Ohio State Chiropractic Ass'n v. Humana Health Plan Inc.

647 F. App'x 619
CourtCourt of Appeals for the Sixth Circuit
DecidedMay 9, 2016
DocketNo. 15-3130
StatusPublished
Cited by30 cases

This text of 647 F. App'x 619 (Ohio State Chiropractic Ass'n v. Humana Health Plan Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ohio State Chiropractic Ass'n v. Humana Health Plan Inc., 647 F. App'x 619 (6th Cir. 2016).

Opinion

BOGGS, Circuit Judge.

When Humana discovered that it had accidentally paid chiropractors more than was required by Medicare, it decided to withhold portions of subsequent payments. The chiropractors brought suit in state court and Humana used the officer-removal statute to remove the case to federal court. Humana does not act under a federal agency in its capacity as a Medicare Advantage organization. We therefore reverse and remand with instructions that the district court remand this case to the state court from which it was removed.

I

Medicare Advantage (MA) allows individuals to receive Medicare benefits through private health-insurance plans instead of Medicare Parts A and B, the government’s fee-for-service program. See 42 U.S.C. § 1395w-21. To participate, insurers referred to as Medicare Advantage organizations (MAOs) contract with the federal Centers for Medicare & Medicaid Services (CMS). Id. § 1395w-27; 42 C.F.R. § 422.503. CMS makes monthly per-beneficiary payments to MAOs, which take on the prospective financial risk of serving Medicare beneficiaries. 42 U.S.C. §§ 1395w-23, — 25(b).

Generally speaking, MAOs have latitude to “select the [health-care] providers from whom the benefits under the plan are provided.” Id.. § 1395w-22(d)(l). To that end, MAOs often contract with physicians and hospitals. Id, § 1395w-22(a)(2)(A). But to cover the full panoply of Medicare benefits, MA plans include services that are sometimes furnished by non-contract providers. Ibid.; 42 C.F.R. § 422.100(b). Payment to non-contract providers must be “equal to at least the total dollar amount of payment for such items and services as would otherwise be authorized under [P]arts A and B” — the fee-schedule amount. 42 U.S.C. § 1395w-22(a)(2)(A)(i) — (ii). Non-contract providers, in turn, “must accept, as payment in full, the amounts that the[y] could collect if the beneficiary were enrolled in [Parts A and B].” 42 C.F.R. § 422.214(a)(1).

That brings us to this case. Humana is an MAO. It had no contract with Thaddeus C. Bosman, D.C., Inc., which would invoice Humana for its chiropractic services. For years, Humana paid Bosman for care furnished to its MA plan enrollees at the fee schedule, regardless of the amounts invoiced. But in 2012, a “technical error” in its claims-processing system caused Hu-[621]*621mana to pay Bosman the full amounts billed. By the time the glitch was corrected, payments to Bosman had, by Humana’s accounting, exceeded the fee schedule by $1,287.48. Humana mailed Bosman several notices of the error. Each advised that remittances above the fee schedule were overpayments and requested their refund. Bosman balked and sought to appeal that decision within Humana. Humana upped the ante. To offset the alleged overpay-ments, it withheld portions of subsequent payments to Bosman for care provided to members of its MA plan.

In 2014, Bosman and the Ohio State Chiropractic Association filed suit against Humana in Ohio state court. Their amended complaint sought: damages for conversion, unjust enrichment, and breach of implied contract; an order declaring that Humana cannot “recoupf ] fees which it alleges were ‘overpaid,’ ” and an injunction preventing it from doing so; and class certification. Humana removed the case to federal district court pursuant to 28 U.S.C. §§ 1441 and 1442(a). A week later, it moved to dismiss, arguing that Bosman failed to exhaust administrative remedies available through the Medicare Act. See 42 U.S.C. § 405(g). Bosman responded with a motion to remand for lack of subject-matter jurisdiction. Without ruling on Bosman’s motion, the district court granted Humana’s motion and dismissed the complaint for failure to exhaust administrative remedies.

On appeal, Bosman argues that the district court lacked subject-matter jurisdiction to hear the case and, alternatively, that its claims are not subject to the Medicare Act’s exhaustion requirement.

II

Our analysis starts (and, in this case, ends) with the threshold question whether Humana could avail itself of § 1442(a) to remove the suit.1 The statute provides a federal forum to “[t]he United States or any agency thereof or any officer (or any person acting under that officer) of the United States or of any agency thereof, in an official or individual capacity, for or relating to any act under color of such office.” Humana is not a federal agency or officer. Removal was nonetheless proper, Humana argues, because the federal government delegates authority to MAOs to administer Medicare benefits. Humana claims that its contract to “administer[] Part C of Medicare” amounts to a government function without which “providers would receive payment directly from the federal government.” By Huma-na’s reckoning, to carry out that function it is “contractually obligated to comply with applicable federal statutes, directives and guidance,” which govern “all facets” of its relationship with Bosman. In particular, it points to the MA statute and attendant CMS regulations that address aspects of MAO payment to non-contract providers. See 42 U.S.C. §§ lS94w-22(a)(2)(A), (k)(l), 1395w-27(f); 42 C.F.R. §§ 422.100(b), 422.214(a).

Section 1442 permits removal only if Humana was “acting under” an “agency” or “officer” of “the United States.” § 1442(a)(1). Humana contends that “acting under” requires only that its “relation[622]*622ship to the plaintiff ‘derived solely from [Humana’s] official duties.’” Magnin v. Teledyne Cont’l Motors, 91 F.3d 1424, 1428 (11th Cir.1996) (quoting Willingham v. Morgan, 395 U.S. 402, 409, 89 S.Ct. 1813, 23 L.Ed.2d 396 (1969)). That interpretation moves the goalposts. First, the quoted language from Willingham referred to “a civil suit of’ a particular “nature” — one involving “senior” federal “officials” whose alleged conduct arose from “official duties.” 395 U.S. at 409, 89 S.Ct. 1813.

More fatal, Willingham preceded Watson v. Philip Morris Cos., 551 U.S. 142, 127 S.Ct. 2301, 168 L.Ed.2d 42 (2007). In Watson, the Supreme Court held that a private person’s “acting under” a federal agency “must involve an effort to assist, or to help carry out, the duties or tasks of the federal superior.” 551 U.S. at 152, 127 S.Ct. 2301.

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647 F. App'x 619, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ohio-state-chiropractic-assn-v-humana-health-plan-inc-ca6-2016.