Northeast Emergency Medical Associates v. Califano
Decision Date | 11 May 1979 |
Docket Number | Civ. A. No. 79-581. |
Citation | 470 F. Supp. 1111 |
Parties | NORTHEAST EMERGENCY MEDICAL ASSOCIATES, P. C., Neema Emergency Medical, P. C., EPM Medical Associates, P. C., Northeast Emergency Medical Associates, P. C., t/a Physicians Emer. Assoc., Northeast Emergency Medical Associates, P. C., t/a Mercy Emergency Phys., Herbert T. Caskey, M. D., Joseph F. Nowoslawski, M. D. v. Joseph A. CALIFANO, Stanley Katz, Department of Health, Education and Welfare, Stanford Ross. |
Court | U.S. District Court — Eastern District of Pennsylvania |
COPYRIGHT MATERIAL OMITTED
Tod I. Mammuth, Philadelphia, Pa., for plaintiffs.
William J. McGettigan, Asst. U. S. Atty., Philadelphia, Pa., for defendant H.E.W.
This civil action stems from a dispute over the proper interpretation of section 1842(b)(5) of the Social Security Act, 42 U.S.C. § 1395u(b)(5) (1976), Medicare-Medicaid Anti-Fraud and Abuse Amendments, Pub.L.No. 95-142, § 2(a)(1), 91 Stat. 1175 (1977). The corporate plaintiffs, under contracts with several Pennsylvania hospitals, have furnished physicians' services and other services in the emergency rooms of those hospitals since 1976. A Medicare patient treated in one of these emergency rooms typically assigns his right to receive Part B Medicare benefits for the emergency-room services to the particular corporate plaintiff involved, as payment for those services, and the benefits are then paid directly to that corporation by Pennsylvania Blue Shield, a local Medicare insurance carrier. See generally 42 U.S.C.A. § 1395u (West 1974 & Supp.1978). Late in 1978, however, Pennsylvania Blue Shield determined, after some prodding by the Medicare Bureau,1 that section 1842(b)(5) of the Social Security Act prohibits assignments of this type, and that payments would thereafter be made to the individual attending physician(s), rather than to plaintiff corporations. Plaintiffs filed this action, seeking a declaration that defendants — the Director of Technical Policy within the Medicare Bureau, the Secretary of HEW, and the Department of HEW — have misinterpreted the law, and that section 1842(b)(5) does not bar the assignment of benefits to the corporate plaintiffs. In addition, plaintiffs urge that they were denied procedural due process when defendants informally adopted their unfavorable interpretation of that provision without affording plaintiffs a prior hearing. Defendants now seek either (1) dismissal of the complaint for lack of subject-matter jurisdiction, or (2) summary judgment in their favor, and plaintiffs in turn seek summary judgment in their favor. For the reasons hereafter stated, I conclude that subject-matter jurisdiction is lacking with respect to plaintiffs' statutory claim, and that defendants are entitled to summary judgment on the merits of plaintiffs' constitutional claim.
The facts here are undisputed. In 1978, the regional office of the Medicare Bureau undertook a review of "reassignment accounts" established by Medicare insurance carriers in Region III. This review disclosed that Pennsylvania Blue Shield had established — and paid reassigned benefits into — six such accounts. Although each account bore a different corporate or fictitious name, each represented emergency-room services rendered by physicians under contract to Northeast Emergency Medical Associates, P. C. (NEMA), the first-named corporate plaintiff in this action. The Medicare Bureau then sought further information about NEMA from Pennsylvania Blue Shield, so that it could determine whether section 1842(b)(5) prohibited the assignment of benefits under these circumstances.
In August of 1978, the director of the Bureau's Division of Program Operations wrote to a Mr. Tolin of Pennsylvania Blue Shield. Attachment A to Defendants' Motion (Document No. 6). His letter stated in part:
Pennsylvania Blue Shield apparently cooperated fully with this request of the Medicare Bureau. According to the affidavit submitted by the Bureau's regional director:
Hartman Aff. ¶ 3.
On November 20, 1978, Pennsylvania Blue Shield sent a series of letters to plaintiff Caskey. Each letter dealt with one of the NEMA reassignment accounts, and each stated that the account "will be dissolved effective immediately and will be removed from our files as an eligible provider thirty (30) days from the date of this letter (December 19, 1978)." Exhibits A-E to Complaint (Document No. 1). Each letter also stated that all future claims for Medicare benefits would "be processed and paid under the name and number of the individual doctor performing the services." Id. By way of explanation, Pennsylvania Blue Shield stated that, under the Social Security Act, benefits could be assigned to a group or corporate entity only where that entity either employed the physicians who actually performed the services or satisfied one of two other exceptions that are not material here. As the earlier correspondence quoted above confirms, Pennsylvania Blue Shield and the Medicare Bureau found that the absence of an employer-employee relationship between NEMA and the emergency-room physicians invalidated the several reassignment accounts that involved NEMA.
On January 2, 1979, plaintiffs' counsel wrote to defendant Katz, the Director of Technical Policy for the Medicare Bureau. Exhibit F to Complaint (Document No. 1). In that letter, counsel emphasized that the restrictions of section 1842(b)(5) applied only where payments were assigned to someone other than the patient who received the service or "the physician or other person who provided the service." Counsel argued that NEMA was a "person" who "provided" emergency-room services within the meaning of that provision, so that benefits could be assigned to NEMA without regard to whether an employer-employee relationship existed between NEMA and the physicians who actually performed the emergency-room services. Finally, counsel asked that "the Department" reconsider its determination with respect to NEMA, and added: "In the event the Department's decision is not changed, NEMA wishes to exercise its right under the Social Security Act to a hearing by the Secretary of HEW and specifically requests that such a hearing be scheduled in this matter as soon as possible."
On February 2, 1979, defendant Katz replied to counsel's letter as follows:
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Colonial Penn Ins. Co. v. Heckler
...F.2d 134, 139-141 (4th Cir.1983); United States v. Aquavella, 615 F.2d 12, 18-21 (2d Cir.1979); Northeast Emergency Medical Associates v. Califano, 470 F.Supp. 1111, 1119-20 (E.D.Pa.1979), aff'd mem., 614 F.2d 771 (3d After considering the conclusions reached by the various courts, we hold ......
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Miller v. Heckler, TY-84-453-CA.
...Still other courts have decided that section 405(h) does preclude mandamus jurisdiction. See, e.g. Northeast Emergency Medical Associates v. Califano, 470 F.Supp. 1111, 1118 (E.D.Pa.1979) ("Section 405(h) does not simply dissolve whenever an aggrieved claimant invokes the mandamus statute."......
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McLaughlin, Piven, Vogel, Inc. v. Gross
...Monumental Health Plan v. Department of Health and Human Services, 510 F.Supp. 244, 249 (D.Md. 1981); Northeast Emergency Medical Assoc. v. Califano, 470 F.Supp. 1111, 1121 (E.D.Pa.1979) H. Friendly, "Some Kind of Hearing", 123 U.Pa.L.Rev. 1267, 1281 (1975); Sullivan v. Carignan, 733 F.2d 8......