Winter v. California Medical Review, Inc.

900 F.2d 1322, 1990 WL 41703
CourtCourt of Appeals for the Ninth Circuit
DecidedDecember 18, 1989
DocketNo. 88-6499
StatusPublished
Cited by28 cases

This text of 900 F.2d 1322 (Winter v. California Medical Review, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Winter v. California Medical Review, Inc., 900 F.2d 1322, 1990 WL 41703 (9th Cir. 1989).

Opinion

ORDER

This case was originally decided by a memorandum disposition filed on December 18, 1989, 892 F.2d 85. The memorandum disposition has been amended and is now being published as an Opinion authored by Judge Trott pursuant to Ninth Circuit Rule 36-4.

OPINION

TROTT, Circuit Judge:

Appellant Dr. Benjamin Winter claims that appellee California Medical Review, Inc. (CMRI), a peer review organization [1324]*1324(PRO) under contract with the Secretary of Health and Human Services to review various medical services in the State of California, lacked jurisdiction to investigate him because the surgery he performed was not covered under the Medicare program. The district court dismissed appellant’s request for injunctive and declaratory relief, finding that he had failed to exhaust his administrative remedies. We affirm on that basis and on the ground that the case is not ripe for judicial review.

FACTUAL and PROCEDURAL BACKGROUND

After conducting an investigation and review of patient records, CMRI made a preliminary determination that appellant had violated certain statutory obligations under 42 U.S.C. § 1320c-5 (1982 & Supp. V 1987).1 CMRI notified appellant of this determination and informed him that it was considering recommending sanctions to the Office of the Inspector General (OIG) of the Department of Health and Human Services (“the Department”).2

After appellant received this notice, and after the hospital at which appellant worked received notice of an independent CMRI investigation against the hospital itself, the hospital suspended appellant’s staff privileges. Appellant, citing a 1980 administrative ruling excluding the type of procedure which he performs from Medicare coverage,3 claimed that CMRI had no jurisdiction to investigate him. His counsel apparently discussed this contention in a series of telephone calls with Department and CMRI attorneys and with representatives of the Health Care Financing Administration. Appellant’s counsel apparently told at least some of these agency representatives that the conversations were “off the record.” Appellant then filed suit in district court, seeking, inter alia, a preliminary injunction' enjoining the Secretary from further investigation of the issues raised by CMRI. The district court granted appellees' motion to dismiss, finding that appellant failed to exhaust his administrative remedies.

ANALYSIS

This court has jurisdiction under 28 U.S.C. § 1291 (1982). The district court’s decision that appellant failed to meet statutory exhaustion requirements4 is essentially a jurisdictional finding. The existence of subject matter jurisdiction presents a question of law reviewed de novo by this court. Kruso v. International Tel. & Tel. Corp., 872 F.2d 1416, 1421 [1325]*1325(9th Cir.1989). The district court’s factual findings on jurisdictional issues must be accepted unless clearly erroneous. Id.

A. Ripeness

The ripeness doctrine serves “to prevent the courts, through avoidance of premature adjudication, from entangling themselves in abstract disagreements over administrative policies, and also to protect the agencies from judicial interference until an administrative decision has been formalized and its effects felt in a concrete way by the challenging parties.” Abbott Laboratories v. Gardner, 387 U.S. 136, 148-49, 87 S.Ct. 1507, 1515-16, 18 L.Ed.2d 681 (1967). In considering whether a case is ripe for review, a court must evaluate “the fitness of the issues for judicial decision and the hardship to the parties of withholding court consideration.” Id. at 149, 87 S.Ct. at 1515; see also Standard Alaska Prod. Co. v. Schaible, 874 F.2d 624, 627 (9th Cir.1989), petition for cert. filed, No. 89-1375 (Feb. 27, 1990). “A claim is fit for decision if the issues raised are primarily legal, do not require further factual development, and the challenged action is final.” Schaible, 874 F.2d at 627. In interpreting the finality requirement, a court “looks to whether the agency action represents the final administrative word to insure that judicial review will not interfere with the agency’s decision-making process.” State of Cal., Dep’t of Educ. v. Bennett, 833 F.2d 827, 833 (9th Cir.1987).

To meet the hardship requirement, a litigant must show that withholding review would result in “direct and immediate” hardship and would entail more than possible financial loss. Id. at 833-34; see also Portland Police Ass’n v. City of Portland, 658 F.2d 1272, 1273 (9th Cir.1981).

Winter has satisfied neither the fitness nor the hardship requirement. CMRI’s preliminary finding is clearly not the agency’s “final administrative word,” as CMRI may review appellant’s arguments and decide not to recommend sanctions.5 Moreover, where a series of contingent events must occur to produce an injury, a court may find the case inappropriate for judicial resolution. See Portland Police, 658 F.2d at 1274-75.

Appellant’s claim that the investigation itself represented final agency action lacks merit. As appellees note, after reviewing information submitted by appellant, the agency might agree with his assertion that CMRI’s investigation was improper. This court must give the agency an opportunity to formulate a final position.6

Appellant has also failed to demonstrate direct and immediate hardship. He points to suspension of staff privileges as the primary source of his harm. The cause of this harm, however, is the hospital, which suspended appellant’s staff privileges after receiving notice of an independent investigation against the hospital itself. The nexus between CMRI’s investigation of appellant and appellant’s alleged injuries is too attenuated to support his claim.

B. Judicial Review Under 42 U.S.C. § 405(9)

42 U.S.C. § 1320c-5(b)(4) provides that practitioners who wish to contest penalties imposed by the Secretary are entitled “to judicial review of the Secretary’s final decision after such hearing as is provided in section 405(g) of this title.” 42 U.S.C. § 1320c-5(b)(4). Section 405(g), in turn, permits an individual to file suit in federal court “after any final decision of the Secretary made after a hearing.” 42 U.S.C. § 405(g).

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Bluebook (online)
900 F.2d 1322, 1990 WL 41703, Counsel Stack Legal Research, https://law.counselstack.com/opinion/winter-v-california-medical-review-inc-ca9-1989.