Art of Healing Med., P.C. v. Burwell

• Decision Date: 10 March 2015
• Docket Number: No. 14–CV–4001.,14–CV–4001.
• Citation: 91 F.Supp.3d 400
• Parties: ART OF HEALING MEDICINE, P.C., Plaintiff, v. Sylvia Mathews BURWELL, in her official capacity as Secretary of Health and Human Services, Defendant.
• Court: U.S. District Court — Eastern District of New York

91 F.Supp.3d 400

ART OF HEALING MEDICINE, P.C., Plaintiff
v.
Sylvia Mathews BURWELL, in her official capacity as Secretary of Health and Human Services, Defendant.

No. 14–CV–4001.

United States District Court, E.D. New York.

Signed March 10, 2015.
Filed March 11, 2015.

91 F.Supp.3d 401

Martin Bienstock, Weisbrod Matteis & Copley PLLC, Washington, DC, for Plaintiff.

91 F.Supp.3d 402

Layaliza K. Soloveichik, Margaret M. Kolbe, United States Attorney's Office, Eastern District of New York, Civil Division, Brooklyn, NY, for Defendant.

MEMORANDUM & ORDER

JACK B. WEINSTEIN, Senior District Judge.

Table of Contents

I.	Introduction	402
II.	Facts	403

A. Medicare Payment Process Regarding Supplemental Health Insurance Benefits 403

1.	Requirements for Documenting Psychiatric Services	403
2.	MACs and Initial Medicare Payment Determinations	404
3.	RACs and the Medicare Integrity Program	405

B. Challenging an Audit Finding: Five–Stage Appeals Process 405

1.	MAC Redetermination Request	406
2.	QIC Reconsideration	406

a.	Procedural Dismissal	406
b.	Substantive Redetermination	406

3.	Administrative Law Judge Hearing	407
4.	Appeals Council Review	407
5.	Judicial Review	407

C. Denial of Plaintiff's Medicare Reimbursement Claims 408

1.	Dr. Pinkusovich's Psychiatric Practice	408
2.	SafeGuard Services Audits Dr. Pinkusovich's Billing Records	408
3.	Art of Healing Appeals the Audit Findings	409

a.	MAC Dismisses Art of Healing's Appeal for Failure to Identify Beneficiaries Whose Claims Had Been Denied	409
b.	Plaintiff Resubmits Redetermination Request to MAC	410
c.	Plaintiff Initiates Concurrent Action with QIC to Appeal MAC Dismissal	410
d.	MAC Issues Merits Decision Adverse to Plaintiff	410
e.	QIC Vacates Dismissal But Still Issues Unfavorable Merits Determination	410
f.	Plaintiff Unsuccessfully Appeals MAC's Merits Redetermination to QIC	411
g.	Plaintiff Exercises Its Right to Present Its Case to Appeals Council, Which Upholds Overpayment Determination	412

D. Timeline of Events 413

III. Law 415

A. Administrative and Judicial Review Under the Medicare Act 415

1.	Relevant Statutory Authority	415
2.	Section 405(g) Sixth Sentence Remands	416

B.	The Accardi Doctrine	417
C.	The Administrative Procedure Act	418

IV.	Application of Facts to Law	419
V.	Conclusion	419

I. Introduction

Plaintiff Art of Healing, P.C. (“Art of Healing”) brings this action pursuant to the...