United States Court of Appeals

For the First Circuit

No. 04-1753

UNITED STATES OF AMERICA,

Plaintiff, Appellee,

v.

LAHEY CLINIC HOSPITAL, INC.,

Defendant, Appellant.

APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF MASSACHUSETTS

[Hon. Rya W. Zobel, U.S. District Judge]

Before

 Lynch, Lipez, Howard, Circuit Judges.

Richard P. Ward, with whom Ropes & Gray LLP was on brief, for

appellant.

Jeffrey Clair, Attorney, Civil Division, United States Justice

Department, with whom Peter D. Keisler, Assistant Attorney General,

Michael J. Sullivan, United States Attorney, Douglas N. Letter, and

Nancy Rue, Attorneys, Civil Division, United States Justice

Department, were on brief, for appellee.

February 4, 2005
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LYNCH, Circuit Judge. The United States filed a civil

complaint in federal district court under 42 U.S.C. § 1345 alleging

that the Lahey Clinic Hospital billed Medicare and received payment

for tests and other diagnostic procedures performed by its clinical

laboratory when Lahey knew, or reasonably should have known, that

the tests were not reasonable and necessary for diagnosis or

treatment of illness or injury of Medicare beneficiaries. The

United States sought restitution for these overpayments, including

an accounting, disgorgement of improper gains of over $311,000, and

prejudgment interest, under common law theories of unjust

enrichment and payment under mistake of fact.

Lahey moved for judgment on the pleadings and, in the

alternative, for summary judgment. Lahey argued that the Medicare

Act, 42 U.S.C. § 1395, et seq., and the attendant administrative

procedures promulgated by the Secretary of Health and Human

Services (HHS), are the exclusive avenue for recovery by the United

States of Medicare overpayments, and as such, the district court

had no subject matter jurisdiction. The court denied the motion

and certified the question of subject matter jurisdiction to this

court under 28 U.S.C. § 1292(b).

On interlocutory appeal, the question presented is

whether the district court lacks subject matter jurisdiction

because the Medicare Act explicitly or implicitly repeals the grant

of federal court jurisdiction under 28 U.S.C. § 1345 or displaces
1The Health Care Financing Administration is now referred to

as the Center for Medicare and Medicaid Services. 

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the underlying common law causes of action over which § 1345 gives

federal courts jurisdiction. We hold that the Medicare Act does

not repeal 28 U.S.C. § 1345 or displace the underlying common law

causes of action. We affirm. 

I. 

Congress established the Medicare program in 1965 by

Title XVIII of the Social Security Act. 42 U.S.C. § 1395 et seq.

Medicare is a federally subsidized health insurance program for the

elderly and certain disabled individuals. See id. § 1395c. The

Secretary of HHS is responsible for the Medicare program, and

during the time period relevant to this case, the Health Care

Financing Administration (HCFA)1 was the component of HHS

responsible for administering the Medicare program. 

Medicare is divided into two parts: Part A and Part B.

Part A provides insurance for covered inpatient hospital and

related post-hospital services. Part B provides voluntary and

supplementary insurance which covers physicians' and certain other

medical and health services, including laboratory tests

administered by a hospital and furnished to outpatients for the

purpose of diagnosis. Id. §§ 1395j, 1395k, 1395x(s). The

Secretary contracts with "fiscal intermediaries" (FIs) and

"carriers" to make initial reimbursement determinations and to
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administer payments. These entities are often private insurance

companies. In most circumstances, FIs administer Part A and

carriers administer Part B, but FIs administer the program with

respect to hospitals for outpatient services covered under Part B.

The claims here concern payments for services provided

under Part B of Medicare. During the relevant time period involved

in this case, these payment decisions were made "by the Secretary

in accordance with the regulations prescribed by him." Id. §

1395ff(a). In order to be reimbursed through Medicare Part B,

participating providers must first file a claim with their FI. As

for the services involved in this case, they must be reasonable and

necessary for diagnosis or treatment of illness or injury; they

were covered only if ordered by a treating physician who used the

test results in the management of the beneficiary’s specific

medical problem. 42 C.F.R. § 410.32. Once a payment decision has

been made, a dissatisfied provider may seek administrative review

of this determination and then judicial review of the Secretary's

final decision after the avenues of administrative appeal have been

exhausted. Id. § 1395ff(b)(1). 

In the late 1980's, Medicare's escalating payments for

laboratory services became a source of increasing concern to

Congress, the Secretary, and HHS's Office of Inspector General. In

legislation that took effect in 1986, Congress imposed payment caps

on the amount individual carriers could pay in reimbursement for
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laboratory services. See 42 U.S.C. 1395l(h). Nonetheless,

payments for Part B laboratory services continued to rise, reaching

$3.9 billion in fiscal year 1987. 

In response to these rising costs, in 1990, the HHS

Inspector General (IG) conducted a review of a sample of Medicare

billings for the year 1988 and determined that Medicare was paying

nearly twice as much as physicians for the same tests. The IG

found that much of the added cost was attributable to Medicare's

reimbursement of panels of tests. These tests were bundled

together and performed at the same time, as an integrated group.

The IG found that when physicians ordered these panels of tests,

they were billed at a reduced rate to account for savings from

performing the tests as a group. However, when Medicare was billed

for these tests, the individual tests within the panel were billed

separately at their full rate, resulting in greatly increased costs

to Medicare.

A 1998 audit by the IG found the same problem in claims

for clinical tests performed by hospital laboratories serving

outpatients. The 1998 audit also raised concerns about certain

hematology indices, which can be generated from the results of

other tests. The report concluded that in many instances these

indices were automatically prepared when other related tests were

ordered and then separately billed to Medicare, even if the index

was duplicative or medically unnecessary.
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Within the narrow category of services of clinical

laboratory tests performed by hospital outpatient laboratories,

including chemistry, hematology, and urinalysis tests, the IG found

that "Medicare FIs overpaid hospital outpatient department

laboratories about $43.6 million . . . during a two year period

from January 1, 1994 to December 31, 1995." The IG found for that

same time period "an additional $15.6 million could have been saved

if policies had been developed to preclude payment for additional

automated hematology indices."

Accordingly, the IG recommended that the Secretary

implement controls to stop these overpayments and seek to recover

overpayments previously made. The Secretary agreed and noted that

he would "coordinate any recovery activity with the Department of

Justice through our Office of General Counsel." A number of civil

actions have been instituted to recover some of these costs under

various theories. See, e.g., United States v. Blue Cross & Blue

Shield of Ala., 156 F.3d 1098 (11th Cir. 1998) (False Claims Act);

United States v. Tenet Healthcare Corp., 343 F. Supp. 2d 922 (C.D.

Cal. 2004) (common law mistake and negligent misrepresentation).

The current dispute between Lahey and the United States arose

against this background. 

We are careful to say that Lahey does not argue that the

United States may not recover overpayments, only that it has chosen
2Lahey does assert in its statement of facts and in its reply

brief that the Medicare statute limits the Secretary’s authority to

seek restitution of overpayments more than three years after

determination of the initial claim. Lahey relies on 42 U.S.C.

§ 1395gg(b) for the proposition that no collection may be had from

a provider who is "without fault," and that the statute presumes

that a provider is without fault if the reimbursement determination

is more than three years' old. The United States disputes this

assertion and offers a different interpretation of the statute.

The United States argues that the statute's three-year presumption

of "without fault" is limited by the language, "in the absence of

evidence to the contrary." Id. This claim does not go to the

subject matter jurisdiction of the district court, and therefore we

do not address it.

328 U.S.C. § 1345 grants broad jurisdictional power to the

district courts over suits when the United States is plaintiff.

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the wrong approach in doing so.2 Similarly, the United States has

not alleged fraud on Lahey's part in this action. Lahey is a

renowned academic medical center that participates in the Medicare

program as a "provider of services" to Medicare beneficiaries.

Lahey has entered into a provider agreement with the Secretary

pursuant to 42 U.S.C. § 1395cc. The agreement provides that Lahey

will be reimbursed by Medicare through Blue Cross/Blue Shield of

Massachusetts (Lahey's FI during the relevant time period) for

medical services that are "reasonable and necessary for the

diagnosis or treatment of illness or injury or to improve the

functioning of a malformed body member." 42 U.S.C. §

1395y(a)(1)(A). 

On January 30, 2003, the United States filed an action

under 28 U.S.C. § 13453 against Lahey alleging "violations of the

common law giving rise to causes of action for unjust enrichment
-8-

and payment under mistake of fact." The allegations were split

into two different groups. The first group asserted that Lahey

"repeatedly billed Medicare for separate individual laboratory

tests that could practically and more economically be performed as

a single panel of tests." This billing practice violated Medicare

reimbursement policies which required the tests to be billed as "an

integrated, single panel of tests rather than separately." The

government also alleged that Lahey knew or should have known of

this reimbursement requirement and that Lahey nonetheless submitted

numerous individual claims between July 1, 1993 and June 30, 1994.

In total, the United States stated that Lahey submitted over 9,300

Medicare claims for unbundled blood chemistry tests. 

A second group of allegations asserted that virtually

every time a complete blood count test was ordered for a patient

and Lahey billed the United States for this test, Lahey performed

a medically unnecessary hematology test. Specifically, between

July 1, 1993 and December 31, 1996, Lahey submitted over 88,000

claims for payment of certain "automated hemogram indices," which

were generated every time a complete blood count was ordered. The

United States alleges that Lahey repeatedly billed Medicare for

these tests without making any determination that they were

medically necessary or actually sought by the treating physician

and that in fact these tests were rarely medically useful. 

Lahey moved for judgment on the pleadings or in the
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alternative, summary judgment, primarily arguing that the district

court did not have subject matter jurisdiction because Medicare's

jurisdictional provisions, specifically 42 U.S.C. §§ 405(h) and

405(g), bar the United States from seeking to recover a prior

overpayment through a direct action in federal court. Lahey

asserted that the initial decision by the FI to reimburse Lahey for

the tests is a final decision of the Secretary, and this final

decision can only be reopened by the Secretary through the

processes and procedures outlined in the Medicare Act and the

regulations promulgated pursuant to it.

Finding that it had subject matter jurisdiction, the

district court denied Lahey's motion on March 25, 2004. The court

held that the statutory provisions in the Medicare Act apply to

claims brought against the United States not claims brought by the

United States as plaintiff. The district court based its decision

on several factors: the language of the statutory provisions; the

decision in United States v. Aquavella, 615 F.2d 12, 21 (2d. Cir.

1979), which concluded that "§ 405(h) by its terms applies only to

actions brought against the government and not by the government";

and that the policy reasons for requiring administrative review are

not implicated when the government is the plaintiff. 

Lahey requested that the district court certify its order

for interlocutory appellate review. On April 30, 2004, the

district court amended its prior order and certified the issue for
4Indeed there is a conflict of views within the district of

Massachusetts. Compare United States v. Univ. of Mass. Mem'l Med.

Ctr., 296 F. Supp. 2d. 20 (D.Mass. 2003) (finding that § 405(h)

barred an exercise of subject matter jurisdiction and dismissing

the action), with United States v. Lahey Clinic Hosp., No. 03-

10194-RWZ (D. Mass. April 30, 2004) (finding that § 405(h) did not

apply when the action was brought by the United States). Our

opinion today overrules the reasoning in Univ. of Mass. Mem'l Med.

Ctr., supra. 

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interlocutory appeal under 28 U.S.C. § 1292(b), stating that the

denial of summary judgment involved "a controlling question of law

as to which there is a substantial ground for difference of opinion

and that an immediate appeal from this Order may materially advance

the ultimate termination of the litigation."4 Lahey then

petitioned this court for permission to take an interlocutory

appeal, and framed the question presented as whether "Lahey Clinic

Hospital, Inc. [is] entitled to dismissal pursuant to Fed. R. Civ.

P., Rule 12(b)(1) because the Court lacks subject matter

jurisdiction." This court granted permission to appeal on June 9,

2004, and we have jurisdiction pursuant to 28 U.S.C. § 1292(b). 

II.

Lahey's opening brief to us argues that the district

court lacks subject matter jurisdiction because: 

By virtue of the incorporation of §§ 405(g)

and 405(h) into the Medicare Act, federal

district courts only have subject matter

jurisdiction to review Medicare payment

decisions that have initially been presented

to and determined by the Secretary and any

such determinations have been fully reviewed

under the Secretary's regulations establishing

administrative review procedures. Only after
5This argument does not implicate the district court's subject

matter jurisdiction under 12(b)(1) and is beyond the scope of this

interlocutory appeal. 

6"A motion to dismiss an action under Rule 12(b)(1) . . .

raises the fundamental question whether the federal district court

has subject matter jurisdiction over the action before it." 5B

Charles Alan Wright & Arthur B. Miller, Federal Practice and

Procedure § 1350, at 61 (3d ed. 2004). While this challenge is

usually employed in the instance in which the moving party believes

there is no federal question jurisdiction under 28 U.S.C. § 1331 or

diversity of citizenship jurisdiction under 28 U.S.C. § 1332, "the

scope of Rule 12(b)(1) is flexible," and it can serve as "a

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the Secretary has made a "final decision"

after affording the provider of services an

administrative evidentiary hearing to

determine the many factual issues that bear on

whether under applicable Medicare principles

there were any overpayments for which the

provider is liable, does a federal court have

jurisdiction to review a decision of the

Secretary.

These preliminary procedures did not take place, and therefore,

Lahey argues, the district court does not have subject matter

jurisdiction.

Lahey also argues that the district court lacks subject

matter jurisdiction for a number of other reasons: (1) the

judicially established doctrines of exclusive or primary

jurisdiction; (2) the lack of justiciability under the doctrines of

ripeness and exhaustion of administrative remedies; (3) exercising

jurisdiction in this case would deprive Lahey of procedural due

process mandated by the Medicare Act;5 and (4) the United States

failed to meet its burden of proof to present sufficient facts to

establish subject matter jurisdiction.6
procedural vehicle" for raising a variety of challenges to the

court's power to hear the case. Id. at 100-02. Failure to exhaust

administrative remedies and ripeness challenges may be appropriate

in a motion to dismiss for lack of subject matter jurisdiction.

See Bonilla v. Muebles J.J. Alvarez, Inc., 194 F.3d 275 (1st Cir.

1999); Deniz v. Municipality of Guaynabo, 285 F.3d 142 (1st Cir.

2002). In addition, jurisdictional facts might be relevant for

determining whether the district court has subject matter

jurisdiction in a Rule 12(b)(1) motion when there is a dispute over

those facts. See Skwira v. United States, 344 F.3d 64 (1st Cir.

2003) (discussing the different standard of review of the district

court's findings as to jurisdictional facts and the district

court's ultimate conclusion of subject matter jurisdiction, which

is a question of law subject to de novo review). There are,

however, no relevant jurisdictional facts in dispute here as the

issue is one of law. 

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Lahey's order of argument is misplaced. Each of its

arguments assumes the premises that the Medicare Act is the only

avenue available to the United States to recover Medicare

overpayments and that the Act repeals the grant of federal court

jurisdiction under § 1345 and displaces the underlying common law

causes of action. We first address whether those premises are

correct. 

Subject matter jurisdiction in this case is barred by the

Medicare Act only if Congress in enacting the Medicare Act has

removed federal court jurisdiction over these claims brought by the

United States as plaintiff under 28 U.S.C. § 1345. A related issue

is whether the Medicare Act displaced the underlying common law

causes of action relied on by the government in this case to

exercise its right to recover payments wrongfully made out of the

public fisc. Congress undoubtedly has the ability to do both of
7Lahey argues that the Supreme Court reasoned in Weinberger

v. Salfi, 422 U.S. 749, 766 (1975), that the federal courts do not

have jurisdiction over claims involving Medicare overpayment

decisions, until the two jurisdictional prerequisites of § 405(h)

-- initial presentment to the Secretary and administrative

exhaustion through the agency's administrative review and hearing

procedures -- are satisfied. We disagree with Lahey's reading of

Salfi as it relates to this case for two reasons. First, Salfi

involved a constitutional challenge by a class of individuals who

brought an action against the Secretary seeking to recover Social

Security benefits. Id. at 755. Second, the United States does

not rely on the Medicare Act as the source of its cause of action

or the jurisdictional basis of its claim. It relies on 28 U.S.C.

§ 1345 for jurisdiction and common law remedies to recover payments

erroneously made out of the public fisc. Salfi is factually

distinct, and the Salfi Court did not engage in an analysis of

implied repeal of § 1345 or the displacement of the federal common

law claims. 

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these actions. See Colorado River Water Conservation Dist. v.

United States, 424 U.S. 800 (1976); City of Milwaukee v. Illinois,

451 U.S. 304 (1981). 

But if Congress has not acted in this manner, then

Lahey's argument, concerning the need for a final overpayment

decision that was initially presented to and determined by the

Secretary and was fully reviewed under the Secretary's

administrative regulations prior to the exercise of federal court

jurisdiction, is irrelevant.7 The federal court has an independent

jurisdictional grant under § 1345 and the United States has an

independent cause of action for recovery under the common law. 

We now turn to those two critical issues and treat them

as corollary. Both are pure questions of law, and our review is de
8Lahey's argument appears to assume that if the federal courts

lack jurisdiction, the United States could not bring a common law

action in state courts. That might be a possible conclusion out of

Lahey's second argument (displacement of the common law causes of

action), but surely not as to the first (repeal of § 1345). 

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novo. P.R. Tel. Co. v. Telecomm. Regulatory Bd. of P.R., 189 F.3d

1, 7 (1st Cir. 1999). 

28 U.S.C. § 1345 grants broad jurisdictional power to the

district courts over suits when the United States is plaintiff.

The statute provides:

Except as otherwise provided by Act of

Congress, the district courts shall have

original jurisdiction of all civil actions,

suits, or proceedings commenced by the United

States or by an agency or officer thereof

expressly authorized to sue by Act of

Congress.

28 U.S.C. § 1345.8 

Section 1345 creates subject matter jurisdiction, and the

statute can only be limited, as the initial proviso provides, by

(1) an explicit repeal of the statute by an Act of Congress or (2)

an implicit repeal by total irreconcilability of the two acts. See

Colorado River, 424 U.S. at 808. Repeal of a federal statute by

implication is disfavored, and the individual arguing for repeal

has the burden of showing that the statute has been repealed. Cf.

King v. Collagen Corp., 983 F.2d 1130 (1st Cir. 1993) (burden on

the individual arguing for preemption of state law to show that the

law is preempted). The intention of Congress to repeal must be

clear and manifest. Radzanower v. Touche Ross & Co., 426 U.S. 148,
9It is unclear whether implied repeal of a jurisdictional

statute, such as § 1345, can be effectuated by the second test

articulated in Kremer. Kremer did not deal with a grant of federal

court jurisdiction. This court has adopted the reasoning of Kremer

as it applies to the implied repeal of § 1345. See United States

v. Commonwealth of Puerto Rico, 721 F.2d 832 (1st Cir. 1983).

However, there the court limited its repeal analysis to whether §

1345 was irreconcilable with the subsequent statute and determined

that it was not. Congress could easily wish to change a

substantive rule without depriving the federal courts of

jurisdiction. 

The second test articulated in Kremer is relevant when dealing

with the implied repeal of a rule of law apart from the

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154 (1976). There is a strong presumption against implied repeals

of federal statutes, see Kremer v. Chemical Constr. Corp., 456 U.S.

461, 468 (1982); United States v. Commonwealth of Puerto Rico, 721

F.2d 832, 836 (1st Cir. 1983), and this presumption is perhaps an

even stronger one when the repeal is a grant of jurisdiction to the

federal courts. Where, in particular, the subject matter

jurisdiction of the federal courts is involved, jurisdiction

"should not be disturbed by mere implication from the subsequent

legislation." Colorado River, 424 U.S. at 808 (quoting Rosecrans

v. United States, 165 U.S. 257, 262 (1897)).

To show an explicit repeal of a grant of federal court

jurisdiction under § 1345, Lahey must point to a later enacted

statute which by its terms explicitly repeals this jurisdiction. 

Second, if Congress has not explicitly repealed § 1345,

then Lahey must point to total irreconcilability with a later

statute or, perhaps, that the later act was meant as a substitute

by covering the whole subject matter.9
jurisdiction of the court. However, Colorado River may limit the

implied repeal of jurisdictional statutes only to situations where

jurisdiction of the federal courts under § 1345 is irreconcilable

with the subsequent statute. See Colorado River, 424 U.S. at 808

("In the absence of some affirmative showing of an intention to

repeal, the only permissible justification for a repeal by

implication is when the earlier and later statutes are

irreconcilable.") (quoting Morton v. Mancari, 417 U.S. 535, 550

(1974)). 

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Kremer, a case not involving the repeal of a grant of

federal court jurisdiction, sets forth a two-part test for implied

repeals of federal statutes:

(1) where provisions in the two acts are in

irreconcilable conflict, the later act to the

extent of the conflict constitutes an implied

repeal of the earlier one; and (2) if the

later act covers the whole subject of the

earlier one and is clearly intended as a

substitute, it will operate similarly as a

repeal of the earlier act. But, in either

case, the intention of the legislature to

repeal must be clear and manifest. . . . 

Kremer, 456 U.S. at 468 (citing Radzanower v. Touche Ross & Co.,

426 U.S. at 154 (quoting Posadas v. Nat'l City Bank, 296 U.S. 497,

503 (1936))). We assume in Lahey's favor that both prongs of the

Kremer test are available for all aspects of its claims. In

shorthand terms, to show an implicit repeal of § 1345, Lahey must

show that (1) the provisions of § 1345 are in irreconcilable

conflict with the Medicare Act or (2) the Medicare Act, by clear

and manifest intent, covers the whole subject matter area and was

meant as a substitute. 
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As for Lahey's second claim that a federal statute

displaces the federal common law, "the relevant inquiry is whether

the statute [speaks] directly to [the] question otherwise answered

by the common law." See County of Oneida, New York v. Oneida

Indian Nation, 470 U.S. 226, 237 (1985) (quoting City of Milwaukee,

451 U.S. at 315) (internal quotation marks omitted). Although the

Court recognized that Congress need not "affirmatively proscribe"

the common law doctrine at issue, see United States v. Texas, 507

U.S. 529, 534 (1993) (quoting City of Milwaukee, 451 U.S. at 315),

still "[s]tatutes which invade the common law . . . are to be read

with a presumption favoring the retention of long-established and

familiar principles . . . ." Id. (quoting Isbrandtsen Co. v.

Johnson, 343 U.S. 779, 783 (1952)). 

To show displacement of the common law causes of action

relied on by the United States to recover money wrongfully paid by

the Treasury, Lahey must overcome this presumption and demonstrate

that Congress has directly addressed the issue and that Congress

intended to preclude the United States from assertion of common law

rights to recover overpayments by enactment of the Medicare Act. 

Inconsistency between the two statutes (or claimed

inconsistency of a statute with common law) is not enough: "where

two seemingly inconsistent acts can reasonably stand together, a

court must interpret them in a manner which gives harmonious

operation and effect to both, in the absence of clear and
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unambiguous expression of Congressional intent to the contrary."

United States v. Kenaan, 557 F.2d 912, 917 (1st Cir. 1977) (citing

Morton v. Mancari, 417 U.S. 535, 549-51 (1973)). 

A. Explicit Repeal of Section 1345

Lahey asserts that jurisdiction under § 1345 is expressly

limited by the introductory proviso that states: "Except as

otherwise provided by Act of Congress . . . ." 28 U.S.C. § 1345.

Lahey argues that §§ 405(g) and 405(h), of the Medicare Act, 42

U.S.C. § 1395ff(b) and 42 U.S.C. § 1395ii respectively, repeal the

jurisdictional grant of § 1345 as they are "Act[s] of Congress"

that come within this limiting proviso.

Section 405(g) provides for judicial review in the

federal courts of the Secretary's final administrative decision by

an individual. The relevant part of § 405(g) states as follows: 

(g) Judicial Review

Any individual, after any final decision of

the Commissioner of Social Security made after

a hearing to which he was a party,

irrespective of the amount in controversy, may

obtain a review of such decision by a civil

action commenced within sixty days after the

mailing to him of notice of such decision or

within such further time as the Commissioner

of Social Security may allow. Such action

shall be brought in the district court of the

United States for the judicial district in

which the plaintiff resides, or has his

principal place of business, or, if he does

not reside or have his principal place of

business within any such judicial district, in

the United States District Court for the

District of Columbia. 
10The text of 405(g) and 405(h) refers to the "Commissioner of

Social Security" rather than the Secretary. The statutory

provisions applying § 405(h) to Medicare, however, make clear that

references to the Commissioner should be deemed to be references to

the "Secretary" where the context indicates. See 42 U.S.C. §

1395ii. 

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42 U.S.C. § 405(g).10

Lahey argues that § 405(h), in turn, makes § 405(g) the

exclusive avenue for judicial review of the Secretary's final

determinations. Section 405(h) provides: 

(h) Finality of Commissioner's decision

The findings and decision of the Commissioner

of Social Security after a hearing shall be

binding upon all individuals who were parties

to such hearing. No findings of fact or

decision of the Commissioner of Social

Security shall be reviewed by any person,

tribunal, or governmental agency except as

herein provided. No action against the United

States, the Commissioner of Social Security,

or any officer or employee thereof shall be

brought under section 1331 or 1346 of Title 28

to recover on any claim arising under this

subchapter.

Id. § 405(h).

Specifically, Lahey points to the second sentence in

§ 405(h) -- "[n]o findings of fact or decision of the [Secretary of

HHS] shall be reviewed by any person, tribunal, or governmental

agency except as herein provided" -- and argues the language

manifests an express congressional intent to repeal § 1345 in

decisions regarding the payment or overpayment of Medicare claims.

Lahey contends that the initial payment decision to reimburse Lahey
11Lahey's brief also directs the court's attention to the

Federal Claims Collection Act, 31 U.S.C. § 3711(a)(1). In this

statute, Congress mandated that heads of agencies attempt to

recover overpayments. The statute provides in pertinent part:

§ 3711. Collection and compromise

(a) The head of an executive, judicial, or legislative

agency - -

(1) shall try to collect a claim of the United States

Government for money or property arising out of the

activities of, or referred to, the agency . . . .

31 U.S.C. § 3711(a)(1). Quite correctly Lahey does not suggest

that this statute somehow expresses a congressional intent to

preclude the United States from pursuing overpayment actions under

§ 1345 or displaces the federal common law remedies available to

the United States.

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for the tests is "a decision of the Secretary" and § 405(h) makes

§ 405(g) the exclusive avenue for judicial review of this decision,

regardless of whether the plaintiff is the United States or a

dissatisfied beneficiary or provider.11 

The argument fails. By its terms, neither the sentence

Lahey cites nor § 405(h) as a whole mention § 1345. Also, they do

not apply where, as here, the Secretary has made neither findings

of fact nor a decision after a hearing. The United States is not

asking the federal courts to review a decision of the Secretary, it

is bringing an independent action to establish the United States'

right to obtain restitution of monies wrongfully paid from the

public fisc. 

Indeed, by its terms, § 405(h) is more consistent with

congressional intent to preserve jurisdiction under § 1345. The

third sentence of § 405(h) is explicit that no action "against the
12Subsequent case law suggests that resort to legislative

history is more appropriate in the implied repeal analysis. See

Kremer, 456 U.S. 461 (examining legislative history to determine

whether a previous statute had been implicitly repealed by a

subsequent statute); Commonwealth of Puerto Rico, 721 F.2d 832

(examining legislative history to determine whether Congress

impliedly repealed § 1345); Kenaan, 557 F.2d at 916. Regardless of

under which prong of the repeal analysis legislative history is

considered, the legislative history relevant to Lahey's claims does

not advance Lahey's argument that § 1345 was repealed by the

Medicare Act. 

-21-

United States . . . shall be brought under § 1331 or 1346 of Title

28 to recover on any claim arising under this subchapter." 42

U.S.C. § 405(h) (emphasis added). Section 405(h) does not refer to

actions brought by the United States or actions brought under 28

U.S.C. § 1345. And § 405(g), the terms of which Lahey argues are

the exclusive route to judicial review, refers to "individuals,"

not to the "United States." 

Lahey's argument is also inconsistent with Colorado

River, which involved the question of whether the same statute here

at issue, 28 U.S.C. § 1345, had been repealed by the McCarran

Amendment. Colorado River, 424 U.S. at 807-09. The Court noted

that the McCarran Amendment did contain some limitations but, as

here, did not mention § 1345. The court concluded that the statute

by its terms did not "indicate any repeal of jurisdiction under §

1345." Id. at 807.

A reading of the text of the statute alone may not be

dispositive of the explicit repeal question. When determining the

intent of Congress, Colorado River at least encourages12 a further
-22-

examination of the legislative history of the Medicare Act to see

if it evidences "a clear purpose to terminate any portion of § 1345

jurisdiction." Id.; see also Commonwealth of Puerto Rico, 721 F.2d

at 836. The United States argues that "the fundamental purpose of

Medicare's jurisdictional scheme is to channel all claims pressed

by dissatisfied providers or beneficiaries through a detailed

process of administrative review before such claims are presented

in federal court." See Shalala v. Ill. Council on Long Term Care,

Inc., 529 U.S. 1, 13 (2000) (The Medicare scheme requires the

"channeling" of "virtually all legal attacks" on the Secretary's

decisions and determinations through the agency.). 

Lahey has provided no legislative history in support of

its argument that Congress intended to repeal jurisdiction under §

1345. Nor has it refuted the government's assertions as to the

purpose of the review provisions. The burden is on Lahey, and it

does not meet its burden. Our own review shows the legislative

history supports the government's position. The 1965 Amendments to

the Social Security Act established the Medicare program and the

appeals process for payment determinations. Social Security

Amendments of 1965, Pub. L. No. 89-97, 79 Stat. 286 (1965). Senate

Report 89-404 accompanies this law. S. Rep. No. 89-404. The

Senate Report is void of any expression by Congress of intent to

repeal federal court jurisdiction under § 1345. Instead, the

report focuses on the need for the appeals process in order for the
-23-

individual to challenge the determinations of the Secretary. Id.

at 58. 

B. Implied Repeal of § 1345 and Displacement of Common Law

Even if Lahey cannot prevail on the express repeal prong,

a second avenue of argument is available: that Congress impliedly

repealed § 1345 jurisdiction. Lahey also argues that Congress

displaced the underlying common law causes of action as to claims

by the United States for recovery of Medicare overpayments. 

We understand Lahey to argue as follows: Congress

authorized the Secretary of HHS to recover Medicare overpayments

and to promulgate regulations to this end. Those regulations

provide detailed procedures under which providers can challenge

decisions made by the Secretary. The law is clear that a provider

must make an initial presentation to the agency, which then must

make a final determination, before there is any federal court

review. The law is also clear that once this initial payment

decision is final, in order to reopen it, the Secretary must follow

established procedures. As a result, the administrative claims

procedure is in irreconcilable conflict with § 1345 and it speaks

directly to and hence displaces the United States' independent

action for restitution. According to Lahey, under the provisions

of the Medicare Act, only the Secretary, in accordance with

established procedures, may collect overpayments because only the

Secretary can make and reopen final payment determinations, not the
-24-

Department of Justice. In other words, the detailed remedies for

recoupment established under the statute are exclusive and cannot

be bypassed by the Department of Justice. 

Lahey argues that "under the Medicare Act and its

supplementary regulations, Congress has provided for very

specialized remedies relating to and dealing with the recoupment of

any overpayment." Lahey's argument of implied repeal of § 1345 and

displacement of common law rests entirely, not on the Medicare Act

itself, but on a supposed conflict between suit to recover

overpayment under § 1345 and an administrative remedial scheme for

collection of overpayments, see 42 C.F.R. §§ 405.370, 405.371,

405.372, promulgated by the Secretary to carry out the purposes of

31 U.S.C. § 3711 and 42 U.S.C. § 1395g. The argument is based on

a fundamental misunderstanding. 

Congress could, perhaps (we need not decide), attempt to

expressly provide for repeal of a statute or displacement of the

common law through delegation of such power to an agency. But

Congress has not done so here. In the absence of such a

delegation, a statute, § 1345, cannot be repealed by administrative

regulation from an executive branch agency. First, § 1345 by its

terms states, "except as otherwise provided by Act of Congress"; it

does not state "except as provided by administrative regulation of

an agency." In addition, the tests for implied repeal established

through the case law involve congressional intent, not the intent
13As to reimbursement determinations made after October 1,

2002, an amendment, which was enacted in October 2000 and is not

relevant to the claims at issue in this case, provides: 

(G) Reopening and Revision of Determinations.

The Secretary may reopen or revise any initial

determination or reconsidered determination described in

this subsection under guidelines established by the

Secretary in regulations.

42 U.S.C. § 1395ff(b)(1)(G). It expresses no intent by Congress to

displace the federal common law or repeal federal jurisdiction

under § 1345, by making this the exclusive avenue for reopening or

revisiting initial payment determinations. Indeed the language of

the statute itself suggests that the Secretary is not required to

reopen or revise initial determinations. Surely Congress would not

limit the ability to the government to bring an action outside of

the administrative scheme yet not require the Secretary to collect

overpayments. 

-25-

of an agency's regulations, regardless of how extensive they are.

As for displacement of common law, the tests concern whether

Congress directly spoke to the issue and whether Congress intended

to deprive the government of a longstanding power. Thirdly, to

permit an agency by its actions to repeal an act of Congress or

displace a long standing power of the United States would pose

grave constitutional questions of violation of separation of

powers. Cf. Clinton v. New York, 524 U.S. 417 (1998). 

There is nothing in the Medicare Act which establishes

that the administrative remedy chosen by the Secretary here to

collect overpayments and the limited judicial review provided for

in §§ 405(b) and 405(h) are mandated by Congress as the exclusive

remedy or that Congress delegated any such a choice to the

Secretary.13 
14Section 1395oo creates the Provider Reimbursement Review

Board which is charged with holding hearings and rendering

decisions in disputes over Part A payments. The claims in this

case involve payments under Part B of Medicare. Additionally, §

1395oo by its terms provides for administrative and judicial review

of claims filed by providers. 

15In addition, Lahey reads the judicial review provisions of

the Medicare Act out of context. Section 1395ff(b), during the

-26-

As to the implied repeal of § 1345, we reject Lahey's

argument that an irreconcilable conflict arises from the fact that

in §§ 405(h), 405(g), and 42 U.S.C. § 1395oo14 Congress deprives the

federal courts of jurisdiction except on review of final decisions

after an administrative hearing, and then only on a substantial

evidence basis. Again, Lahey's argument is misplaced; these

statutes do not purport to limit the government's ability to bring

a claim against Medicare providers under a different grant of

jurisdiction. "The mere fact that some acts are made reviewable

should not suffice to support an implication of exclusion as to

others." Verizon Md., Inc. v. Pub. Serv. Comm. of Md., 535 U.S.

635, 644 (2000). In Verizon, the Court concluded that the

Congress did not strip the general grant of federal question

jurisdiction in 28 U.S.C. § 1331 when it provided for federal

review of state commission determinations under a specific

provision of the Telecommunications Act. See id. Similarly, the

fact that Congress has provided a limited avenue for judicial

review in some circumstances does not support an implication that

other avenues of judicial review are precluded.15
time relevant to this appeal, provided that "[a]ny individual

dissatisfied with any determination under subsection (a) of this

section as to . . . the amount of benefits . . . shall be entitled

to a hearing thereon by the Secretary to the same extent as is

provided in § 405(b) of this title and to judicial review of the

Secretary's final decisions after such hearing as is provided in §

405(g) of this title." After the individual or provider has

exhausted the administrative provisions laid out in § 405(b), the

individual is then allowed to seek judicial review under § 405(g).

The United States' ability to bring claims against the providers is

not implicated at all in the provisions relating to how to

challenge the FI's payment decisions. It is this administrative

mechanism, as it relates to claims by providers, that § 405(h)

makes the exclusive avenue of judicial review. 

-27-

Before addressing Lahey's contention that the Medicare

Act displaces the United States' common law causes of action, we

add a few words about special problems raised by the claim. First,

it does not go to subject matter jurisdiction at all. The Supreme

Court has stated that "[i]t is firmly established in our cases that

the absence of a valid (as opposed to arguable) cause of action

does not implicate subject-matter jurisdiction, i.e., the courts'

statutory or constitutional power to adjudicate the case."

Verizon, 535 U.S. at 642-43 (quoting Steel Co. v. Citizens for

Better Environment, 523 U.S. 83, 89 (1998)). 

Jurisdiction . . . is not defeated . . . by

the possibility that the averments might fail

to state a cause of action on which

petitioners could actually recover. Rather,

the district court has jurisdiction if the

right of the petitioners to recover under

their complaint will be sustained if the

Constitution and laws of the United States are

given one construction and will be defeated if

they are given another, unless the claim

clearly appears to be immaterial and made

solely for the purpose of obtaining
-28-

jurisdiction or where such a claim is wholly

insubstantial and frivolous.

Steel Co., 523 U.S. at 89 (internal quotations and citations

omitted). There is no allegation that the United States' claim is

"wholly insubstantial and frivolous." 

Regardless, Lahey's argument, even if viewed as an

argument for failure to state a claim, is simply wrong: the

Medicare Act does not displace the common law remedies asserted by

the United States. Lahey relies on City of Milwaukee for the

proposition that "when Congress addresses a question previously

governed by a decision rested on federal common law the need for

such an unusual exercise of lawmaking by federal courts

disappears." City of Milwaukee, 451 U.S. at 314. Lahey contends

that the Medicare Act is a "comprehensive scheme" enacted by

Congress that "directly addresses" the United States' remedy for

collecting overpayments, and therefore the need for the common law

remedy "disappears." 

The Court in a subsequent decision, United States v.

Texas, recognized that although Congress need not "affirmatively

proscribe" the common law doctrine at issue, 507 U.S. at 534

(quoting City of Milwaukee, 451 U.S. at 315), nonetheless

"[s]tatutes which invade the common law . . . are to be read with

a presumption favoring the retention of long-established and

familiar principles . . . ." Id. (quoting Isbrandtsen Co. v.

Johnson, 343 U.S. 779, 783 (1952)). 
16United States v. Wurts and the cases it relies on do not

refer to the government's power to collect money wrongfully paid as

a construction of the common law. See 303 U.S. 414 (1938).

Indeed, the power of the United States to recover sums illegally or

erroneously paid has been described by one court as part of the

United States' "inherent authority." Aetna Cas. & Sur. Co. v.

United States, 526 F.2d 1127, 1130 (Ct. Claims 1975). The Court of

Claims suggested that an erroneously or illegally made payment is

tied to a direct violation of the United States Constitution,

Article IV, section 3, clause 2, id., which lodges with the

Congress the power to "release or otherwise dispose of the rights

and property of the United States." See Royal Indemnity Co. v.

United States, 313 U.S. 289, 294 (1941). The causes of action

asserted here for exercising this right are common law causes of

action, but the right itself seems to be something more intimately

tied with the power of the United States. 

-29-

This presumption may be even stronger when a longstanding

power of the United States is involved. In the context of recovery

of overpayments, the government has broad power to recover monies

wrongly paid from the Treasury, even absent any express statutory

authorization to sue. See United States v. Wurts, 303 U.S. 414

(1938). "The Government by appropriate action can recover funds

which its agents have wrongfully, erroneously, or illegally paid.

'No statute is necessary to authorize the United States to sue in

such a case. The right to sue is independent of statute . . . .'"

Id. at 415 (quoting United States v. Bank of Metropolis, 15 Pet.

377, 401 (1841)).16 

Congress, of course, by statute can curtail the

government's right to sue; however, "courts may take it as a given

that Congress has legislated with an expectation that the [common

law] principle will apply except 'when a statutory purpose to the
17The fact that the Medicare Act will be relevant to the common

law action does not mean it displaces suit by the United States.

In order to prove the allegations in the complaint, that indeed the

payments were wrongfully made, the United States will have to refer

to Medicare manuals, regulations, and other materials that relate

to the appropriateness of the previous payments. However they in

no way displace or limit the underlying ability to bring the

independent claim for recovery. "Congress's obvious desire to

enhance the common law in specific, well-defined situations does

not signal its desire to extinguish the common law in other

situations." Texas, 507 U.S. at 535 n.4. 

-30-

contrary is evident.'" Texas, 507 U.S. at 534 (quoting Astoria Fed.

Sav. & Loan Ass'n. v. Solimino, 501 U.S. 104, 108 (1991)).

Statutes are presumed not to divest the United States of preexisting rights, such as the ability to collect wrongfully paid

monies, absent a clear congressional command. See United States v.

United Mine Workers of America, 330 U.S. 258, 272 (1947)("There is

an old and well-known rule that statutes which in general terms

divest pre-existing rights or privileges will not be applied to the

sovereign without express words to that effect.").

Although provisions of the Medicare Act expressly

authorize the Secretary to reopen initial payment determinations

and to recoup overpayments administratively in certain

circumstances, see 42 U.S.C. § 1395g(a) and 1395gg, the statute

does not displace the United States' long standing power to collect

monies wrongfully paid through an action independent of the

administrative scheme,17 nor is there any inconsistency. To the

extent that a congressional purpose and intent to collect money

wrongfully paid by the Medicare program is expressed through the
-31-

Medicare statutes allowing the Secretary to collect these

overpayments, allowing the United States to pursue collection

independently is fully consistent with this purpose. 

Indeed, the Secretary's very choice of how to proceed

illustrates that the administrative remedies are not exclusive when

the United States institutes suit. First, the Secretary chose to

allow for only particular remedies in the administrative scheme, an

indication that the administrative scheme is not exclusive of other

remedies elsewhere. Second, the plaintiff in this case is "the

United States of America, acting through the Department of Health

and Human Services," which reflects the Secretary's position that

the common law remedy and federal court jurisdiction under § 1345

are also available. Third, if the administrative remedy were

exclusive, that would, in some situations, hinder or preclude the

United States from recovering overpayment. 

The Secretary has chosen the administrative remedies of

suspension, recoupment, and offset (also called a setoff). See 42

C.F.R. §§ 405.370, 405.371. These are terms of art; "the pertinent

distinction between a setoff and a recoupment is whether the debt

owed the creditor . . . arose out of the 'same transaction' as the

debt the creditor owes the debtor." See In re Holyoke Nursing

Home, Inc., 372 F.3d 1, 3 (1st Cir. 2004). The Secretary's

regulations specifically define the types of remedies available to

the Secretary for recovering overpayments administratively. An
-32-

"Offset" is defined as "[t]he recovery by Medicare of a

non-Medicare debt by reducing present or future Medicare payments

and applying the amount withheld to the indebtedness." 42 C.F.R.

§ 405.370. The regulation defines a "Recoupment" as "[t]he

recovery by Medicare of any outstanding Medicare debt by reducing

present or future Medicare payments and applying the amount

withheld to the indebtedness." Id. Finally, a "Suspension of

payment" is defined as "[t]he withholding of payment by an

intermediary or carrier from a provider or supplier of an approved

Medicare payment amount before a determination of the amount of the

overpayment exists." Id. 

Each of these remedies of recoupment, offset, and

suspension assume an ongoing relationship between the Secretary and

the provider. In situations in which there is no ongoing Medicare

relationship between the Secretary and the provider, such as where

the provider has ceased to treat Medicare beneficiaries or has gone

out of business, neither recoupment nor offset would provide the

United States with an opportunity to recover the overpaid Medicare

payments. In addition, in situations in which the government seeks

damages in the form of a complete payment from the provider for the

Medicare overpayments, the recoupment, suspension, and offset

procedures do not provide for this relief. 

Were more needed, we would say other parts of the federal

statutory scheme also refute Lahey's "repeal" and "displacement"
-33-

arguments and demonstrate that the administrative scheme is not

exclusive. In fact, Congress in other statutes has provided for

the collection of overpayments independent of the scheme set up by

the Medicare Act and the Secretary of HHS. In addition to the

common law remedies available to the United States under § 1345,

Congress has provided the government two other independent methods

to recover overpayments. Under 42 U.S.C. § 1320a-7a(a)(1)(A), the

Secretary may seek civil money penalties for knowing violations of

the Medicare Act. Further, and wholly independent of the

Secretary, the Attorney General may seek to recover Medicare

payments made on the basis of a false or fraudulent claim. 31

U.S.C. §§ 3729-3733. The existence of these other statutes

expresses a clear congressional intent to provide several avenues

for the United States to recover monies owed to it and not to limit

the means of recovery to those promulgated by the Secretary in the

Medicare Act. 

To its credit, Lahey correctly concedes that if the

statute sued on were the False Claims Act, 31 U.S.C. § 3729-3733,

rather than § 1345, the district court would have subject matter

jurisdiction, admitting that the Medicare scheme does not impliedly

repeal the False Claims Act. The difference, Lahey argues, is that

§ 1345 simply provides jurisdiction for common law actions, while

the False Claims Act embodies a congressionally created cause of

action. It is hard for us to fathom why Congress would intend to
18Lahey also argues that there is a meaningful difference for

these purposes between actions for fraud and actions for recovery

which do not assert fraud, as under § 1345. Lahey argues the court

is particularly well equipped to handle cases involving fraud as

opposed to cases involving unjust enrichment and payment under

mistake of fact, which implicate the expertise of the agency. We

do not see a meaningful distinction: a False Claims Act action

would involve the same interpretation of Medicare codes as an

overpayment action with the largest difference being that the

government under the False Claims Act must also show fraudulent

intent. 

-34-

give the government access to a judicial forum by statute when the

overpayment was procured by fraud but to preclude the government

from a routine common law damages action for overpayment.18 

Finally, where two different statutory schemes give

concurrent jurisdiction to courts "[t]here is no irreconcilability

in the existence of concurrent state and federal jurisdiction."

Colorado River Water Conservation District, 424 U.S. at 809. That

being so, it is hard to understand why concurrent jurisdiction in

a court and the discretionary decision by an agency to create a

partially overlapping administrative forum would lead to implied

repeal of the court's statutory jurisdiction or displacement of the

United States' common law remedies.

C. Primary Jurisdiction

Lahey makes a final plea for deference to the Secretary's
19Lahey also asserts a parade of horribles argument: that the

case is too complex to be tried in federal court, that the problems

of proof of overpayment of numerous claims are insurmountable, and

that the case would take twenty years to try. One response is that

these cases are less complicated to try than fraud cases, which

Lahey concedes are permissible. Further, sampling of similar

claims and extrapolation from the sample is a recognized method of

proof. Chaves County Home Health Serv., Inc. v. Sullivan, 931 F.2d

914, 919 (D.C. Cir. 1991); Ratasen v. Cal. Dept. of Health Servs.,

11 F.3d 1467, 1471 (9th Cir. 1993). There is no reason to doubt

the competence of courts; both civil and criminal cases for abuse

of the Medicare system by providers are sadly common. See, e.g.,

United States v. McGovern, 329 F.3d 247 (1st Cir. 2003).

-35-

administrative expertise19 by arguing that there should be a primary

jurisdiction referral. The primary jurisdiction referral request,

denied by the district court, invokes prudential doctrines, and

"does not implicate the subject matter jurisdiction of the federal

court." See P.R. Mar. Shipping Auth. v. Fed. Mar. Comm'n, 75 F.3d

63, 67 (1st Cir. 1996). It is not within the scope of the

certified question to us. Even if we arguably had some form of

supplemental appellate jurisdiction to reach the question, we see

no basis on which to upset the district court's order. 

III.

Conclusion

We affirm the judgment of the district court. Costs are

awarded to the United States.