Opinion ID: 788969
Heading Depth: 2
Heading Rank: 2

Heading: RenCare's Claims are Excluded from the M+C Administrative Appeals Process

Text: 16 Not only is this case significantly different from other cases in which courts have held that claims arose under the Medicare Act, but it appears that the administrative review process attendant to Part C does not extend to claims in which an enrollee has absolutely no interest. 17 Part C and CMS's implementing regulations establish mandatory administrative appeals procedures for resolving disputes over organization determinations. See 42 U.S.C. § 1395w-22(g); 42 C.F.R. §§ 422.560-422.622. Disputes over any other matter are not subject to the same appeals process to which organization determinations are subject, but, instead, have their own grievance procedures. 42 C.F.R. §§ 422.562(a)(1)(i), 422.564. An organization determination is a decision by an M+C organization regarding the benefit an enrollee is entitled to receive under an M+C plan ... and the amount, if any, that the enrollee is required to pay for a health service. 42 C.F.R. § 422.566. More specifically, an organization determination may be the M+C organization's refusal to provide or pay for services, in whole or in part,... that the enrollee believes should be furnished or arranged for by the M+C organization. 42 C.F.R. § 422.566(b)(3). Enrollees have a right to a timely organization determination, 42 C.F.R. § 422.562(b)(2), and a right to appeal that decision through several levels of review. 42 C.F.R. § 422.562(b)(4)(i)-(vi). However, if an enrollee has no further liability to pay for services that were furnished by an M+C organization, a determination regarding these services is not subject to appeal. 42 C.F.R. § 422.562(c)(2). 18 As is evident from the regulations, the administrative review process focuses on enrollees, not health care providers, and is designed to protect enrollees' rights to Medicare benefits. Here, Humana's failure to pay RenCare is not an organization determination subject to the mandatory exhaustion of administrative remedies. No enrollee has requested an organization determination or appeal. No enrollee has been denied covered service or been required to pay for a service. Rather, the M+C enrollees in this case bear no financial risk inasmuch as they have already received the services for which RenCare seeks reimbursement. In fact, there is a complete absence of M+C beneficiary interest in this dispute. The only interest at issue is RenCare's interest in receiving payment under its contract with Humana. 19 Humana argues that RenCare is acting as an assignee of Humana's M+C beneficiaries and thus may be a party to an organization determination under 42 C.F.R. § 422.574(b), which allows providers to be parties to an organization determination as assignees of beneficiaries. However, the M+C beneficiaries in this case do not have a claim to assign to RenCare. As discussed above, no M+C enrollee has been denied benefits or payment required under the Medicare Act. RenCare is pursuing its own claims against Humana. Thus, Humana's failure to pay RenCare is not an organization determination that RenCare could appeal within the mandatory administrative review mechanism.