AAA Pharmacy, Inc. v. United States

108 Fed. Cl. 321, 2012 U.S. Claims LEXIS 1417, 2012 WL 5873677
CourtUnited States Court of Federal Claims
DecidedNovember 20, 2012
DocketNo. 11-877C
StatusPublished
Cited by4 cases

This text of 108 Fed. Cl. 321 (AAA Pharmacy, Inc. v. United States) is published on Counsel Stack Legal Research, covering United States Court of Federal Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
AAA Pharmacy, Inc. v. United States, 108 Fed. Cl. 321, 2012 U.S. Claims LEXIS 1417, 2012 WL 5873677 (uscfc 2012).

Opinion

MEMORANDUM OPINION AND ORDER

WILLIAMS, Judge.

Plaintiff, AAA Pharmacy, Inc. (“AAA”), seeks $6,000,000 in damages claiming a taking of its property, a violation of its due process rights under the Fifth and Fourteenth Amendments, and a breach of an implied-in-fact contract, stemming from the revocation of its Medicare billing privileges. Plaintiff argues that Defendant’s revocation of its Medicare billing privileges and its undue delay in adjudicating Plaintiffs administrative claim and restoring those privileges resulted in the loss of Plaintiffs business.

Defendant seeks dismissal pursuant to Rule 12(b)(1) of the Rules of the United States Court of Federal Claims (“RGFC”), arguing that this Court lacks subject-matter jurisdiction over Plaintiffs claims because the comprehensive review process set forth under the Social Security Act, 42 U.S.C. § 1395cc (Supp. V 2005), preempts Tucker Act jurisdiction here. 28 U.S.C. § 1491 [324]*324(2006).1 For the reasons set forth below, the Court grants Defendant’s Motion to Dismiss in part.

Background

Medicare Statutes and Regulations2

Under the Supplementary Medical Insurance Benefits for the Aged and Disabled (“Medicare Part B”) program, the elderly and persons with disabilities are provided limited coverage for items such as durable medical equipment, prosthetic devices, pros-thetics, orthotics, and other supplies (“DME-POS”). 42 U.S.C. § 1395x(n); 42 C.F.R. Part 414, Subpart D (2005). Medicare Part B is administered by private organizations known as earners. 42 C.F.R. §§ 414.200-414.232 (2005). Carriers contract with and are overseen by the Centers for Medicare and Medicaid Services (“CMS”), a division of the United States Department of Health and Human Services (“HHS”). Carriers process reimbursement claims for DMEPOS that Medicare suppliers provide to beneficiaries. 42 C.F.R. § 421.210(e).

Carriers also administer DMEPOS supplier enrollment applications, acting as National Supplier Clearinghouses (“NSC”) for specific regions on behalf of HHS. 42 C.F.R. § 421.210(e) (2005); 42 C.F.R. § 424.57(a) (2009).3 Pursuant to 42 C.F.R. § 421.210(e) and 42 C.F.R. § 489.13(c)(2), a NSC reviews a supplier’s initial application to determine whether to issue the supplier a billing number. If an applicant-supplier meets the standards set forth in 42 C.F.R. § 424.57(b) and (c), a NSC may issue a billing number to the supplier. Receipt of a billing number provides billing privileges that allow a supplier to receive reimbursement from Medicare for items and services the supplier provides to Medicare beneficiaries.

A NSC not only processes applications for billing privileges and issues billing numbers, but also monitors the enrolled suppliers to ensure these suppliers continue to comply with regulatory standards. 42 C.F.R. § 424.57(b) and (c). If such standards are not met, a NSC that monitors a supplier, acting as a delegee of the Government, will, together with CMS, revoke a supplier’s billing number. 42 C.F.R. § 424.57(d); 42 C.F.R. § 405.874(b).4 “Revocation is effective 15 days after the [NSC] mails notice [to the supplier] of its determination.” 42 C.F.R. § 405.874(b). Once a supplier’s billing privileges are revoked, it may no longer service Medicare beneficiaries or receive Medicare reimbursement for services rendered. Id.

After a supplier receives notification that its billing privileges will be revoked, the supplier may request a hearing before a neutral party within 90 days. 42 C.F.R. § 405.874(b). A NSC must schedule a hear[325]*325ing within one week after the request. 42 C.F.R. § 405.874(c). Within two weeks of the hearing, the hearing officer must issue a decision. Id. Either party may appeal the hearing officer’s decision within 60 days to an administrative law judge.5 CMS Pub. 100-08, Change Request 8601 (Jan. 14, 2005). A review of the administrative law judge’s decision by the HHS Department Appeals Board may be requested. Id. After exhausting these steps, a supplier may seek judicial review of the revocation decision and subsequent administrative appeal determinations by filing a civil action in district court. 42 U.S.C. § 1395ce(j)(2) (Supp. V 2005); 42 U.S.C. § 405(g) (2000); CMS Pub. 100-08, Change Request 3601. See Anderson v. Sullivan, 959 F.2d 690, 692 (8th Cir.1992); see also Ahmed v. Sebelius, 710 F.Supp.2d 167, 172-73 (D.Mass.2010).

Factual Background6

Plaintiff was a pharmacy operating as a DMEPOS supplier in Oklahoma with Medicare billing privileges. Compl. ¶9. On or around December 15, 2005, Plaintiff received notice that its billing number would be revoked for failure to comply with nine standards in the regulations implementing the Medicare Act. 42 C.F.R. § 424.57(c); Compl. ¶¶ 11-19. The NSC overseeing Plaintiffs billing privileges informed Plaintiff that its billing number would be revoked 15 days later. Compl. ¶ 11. On December 29, 2005, Plaintiff timely requested a hearing from the NSC Hearing and Appeals Department to appeal the revocation, claiming AAA was in compliance with all nine standards. Compl. ¶ 21. Prior to the hearing, in February 2006, the NSC overseeing Plaintiffs billing privileges determined AAA was in compliance with seven of the nine allegedly violated standards, after the NSC received Plaintiffs corrective action plan.

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Related

Steffen v. United States
995 F.3d 1377 (Federal Circuit, 2021)
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112 Fed. Cl. 387 (Federal Claims, 2013)

Cite This Page — Counsel Stack

Bluebook (online)
108 Fed. Cl. 321, 2012 U.S. Claims LEXIS 1417, 2012 WL 5873677, Counsel Stack Legal Research, https://law.counselstack.com/opinion/aaa-pharmacy-inc-v-united-states-uscfc-2012.