Agreement, Debtor agreed to accept assignment of Medicare Part B payments. This means Debtor agreed to request direct Part B payments from the Medicare program.
On January 14, 2015, the Centers for Medicare & Medicaid Services ("CMS"), the agency within the U.S. Department of *44Health and Human Services ("HHS") that administers the Medicare program, through a contractor, sent a letter to Debtor requesting information for an audit to ensure that Medicare claims had been billed and paid in an appropriate manner. On August 12, 2016, CMS notified Debtor of the results of a post-payment program integrity review, resulting in several claims being reopened based on data analysis showing that it was aberrant in billing and reimbursement as compared to its peers. The reopening led to further reviews and data analysis, and in a letter dated September 9, 2016, WPS, a Medicare contractor, notified Debtor of an overpayment in the amount of $1,000,844.00.
In that letter, WPS informed Plaintiff about payment withholding or recoupment, interest assessment, and appeals procedures, all consistent with the supplier agreement. On September 20, 2016, Plaintiff filed a request for redetermination with WPS. WPS issued an unfavorable redetermination decision to Plaintiff on November 7, 2016. WPS found that Plaintiff's records did not support the medical necessity for billed services, did not support the level of billed services, did not substantiate the medical need for home visits, and did not substantiate the medical need for diagnostic tests.
On February 1, 2017, Plaintiff filed a request for reconsideration with a different Medicare contractor known as a qualified independent contractor ("QIC"). On October 3, 2017, the QIC issued a partially favorable decision and the principal amount of the overpayment was reduced from $1,000,844.00 to $732,456.00 with interest (at that time) of $73,532.53.
Plaintiff then filed a third level of appeal on November 10, 2017, by making a request for an ALJ hearing with the Office of Medicare Hearings and Appeals. The appeal is pending and not yet completed.
On March 5, 2018, Plaintiff filed for bankruptcy under Chapter 11 of the Bankruptcy Code and, on May 21, 2018, filed this Adversary Complaint. In its Complaint, Plaintiff alleges that, on an annual basis, its Medicare Receivables represent approximately 35% of Plaintiff's revenues, averaging about $250,000.00 to $350,000.00 per year. Complaint, para. 12. Plaintiff asks for, among other things, the United States to be compelled to turn over the recouped Medicare Receivables and to "end the suspension of payments."
Defendants filed the instant motion to dismiss (the "Motion") on September 14, 2018, arguing the Complaint should be dismissed under Federal Rule of Civil Procedure 12(b)(1) as the Court lacks jurisdiction to decide an unexhausted Medicare dispute. Alternatively, Defendants argue that the complaint should be dismissed pursuant to Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim, as there is an absolute right to offset overpayments notwithstanding the bankruptcy, and where Plaintiff has failed to establish the necessary elements to support issuance of an injunction. Plaintiff filed an objection to the Motion on November 2, 2018, in which Plaintiff argues there is no jurisdictional bar that would preclude a bankruptcy court from hearing a Medicare dispute. Moreover, Debtor argues that it should not be required to exhaust remedies as it has already waited for over a year for a hearing date in front of an administrative law judge, and it will be forced out of business if Defendants can continue to offset future payments to recoup the past alleged overpayments. On November 30, 2018, Plaintiff filed a reply brief.
Statutory and Regulatory Background
A. Medicare Part B
Congress created the Medicare program, under Title XVIII of the Social Security *45Act, to pay for the medical care of the aged and disabled.
Medicare Part B is a voluntary program of supplementary medical insurance covering physician services and some other medical and health services such as outpatient hospital services, x-rays, and durable medical equipment. When a Part B beneficiary receives covered services or goods from a provider, the beneficiary is responsible for paying the service provider and Part B payment can be made to the beneficiary. 42 U.S.C. § 1395u(b)(6) ; 1395u(h). However, the service provider may also execute a Medicare Participating Physician or Supplier Agreement ("Supplier Agreement"). This agreement sets forth many rights and corresponding responsibilities for the supplier. "Supplier" refers to a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services under Part B. 42 U.S.C. § 1395x(d).
First, the supplier receives the right to directly bill Medicare for Part B payments and, in return, receive direct and timely reimbursement from Medicare rather than having to seek payment directly from the beneficiary/patient. 42 U.S.C. §§ 1395u(b)(3)(B)(ii), (b)(6) ; 1395u(h). The supplier agrees to accept the Medicare payment as payment in full and may not charge the beneficiary any additional amounts apart from applicable deductibles and copayments. See Supplier Agreement; see also 42 U.S.C. § 1395u(b)(3)(B)(ii). However, the participating supplier agrees that, "payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws" and on the supplier's compliance with all applicable conditions of Medicare. The supplier explicitly agrees that Medicare may recoup past overpayments from future payments. The Medicare enrollment application requires the supplier to certify that "I agree that any existing or future overpayment made to the supplier by the Medicare program may be recouped by Medicare through the withholding of future payments." The Supplier Agreement renews automatically each year unless either the supplier or CMS terminates it.
1. The Payment of Claims
Medicare covers only services and items that are medically "reasonable and necessary." See 42 U.S.C. § 1395y(a), § 1395u. There are numerous exclusions to coverage and a supplier such as Debtor must furnish to the Medicare contractor sufficient information to determine whether payment is due and in, if so, in what amount.
To be paid for covered services and items, a supplier must file a claim for payment ("claim" or "Medicare claim"). Upfront payment through Part B does not necessarily mean the matter is concluded because a Medicare claim remains potentially subject to post-payment review and recoupment of Medicare payments, in whole or in part. Further, contractors can conduct reviews and audits for the purposes of ensuring the integrity of the Medicare program. 42 U.S.C. § 1395ddd ; 42 C.F.R. Subchapter B, Part 420.
Claims can also be reopened. See 42 U.S.C. § 1395ff(b)(1)(G) (statutory authorization for reopening Medicare claims);
*46
2. The Administrative Appeals Process
If a supplier believes a claim determination is incorrect, it can avail itself of the administrative appeals process. 42 C.F.R. Part 405, Subparts H and I; see 42 U.S.C. § 1395ff. The process has several steps. First, a supplier may seek a redetermination through the appeals department of the Medicare contractor.
B. Motion to Dismiss Standard under Federal Rule of Civil Procedure 12(b)(1)
Federal Rule of Civil Procedure 12(b)(1) allows a party to assert a "lack of jurisdiction" by motion as a defense to a complaint and, if the court finds that it lacks subject matter jurisdiction, the court must dismiss the action. Fed.R.Civ.P. 12(b)(1), (h)(3) ; Fed.R.Bankr.P. 7012. The party invoking federal subject matter jurisdiction bears the burden of proving it. United States v. Fata (In re Korff),
Analysis
A. Jurisdictional Standards
The Court must determine whether it has jurisdiction to consider Plaintiff's Complaint. Generally, as to district courts, Title 42, Sections 405(g) and (h), govern court review of a provider's request for reimbursement. Section 405(g) provides for federal district court review only of a final decision of the Secretary made after an administrative hearing. Section 405(h), made applicable by 42 U.S.C. § 1395ii, provides that § 405(g), to the exclusion of
The Sixth Circuit Court of Appeals has repeatedly dismissed actions involving Medicare where a plaintiff has not yet exhausted its administrative remedies. See, e.g. , Farkas v. Blue Cross & Blue Shield of Mich. ,
And this same jurisdictional bar has been applied to bankruptcy courts in the majority of cases. Andrews v. Blue Cross & Blue Shield of Mich. (In re Clawson Med., Rehab. & Pain Care Ctr., P.C.) ,
However, a minority of courts have held that the statutory bar on federal jurisdiction over unexhausted Medicare disputes does not apply to bankruptcy court jurisdiction under
In contrast, the majority view is that the amendments removing the statute that specifically referenced a bankruptcy *48court's jurisdiction was the result of a drafting error. See, e.g. , Bayou Shores ,
While Plaintiff vigorously argues that this Court should adopt the minority view and allow this case to continue, the Court adopts the majority view endorsed by the Sixth Circuit Court of Appeals. While the minority line of cases note that later revisions omitted reference to bankruptcy court jurisdiction, the revisions also state that Congress did not intend to effectuate any substantive change. Absent a clear direction from Congress or the Sixth Circuit Court of Appeals, the majority should be followed. Since the Plaintiff has not exhausted its administrative remedies, this Court does not have jurisdiction.
B. Michigan Academy Exception
In Nurses' Registry , the court also found that it had jurisdiction based on an exception to the exhaustion requirement promulgated in Bowen v. Michigan Academy of Family Physicians ,
However, the Sixth Circuit has held that the Michigan Academy exception "should not serve to circumvent established mechanisms of judicial review." Giesse v. Dept. of Health & Human Servs. ,
While an exception as articulated in Michigan Academy may exist, the foundation for an exception is not present in this case. As argued by counsel in oral argument, certain requests to expedite the review process may be made that would accelerate administrative review. But Plaintiff has not yet made such a request.
Conclusion
The Court lacks jurisdiction to hear unexhausted Medicare disputes and no exception to this rule applies in this case. The Court grants Defendants' Motion to Dismiss for this reason and does not address the remaining issues raised by Defendants.
Counsel for Defendants is directed to prepare and submit an appropriate order consistent with this Opinion and the entry of order procedures of this Court.
At oral argument, counsel reported that Wisconsin Physicians Service ("WPS") may not be a proper party and that its role would be discussed later. Subsequently, Plaintiff and Defendants stipulated to the dismissal of WPS as a party Defendant.
Plaintiff does not seriously contest Defendants' description of the factual background, statutory and regulatory background, or recitation of legal standard determining lack of subject matter jurisdiction, so the Court adopts Defendants' statements in pages 2-7 of Defendants' brief.
The statements made by counsel at oral argument were not agreed to by Plaintiff, so the Court did not include those statements as factual findings. For purposes of this Opinion, the Court adopts those limited statements as factual findings.
Reference
- Full Case Name
- IN RE: JOSEPHINE C. BELLO, M.D., PLC, Debtor. Josephine C. Bello, M.D., PLC v. Alex Azar, in His Capacity as Secretary of the United States Department of Health and Human Services and Centers for Medicare and Medicaid Services
- Cited By
- 1 case
- Status
- Published