People of the State of California v. Eisengrein

CourtDistrict Court, S.D. California
DecidedJune 2, 2023
Docket3:22-cv-01648
StatusUnknown

This text of People of the State of California v. Eisengrein (People of the State of California v. Eisengrein) is published on Counsel Stack Legal Research, covering District Court, S.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
People of the State of California v. Eisengrein, (S.D. Cal. 2023).

Opinion

1 2 3 4 5 6 7 8 9 10 UNITED STATES DISTRICT COURT 11 SOUTHERN DISTRICT OF CALIFORNIA 12 13 PEOPLE OF THE STATE OF Case No. 22-cv-1648-BAS (WVG) CALIFORNIA ex rel. SAN DIEGO 14 COMPREHENSIVE PAIN ORDER: 15 MANAGEMENT CENTER, INC.; PACIFIC SURGICAL INSTITUTE OF (1) DENYING PLAINTIFFS’ 16 PAIN MANAGEMENT, MOTION TO REMAND 17 (ECF No. 7); Plaintiffs,

18 v. (2) GRANTING DEFENDANTS’ 19 MOTION TO DISMISS JAYSEN EISENGREIN; SANDRA (ECF No. 8); 20 LOVE,

21 Defendants. (3) TERMINATING AS MOOT THE GOVERNMENT’S 22 MOTION TO INTERVENE 23 AND STAY (ECF No. 9); AND

24 (4) TERMINATING AS MOOT 25 MOTION TO WITHDRAW AS COUNSEL (ECF No. 19) 26

27 Plaintiffs San Diego Comprehensive Pain Management Center, Inc. and Pacific 28 Surgical Institute of Pain Management, Inc. are a medical practice and surgery center that 1 treat patients with chronic pain. This case is the second action involving a suspension of 2 their Medicare payments. Previously, Plaintiffs sued the Secretary of the Department of 3 Health and Human Services and a Medicare contractor—Qlarant Integrity Solutions, 4 LLC—to challenge the suspension. This Court dismissed Plaintiffs’ action for lack of 5 subject matter jurisdiction, reasoning Plaintiffs failed to exhaust their administrative 6 remedies under the Medicare Act. 7 Several months later, Plaintiffs filed this state court action against two employees 8 of the Medicare contractor—Defendants Sandra Love and Jaysen Eisengrein. Plaintiffs 9 assert state law claims arising from Defendants’ alleged role in suspending the Medicare 10 payments. Defendant Love removed the case under the federal officer removal statute. 11 Love alleges she can invoke federal officer removal because she is being sued for 12 exercising her Medicare administration duties. 13 Now before the Court are two competing motions. First, Plaintiffs move to 14 remand, arguing removal was improper. Second, Defendants move to dismiss on several 15 grounds, including lack of subject matter jurisdiction. For the following reasons, the 16 Court denies Plaintiffs’ Motion to Remand, grants Defendants’ Motion to Dismiss, and 17 terminates as moot the other pending motions. 18 BACKGROUND 19 I. The Medicare Act 20 Title XVIII of the Social Security Act, commonly known as the Medicare Act, 21 establishes a federally subsidized health insurance program covering the elderly and 22 disabled. 42 U.S.C. §§ 1395–1395lll. The Department of Health and Human Services 23 (“HHS”) administers Medicare. E.g., Aylward v. SelectHealth, Inc., 35 F.4th 673, 675 24 (9th Cir. 2022). The Secretary of HHS delegates this responsibility to the Centers for 25 Medicare and Medicaid Services (“CMS”)—an agency within HHS. Id. 26 Under Parts A and B of Medicare, the Government “pays health care providers on 27 a fee-for-service basis at rates approved by” CMS. Glob. Rescue Jets, LLC v. Kaiser 28 Found. Health Plan, Inc., 30 F.4th 905, 909 (9th Cir. 2022). Medicare, however, “pays 1 only for services that are ‘reasonable and necessary.’” Odell v. U.S. Dep’t of Health & 2 Hum. Servs., 995 F.3d 718, 720 (9th Cir. 2021) (quoting 42 U.S.C. § 1395y(a)(1)(A)). 3 Therefore, providers first submit claims for reimbursement for services, the Government 4 reviews those claims, and then the Government makes appropriate payments to the 5 providers. 42 C.F.R. § 405.920. 6 A. Administrative Contractors 7 From its inception, Medicare has relied on administrative contractors. Nat’l Gov’t 8 Servs., Inc. v. United States, 923 F.3d 977, 979 (Fed. Cir. 2019). CMS is authorized “to 9 facilitate the evaluation and reimbursement of claims for covered medical treatment” by 10 contracting with private entities, which then review and “process those claims on the 11 Government’s behalf.” United States ex rel. Hartpence v. Kinetic Concepts, Inc., 44 12 F.4th 838, 840 (9th Cir. 2022). This type of contractor is known as a Medicare 13 Administrative Contractor. 42 U.S.C. § 1395kk-1(a)(1). Disputes arising under the 14 Medicare Act often start with a contractor’s decision to deny or pay a lower 15 reimbursement amount for a provider’s claim. E.g., Odell, 995 F.3d at 720; Silverado 16 Hospice, Inc. v. Becerra, 42 F.4th 1112, 1117 (9th Cir. 2022). 17 Beyond enlisting contractors for claims processing, CMS uses outside entities for 18 the congressionally mandated “Medicare Integrity Program.” 42 U.S.C. § 1395ddd. One 19 of these entities is labeled a Unified Program Integrity Contractor (“UPIC”). Angel’s 20 Touch Inc. v. Becerra, No. CV-21-08026-PCT-MTL, 2021 WL 2138766, at *1 (D. Ariz. 21 May 26, 2021); Hollywood Home Health Servs., Inc. v. Qlarant Quality Sols., Inc., No. 22 CV 19-6817-DMG (ASX), 2020 WL 3964792, at *1 (C.D. Cal. Feb. 27, 2020). A UPIC 23 performs activities that “promote the integrity of” Medicare, including auditing cost 24 reports, reviewing service providers for fraud, and recovering “payments that should not 25 have been made.” 42 U.S.C. § 1395ddd(a), (b). 26 B. Suspension of Medicare Payments 27 Medicare contractors also assist CMS when it suspends a healthcare provider’s 28 Medicare payments. 42 C.F.R. § 405.372. CMS can suspend payments “in whole or in 1 part” when CMS determines that “a credible allegation of fraud exists against a provider 2 or supplier.” Id. § 405.371(a)(2). Moreover, CMS may suspend payments without notice 3 where there is a “belief that giving prior notice would hinder the possibility of 4 recovering” Medicare funds. Id. § 405.372(a)(3). In enacting a suspension, CMS: 5 (i) In consultation with [the HHS Office of Inspector General] and, as appropriate, the Department of Justice, determines whether to impose 6 the suspension and if prior notice is appropriate; 7 (ii) Directs the Medicare contractor as to the timing and content of the 8 notification to the provider or supplier; and 9 (iii) Is the real party in interest and is responsible for the decision. 10

11 Id. § 405.372. 12 With the Medicare contractor’s help, CMS must give the provider an opportunity 13 to submit a rebuttal statement in writing as to why the suspension should be removed. 42 14 C.F.R. § 405.372(a)(3), (b)(2). Within fifteen days of receiving a rebuttal, CMS 15 determines whether the suspension should stay in effect. Id. § 405.375(a). That 16 conclusion is not “an initial determination and is not appealable” within the Medicare 17 Act’s administrative process. Id. § 405.375(c); see also Maka Hospice v. Azar, No. CV 18 19-7065 DDP, 2020 WL 4284972, at *2 (C.D. Cal. July 24, 2020) (“The [suspension of 19 Medicare payments] is nothing more than a temporary measure necessary to maintain the 20 status quo while the necessary facts are gathered and evaluated.” (quoting Clarinda 21 Home Health v. Shalala, 100 F.3d 526, 530 (8th Cir. 1996))). Instead, after suspending 22 payments, CMS must reevaluate in 180 days whether good cause exists to continue the 23 suspension. 42 C.F.R § 405.371(b). A fraud-based suspension may be further continued 24 if the Department of Justice is pursuing a civil or criminal action. Id. § 405.371(b). 25 C.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Ex Parte McCardle
74 U.S. 506 (Supreme Court, 1869)
Maryland v. Soper, Judge
270 U.S. 9 (Supreme Court, 1926)
Colorado v. Symes
286 U.S. 510 (Supreme Court, 1932)
Landis v. North American Co.
299 U.S. 248 (Supreme Court, 1936)
Willingham v. Morgan
395 U.S. 402 (Supreme Court, 1969)
Mathews v. Eldridge
424 U.S. 319 (Supreme Court, 1976)
Heckler v. Ringer
466 U.S. 602 (Supreme Court, 1984)
Jefferson County v. Acker
527 U.S. 423 (Supreme Court, 1999)
Watson v. Philip Morris Companies, Inc.
551 U.S. 142 (Supreme Court, 2007)
Do Sung Uhm v. Humana, Inc.
620 F.3d 1134 (Ninth Circuit, 2010)
White v. Lee
227 F.3d 1214 (Ninth Circuit, 2000)
Kaiser v. Blue Cross of California
347 F.3d 1107 (Ninth Circuit, 2003)
Wolfe v. Strankman
392 F.3d 358 (Ninth Circuit, 2004)
Moran v. Selig
447 F.3d 748 (Ninth Circuit, 2006)
CSr Ltd. v. Cigna Corp.
405 F. Supp. 2d 526 (D. New Jersey, 2005)
Courthouse News Service v. Michael Planet
750 F.3d 776 (Ninth Circuit, 2014)

Cite This Page — Counsel Stack

Bluebook (online)
People of the State of California v. Eisengrein, Counsel Stack Legal Research, https://law.counselstack.com/opinion/people-of-the-state-of-california-v-eisengrein-casd-2023.