Albert v. Burwell

118 F. Supp. 3d 505, 2015 U.S. Dist. LEXIS 98400, 2015 WL 4546649
CourtDistrict Court, E.D. New York
DecidedJuly 28, 2015
DocketNo. 13-CV-4542 (FB)(RML)
StatusPublished
Cited by2 cases

This text of 118 F. Supp. 3d 505 (Albert v. Burwell) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Albert v. Burwell, 118 F. Supp. 3d 505, 2015 U.S. Dist. LEXIS 98400, 2015 WL 4546649 (E.D.N.Y. 2015).

Opinion

MEMORANDUM AND ORDER

BLOCK, Senior District Judge:

Plaintiff Warren Albert, D.C. (“Dr. Albert”), a chiropractor, seeks judicial review of a final decision by the Secretary of the United States Department of Health and Human Services (“Secretary”), which de-[507]*507terrained that he owes Medicare approximately $575,000 because he provided inadequate documentation of his chiropractic treatment.1 Both, parties move for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). For the reasons that follow, the Court grants Dr. Albert’s motion and remands for further proceedings. The Secretary’s motion is denied.

I.

A. The Statutory and Regulatory Framework

Medicare is the federal health insurance program for the elderly and disabled. See 42 U.S.C. § 1395 et seq. This case concerns chiropractic services provided under Medicare Part B, a voluntary supplemental insurance program covering certain outpatient treatment. See 42 U.S.C. § 1395j et seq. Part B is administered by the Centers for Medicare & Medicaid Services (“CMS”), a federal agency within the Department of Health and Human Services, in conjunction with private contractors known as Medicare Administrative Contractors (“MACs”). See 42 U.S.C. § 1395kk-l.

As a general rule, physicians who provide services under Part B — “providers” in Medicare terminology — may only be reimbursed for treatment that is “reasonable and necessary.” 42 U.S.C. § 1395y(a)(l)(A). Part B coverage of chiropractic service is further limited to include only treatment of the spine by means of manual manipulation — that is, by use of the hands — to correct subluxations, which are “structural misalignments of the joints, other than fractures or complete dislocations, that require treatment only by nonsurgical methods.” 42 C.F.R. §§ 411.15, 410.21(b)(1). In addition, the treatment “must have a direct therapeutic relationship to the patient’s condition'and provide reasonable expectation of recovery or improvement of function.” Medicare Benefit Policy Manual, CMS Pub. No. 100-02, Ch. 15, § 240.1.3.

To obtain reimbursement under Part B, a provider must “fúrnish[ ] such information as may be necessary in order'to determine the amounts due.... ” 42 U.S.C. § 13951(e). Congress did not specify what documentation a provider must submit but rather delegated the authority .to make that determination to the Secretary, who may proceed via “formal regulations and (informal) instructional manuals and letters,” Yale-New Haven Hosp. v. Leavitt, 470 F.3d 71, 74 (2d Cir.2006), or by delegating to MACs, who issue local coverage determinations, or LCDs,2 specifying which services' are reimbursable and what documentation is required to obtain reimbursement, see 42 U.S.C. § 1395ff(f)(2)(B).

As a chiropractor, Dr. Albert was required to follow two documentation guidelines. First, the Medicare Benefit Policy Manual (the “Policy Manual”), an interpretive manual issued by CMS* sets forth requirements for both initial and subsequent patient visits. See Policy Manual, CMS Pub. . No. 100-02, Ch. 15, § 240.1.2. Second, since Dr. Albert submitted claims to National Government Services (“NGS”), a MAC, he was subject to a Local Coverage Determination for Chiropractor Ser-' [508]*508vices (the “Chiropractic LCD”), which was issued byNGS in 2008. See Nat’l Gov’t SERVS,, LCD FOR CHIROPRACTIC SERVICES (L27350): (2008). The Chiropractic LCD largely reiterates the .Policy Manual’s requirements but also “provides clarification to educate providers.” Id.

Three specific requirements contained in both the Policy Manual- and Chiropractic LCD are relevant to this case:

1. Documentation of initial visits must include (1) the patient’s medical history, (2) a description of the present illness, (3) a physical examination of the musculoskeletal system, (4) a diagnosis, (5) a treatment plan, and (6) 'the date of initial treatment. See Policy Manual, CMS Pub. No. 10002, Ch. 15, § 240.1.2.2.A.
2. Documentation of subsequent visits must include (1) the patient’s medical history, (2) a physical examination, (3) documentation of treatment, and (4) progress or lack thereof. See id., Ch. 15, § 240.1.2.2.B.
3. A patient’s medical history — required for both initial and subsequent visits — should include (1) symptoms causing the patient to seek treatment, (2) family history if relevant, (3) past health history, (4) mechanism of trauma, (5) quality and character .of symptoms, (6) onset, duration, intensity, frequency, location and radiation of symptoms, (7) aggravating or relieving factors, and (8) prior interventions, treatments, medications, and secondary complaints. See id., Ch. ■ 15, § 240.1.2.

B. The Medicare Payment System and Appeals Process

The- Part B reimbursement system is administered by MACs, Who “typically authorize payment of claims immediately upon receipt of the claims, so long as the claims- do not contain glaring irregularities.” Gulfcoast Med. Supply, Inc. v. Sec’y, Dep’t of Health & Human Servs., 468 F.3d 1347, 1349 (11th Cir.2006). Later, post-payment audits may be conducted either by MACs or by independent auditors. See Medicare Program Integrity Manual, CMS Pub. No. 100-08, Ch. 3, § 3.2,2. If billing irregularities are discovered, the MAC may then recoup the overpayment from the provider. See 42 C.F.R. §§ 405.370, 405.371(a)(2).

When a MAC determines that a provider has been overpaid, the provider is entitled to five levels of administrative review: (1) redetermination by a MAC employee not involved in the initial overpayment determination, see id. §§ 405.940, 405.948; (2) reconsideration by a Qualified Independent Contractor (“QIC”), see id. § 405.960; (3) a hearing before an Administrative Law Judge (“ALJ”), see id. §§ 405.1000, 405.1002(a);' (4) de novo review by the Medicare Appeals Council (the “Council”), either at the request of the provider, by referral from a- MAC, or upon the Council’s own motion, see id. §§ 405.1100, 405.1102(a), 405.1110; and (5) judicial review in federal court, see 42 U.S.C. § 405(g).

C. Factual Background

Dr.

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Bluebook (online)
118 F. Supp. 3d 505, 2015 U.S. Dist. LEXIS 98400, 2015 WL 4546649, Counsel Stack Legal Research, https://law.counselstack.com/opinion/albert-v-burwell-nyed-2015.