Source: http://ny.findacase.com/research/wfrmDocViewer.aspx/xq/fac.19951011_0000587.SNY.htm/qx
Timestamp: 2018-02-19 08:37:51
Document Index: 231310035

Matched Legal Cases: ['§ 1395', '§ 13951', '§ 405', '§ 1395', '§ 1395', '§ 1395', '§ 405', '§ 405', '§ 1395', '§ 1395', '§ 1935', '§ 405', '§ 1395', '§ 405', '§ 405', '§ 405', '§ 1395', '§ 405']

Currently before the Court are plaintiffs' and defendants' respective motions for summary judgment, pursuant to Federal Rule of Civil Procedure ("Rule") 56(b), as well as defendants' motion to dismiss for lack of subject matter jurisdiction, pursuant to Rule 12(b)(1). Because this Court lacks subject matter jurisdiction over plaintiffs' claims, defendants' Rule 12(b)(1) motion is granted. Moreover, because this Court lacks subject matter jurisdiction, plaintiffs' motion for a writ of mandamus is dismissed.
Part B is analogous to a private medical insurance program subsidized by the federal government. Enrolled individuals pay monthly premiums that, together with contributions from the federal government, 42 U.S.C. §§ 1395r, 1395t, 1395w, secure coverage for the reasonable cost of specified medical services that are excluded from Part A, such as physician services, out-patient therapy, medical equipment, and laboratory testing. 42 U.S.C. § 13951; 42 C.F.R. § 405.231. The Secretary of Health and Human Services ("HHS") contracts with private insurance carriers to process Part B claims, 42 U.S.C. § 1395u, in order to profit from their "great experience," S. Rep. No. 404, 89th Cong., 1st Sess., reprinted in 1965 U.S.C.C.A.N., 1993, and thereby administer the program "with maximum efficiency and convenience." 42 U.S.C. § 1395u(a). Schweiker v. McClure, 456 U.S. 188, 190, 72 L. Ed. 2d 1, 102 S. Ct. 1665 (1982); Isaacs v. Bowen, 865 F.2d 468, 470 (2d Cir. 1989).
The Medicare Act sets forth the procedures private insurance carriers must use to process Part B claims. These procedures direct a Part B enrollee to submit claims for services directly to the carrier in the enrollee's geographic area. The carrier then reviews the claim to determine whether the medical service at issue is within the scope of Part B, whether it was "reasonable and necessary" under the circumstances, and whether its cost was "reasonable." 42 U.S.C. §§ 1395u(b)(3), 1395y(a); 42 C.F.R. §§ 405.501, 421.200. While the Act instructs carriers to consider specific criteria in making these determinations, a carrier may take into account additional factors that it deems necessary to its evaluation. 42 C.F.R. § 405.502(a)(7). If a carrier finds that the claim meets all coverage criteria, it pays enrollee's benefits from federal funds according to Medicare guidelines. 42 U.S.C. § 1395u. In the event an enrollee disputes a carrier's reimbursement determination, Part B details procedures he can use to challenge it. 42 U.S.C. § 1395ff.
Specific provisions of the Medicare Act govern reimbursement disputes concerning Part B services rendered prior to January 1, 1987. 42 U.S.C. §§ 1935u(b)(3)(C), 1395ff, 1395ii. Under these provisions, a claimant who is dissatisfied with a carrier's initial disposition of his claim is entitled to de novo review of the claim by the carrier. 42 C.F.R. §§ 405.807-812. In addition, if the amount in controversy exceeds $ 100, the claimant is entitled to a "fair hearing" before an officer chosen by the carrier. 42 U.S.C. § 1395u(b)(3)(C); 42 C.F.R. §§ 405.801, .820; McClure, 456 U.S. at 191. Fair hearing officers must evaluate each claim in accordance with the Medicare Act, HHS regulations, and the Health Care Finance Administration's ("HCFA") policy statements. 42 C.F.R. § 405.860. The HCFA's Medicare Carrier's Manual ("MCM") provides the primary procedural guidelines for fair hearings.
Decisions rendered by fair hearing officers are final and binding. 42 C.F.R. § 405.835. The Medicare statute explicitly precludes judicial review of fair hearing officers' decisions regarding the amount of benefits due a claimant under Part B. 42 U.S.C. § 1395ii (incorporating 41 U.S.C. § 405(h)); United States v. Erika, Inc., 456 U.S. 201, 208, 72 L. Ed. 2d 12, 102 S. Ct. 1650 (1982); Anderson v. Bowen, 881 F.2d 1, 3 (2d Cir. 1989); Kuritzky v. Blue Shield of Western New York, Inc., 850 F.2d 126, 127 (2d Cir. 1988), cert. denied, 488 U.S. 1006, 102 L. Ed. 2d 778, 109 S. Ct. 787 (1989). *fn1"
Plaintiffs assert that Blue Cross "wrongly underpaid" their Part B reimbursement claims for medical services rendered prior to January 1, 1987. (Plaintiffs' Memorandum of Law in Support of Summary Judgment ("Pls.' Memo") at 2.) To challenge these alleged underpayments, plaintiffs exercised their rights under the Act and requested fair hearings. (Pls.' Complaint at 3.) Plaintiffs complain that, throughout the fair hearing process, Blue Cross and the hearing officers who handled plaintiffs' claims "violated the clear mandates of the law and regulations regarding plaintiffs' 'fair hearing' rights." (Pls.' Memo at 9.) According to plaintiffs, these violations denied them proper reimbursement for their medical expenses as well as their rights to due process under the Fifth Amendment to the Constitution. (Pls.' Memo at 7, 18.)
Plaintiffs claim that defendants' deviations from Medicare Part B appeals procedures deprived plaintiffs of due process of law. Defendants contend that plaintiffs claims are beyond the scope of this Court's subject matter jurisdiction and, alternatively, fail to present this Court with a genuine constitutional controversy. Plaintiffs moved for summary judgment pursuant to Rule 56(b). Defendants cross-moved for summary judgment ...