Medwin Family Med. & Rehab., P. L.L.C. v. Burwell, Case No. 1:15-cv-151
| Decision Date | 31 January 2017 |
| Docket Number | Case No. 1:15-cv-151 |
| Parties | MEDWIN FAMILY MEDICINE AND REHABILITATION, P.L.L.C., Plaintiff, v. SYLVIA MATHEWS BURWELL, Secretary, United States Department of Health and Human Services, Defendant. |
| Court | U.S. District Court — Southern District of Texas |
Plaintiff Medwin Family Medicine and Rehabilitation, P.L.L.C. (hereinafter referred to as "Medwin") has filed a Motion for Summary Judgment in this civil action. Dkt. No. 24. Defendant Sylvia Mathews Burwell, Secretary of the United States Department of Health and Human Services (hereinafter, "the Secretary") has filed a Cross Motion for Summary Judgment. Dkt. No. 27. After full consideration of both Motions for Summary Judgment and all related submissions, it is recommended that the Court: (1) grant the Secretary's Cross Motion for Summary Judgment; (2) deny Medwin's Motion for Summary Judgment; and, (3) dismiss this civil action with prejudice.
This civil action arises under the Medicare Act, which is codified at 42 U.S.C. § 1395 et seq. The Medicare Act is part of Title XVIII of the Social Security Act. Baylor Univ. Med. Ctr. v. Heckler, 730 F.2d 391, 391 (5th Cir. 1984) (per curiam). The Medicare Act was established to provide health insurance to the elderly and disabled. D&G Holdings, LLC v. Sylvia Mathews Burwell, 156 F. Supp. 3d 798, 805 (W.D. La. 2016) (citing 42 U.S.C. §§ 1395-1395lll). The Medicare Act is composed of Parts A, B, C, D, and E. 42 U.S.C. § 1395 et seq. This civil action concerns Part B. See Dkt. No. 1 at ¶ 18; Dkt. No. 27 at 2.
Part B of the Medicare program provides voluntary, supplemental medical insurance. 42 U.S.C. § 1395j. It covers "medical and other health-care services," including "diagnostic tests[.]" Id. at § 1395k(a)(1), and § 1395x(s)(3). The Secretary administers the Medicare program through the Centers for Medicare and Medicaid Services ("CMS"). Arkansas Dep't of Health & Human Servs. v. Ahlborn, 547 U.S. 268, 275 (2006); Miracle Care Hospice, Inc. v. Sebelius, No. 3:12-CV-495-CWR-FKB, 2014 WL 1324279, at *1 (S.D. Miss. Mar. 31, 2014) (same). Through CMS, the Secretary utilizes Medicare contractors to assist with Part B claim determinations. 42 U.S.C. § 1395u.
Medwin is a provider of healthcare services to Medicare beneficiaries under Part B. Dkt. No. 1 at ¶ 7; Dkt. No. 17 at ¶ 7. Medwin's principal office is located in Brownsville, Texas. Dkt. No. 1 at ¶ 5.1 As part of its services, Medwin provides electrodiagnostic studies to help diagnose and treat its patients. Id. at ¶ 17. Medwin performed electrodiagnostic studies on six Medicare patients in 2012. Id. at ¶ 1, 19. Specifically, Medwin performed various sensory and nerve conduction tests for patients presenting with symptoms of radiculopathy/sciatica. Id. at ¶ 25.2
Medicare paid Medwin's claims for these tests initially. Dkt. No. 1 at ¶ 26. Later, however, a Medicare contractor, Novitas Solutions, Inc., ("Novitas"), determined that Medicare had overpaid Medwin and sought to recoup the payments. Id. Medwin proceeded to appeal this decision administratively. Id. at ¶¶ 20-22. On June 24, 2015, the Medicare Appeals Council (hereinafter, the "Council") entered a final decision denying Medwin's appeal. According to the Council, Medwin was overpaid in the amount of $585.32 for each of the six patients at issue. Administrative Record ("AR") at 14, 194-210, 1000-1008.3 Medwin seeks judicial review of the Council's decision. Dkt. No. 1 at ¶ 1.
The parties agree that, pursuant to 42 U.S.C. § 405.1136(d), the Secretary is the proper defendant in this action as the adopter and issuer of final decisions made by the Council. Dkt. No. 1 at ¶¶ 4 and 6; Dkt. No. 17 at ¶¶ 4 and 6. The parties additionally agree that Medwin's Original Complaint is timely, the amount in controversy is satisfied, and all conditions precedent to filing suit have been met. Dkt. No. 1 at ¶¶ 4, 6, 15; Dkt. No. 17 at ¶¶ 4, 6, 15. Jurisdiction and venue are not disputed. Dkt. No. 1 at ¶ 4; Dkt. No. 17 at ¶ 4. The Court finds that: (1) the Secretary is the proper defendant in this action; (2) Medwin's Original Complaint is timely; (3) the amount in controversy is satisfied; (4) all conditions precedent have been met; (5) jurisdiction and venue are proper; and, (6) this Court may review the Council's June 24, 2015 decision as the Secretary's final, appealable decision. See 42 U.S.C. § 405(g), § 405.1006(c), § 405.1130, § 405.1136; § 1395ff(b). See also AR at 3 ().
A. FED. R. CIV. P. 56. The standard applied when ruling on a motion for summary judgment is set forth in Rule 56 of the Federal Rules of Civil Procedure. FED. R. CIV. P. 56(a). In pertinent part, Rule 56 provides that the court "shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Id., see also Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 2552 (1986) (same). Mere allegations of a factual dispute between the parties will not defeat an otherwise proper motion for summary judgment. Rule 56 requires that there be no genuine issue of material fact. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247 (1986).
A fact is material if it might affect the outcome of the lawsuit under the governing law. Anderson, 477 U.S. 242, 248. A dispute about a material fact is genuine if the evidence is such that a reasonable jury could return a verdict for the nonmoving party. Id. Therefore, summary judgment is proper if, under governing laws, there is only one reasonable conclusion as to the verdict. If reasonable finders of fact could resolve a factual issue in favor of either party, summary judgment should not be granted. Id. at 249.
The movant on a summary judgment motion bears the initial burden of providing the court with a legal basis for its motion and identifying those portions of the record which demonstrate the absence of a genuine issue of material fact. The burden then shifts to the resisting party to present affirmative evidence to defeat the motion. Anderson, 477 U.S. 242, 257. All facts and inferences drawn from those facts must be viewed in the light favorable to the party resisting the motion for summary judgment. Scott v. Harris, 550 U.S. 372, 378 (2007). "The court need consider only the cited materials, but it may consider other materials in the record." FED. R. CIV. P. 56(c)(3).
B. The Court's Review of the Secretary's Decision. In Girling Health Care, Inc. v. Shalala, the Fifth Circuit noted:
The summary judgment procedure is particularly appropriate in cases in which the court is asked to review or enforce a decision of a federal administrative agency. The explanation for this lies in the relationship between the summary judgment standard of no genuine issue as to any material fact and the nature of judicial review of administrative decisions. . . . [T]he administrative agency is the fact finder. Judicial review has the function of determining whether the administrative action is consistent with the law—that and no more.
Girling Health Care, Inc. v. Shalala, 85 F.3d 211, 214-15 (5th Cir. 1996) (alterations in original) (quoting 10A Charles Alan Wright, Arthur R. Miller & Mary Kay Kane, Federal Practice and Procedure: Civil 2d § 2733 (1983)). Section 1395ff(b) of Title 42 provides that any individual dissatisfied with the Secretary's final decision regarding a claim may obtain judicial review as provided in 42 U.S.C. § 405(g). 42 U.S.C. § 1395ff(b).
Where § 405(g) governs, review of the Secretary's decision is limited to two inquiries: (1) whether the Secretary applied the correct legal standards; and (2) whether there is substantial evidence in the record to support the Secretary's decision. Estate of Morris v. Shalala, 207 F.3d 744, 745 (5th Cir. 2000) (); Maxmed Healthcare, Inc., v. Burwell, 152 F.Supp.3d 619, 625 (W.D. Tex. 2016) (same). When considering whether the Secretary applied correct legal standards, courts are required to give "substantial deference" to her interpretation of Medicare's regulations. Maxmed Healthcare, Inc., 152 F.Supp.3d 619, 625 (citing Girling Health Care, 85 F.3d at 215). When considering whether substantial evidence exists to support the Secretary's decision, courts must be mindful that substantial evidence is more than a mere scintilla. Id. Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (). The reviewing court "'may neither reweigh the evidence in the record nor substitute [its own] judgment for the Secretary's.'" Id. (quoting Hollis v. Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988)).
Despite the longstanding existence of the above-discussed standard of review, Medwin argues that that the Fifth Circuit has "issued conflicting opinions regarding the appropriate standard of review." Dkt. No. 24 at 10.
In Estate of Morris, the Court rejected a party's contention that the Administrative Procedure Act ("APA") provided the standard of review. 207 F.3d at 745. However, in Texas Clinical Laboratories, Inc. v. Sebelius, the Court cited the APA without any expression of doubt. 612 F.3d 771, 775 (5th Cir. 2010) () (quoting Sun Towers, Inc. v. Schweiker (Sun Towers I), 694 F.2d 1036, 1038 (5th Cir. 1983)).
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