Opinion ID: 450494
Heading Depth: 2
Heading Rank: 1

Heading: Reopening of Initial Determinations

Text: 16 First, we must consider whether Beck waived his right to challenge the reopening of the initial determinations of his 1972 and 1973 claims. For if Beck has waived that right, the revised determinations are final and binding, 42 C.F.R. Sec. 405.842(b), and not subject to judicial review, see United States v. Erika, Inc., 456 U.S. 201, 102 S.Ct. 1650, 72 L.Ed.2d 12 (1982). 17 On October 10, 1977, Blue Cross notified Beck of the amount of overpayments on his 1972 and 1973 claims. The notice advised Beck of his right to seek administrative review of the revised determinations. The letter stated: 18 If you feel that further consideration should be given to any of the overpayment cases on the enclosed listings, the Medical Consultants will be happy to provide further review upon receipt of copies of appropriate office records or other information not previously furnished. 19 In addition to further medical review, you are also entitled to file a written request for a fair hearing on the overpayment cases on the enclosed listings within six months from the date of this letter if you feel that there is a basis for further review or that you have not been overpaid. Such hearings are held to determine whether or not the carrier has followed the Medicare Law, regulations and guidelines established by the Social Security Administration. 20 Some seven months later, Beck requested to meet with a representative of Blue Cross. Although Beck's request was untimely, Blue Cross agreed to meet with him. After a November 3, 1978 meeting with Beck, Blue Cross reevaluated Beck's 1972 claims and reduced the amount of overpayment. Beck was notified of the amount of the revised determination by letter dated December 12, 1978. He was also advised of his right to seek administrative review of that determination. The letter, addressed to Beck's attorney, stated: If Dr. Beck feels that some of the cases still at issue warrant further review, he may wish to again meet with a carrier medical consultant, or he may request a hearing before a carrier hearing officer within six months from the date of this letter. Despite two additional letters from Blue Cross, Beck failed to pursue his administrative remedies. 21 Beck now maintains that Blue Cross's reopening of its initial determinations of both his 1972 and 1973 claims was improper under the regulations. Neither the statute nor the regulations provide a claimant an opportunity to challenge the reopening of an initial determination at the time of the reopening. The regulations do provide, however, a claimant an opportunity to challenge the revision of an initial determination by requesting a hearing: 22 The revision of a determination (see section 405.841) shall be final and binding upon all parties thereto unless a party files a written request for a hearing with respect to a revised determination when the amount in controversy is $100 or more. 23 42 C.F.R. Sec. 405.842(b). 24 As Blue Cross stated to Beck in its October 10, 1977 letter, hearings on revised determinations are held to determine whether or not the carrier has followed the Medicare Law, regulations, and guidelines established by the Social Security Administration. Such a hearing would have been the proper forum for Beck to challenge the validity of the reopening of Blue Cross's initial determinations of his 1972 and 1973 claims and the timeliness with which he was notified of the reopening of the initial determinations. Beck is not entitled to judicial review of the overpayment determinations. 42 C.F.R. Sec. 405.842(b); see United States v. Erika, Inc., 456 U.S. 201, 102 S.Ct. 1650, 72 L.Ed.2d 12 (1982) (carrier determinations of amount of benefits payable under Part B of Medicare Act not reviewable in Court of Claims). 25 Since Beck cannot now challenge the validity of Blue Cross's reopening of its initial determinations of his 1972 and 1973 claims, we need not reach the issue of whether Blue Cross properly reopened those initial determinations.