Opinion ID: 760387
Heading Depth: 2
Heading Rank: 1

Heading: Jurisdiction Based on Section 405(g)

Text: 12 Title 42 U.S.C. § 1395, commonly known as the Medicare Act, establishes a federally subsidized health insurance program that is administered by the Secretary. See Heckler v. Ringer, 466 U.S. 602, 605, 104 S.Ct. 2013, 80 L.Ed.2d 622 (1984). Title 42 U.S.C. § 405(g) is the sole avenue for judicial review of all claims arising under the Medicare Act. Id. Pursuant to her rule-making authority, the Secretary has provided that a final decision is rendered on a Medicare claim only after the claimant has pressed the claim through all designated levels of administrative review. Id. 13 In Mathews v. Eldridge, 424 U.S. 319, 328, 96 S.Ct. 893, 47 L.Ed.2d 18 (1976), the Supreme Court held that jurisdiction under section 405(g) is determined under a two prong test. First, there must have been a presentment to the Secretary. Id. This element can never be waived and no decision of any type can be rendered if this requirement is not satisfied. Id. Second, the claimant must have exhausted his administrative review. 14 Although APRO asserts that the first prong of Eldridge can still be satisfied, 3 there is absolutely no doubt that APRO did not exhaust its administrative remedies before seeking judicial review. Therefore, the failure to satisfy this second prong might be enough to deny them relief. 15 APRO correctly argues that exhaustion of administrative review may be waived. This may occur when a plaintiff asserts a collateral challenge that can not be remedied after the exhaustion of administrative review. Id. at 330-32, 96 S.Ct. 893. 16 On the facts of this case, APRO's claim is not a collateral claim for purposes of exhaustion. Although its claim is framed in constitutional terms and seeks compensatory and punitive damages, APRO also seeks to rescind the termination of its provider status and to halt the suspension of its Medicare payments. Such relief is unquestionably administrative in nature. 17 Additionally, to fully address APRO's claim that their due process and equal protection rights were violated through the improper enforcement of Medicare regulations, a court would necessarily have to immerse itself in those regulations and make a factual determination as to whether APRO was actually in compliance. Given the administrative nature of that inquiry, it cannot be reasonably concluded that APRO's claim is collateral to a claim for administrative entitlement. 18 The constitutional nature of APRO's claim does not, by itself, alter that conclusion. The Supreme Court has recognized that the constitutional tenor of a claim is not a determinative factor in deciding whether a claim is collateral. Instead, the exhaustion requirement is applicable to a constitutionally-based claim when that claim is inextricably intertwined with a substantive claim of administrative entitlement. Id. at 611, 104 S.Ct. 2013; see also Weinberger v. Salfi, 422 U.S. 749, 95 S.Ct. 2457, 45 L.Ed.2d 522 (1975). In this case, there is little doubt that APRO's claim is inextricably intertwined with a demand for benefits. 19 A more difficult issue, however, is whether the facts of this case give rise to a sufficient threat of irreparable harm so as to justify waiver of the administrative exhaustion requirement. 20 The briefs and the record do not address the evidence that was offered in support of the district court's finding of irreparable harm. Furthermore, it seems highly unlikely that the termination of APRO's provider status would result in a measurable loss of home-based health care in three separate counties. Similarly, it seems unreasonable to conclude that APRO's patients will be deprived of adequate home-based health care if APRO is forced out of business. 21