Following the Debtor’s Chapter 7 bankruptcy filing, he initiated an adversary proceeding demanding the Social Security Administration repay the amount it collected from the Debtor on account of an overpayment he received for almost a year and a half. In overturning the district court’s decision, the Fifth Circuit found that the plain language of 42 U.S.C. § 405(h) did not bar bankruptcy courts from relying on their general bankruptcy jurisdictional grant under 28 U.S.C. § 1334(b) to hear the Debtor’s case.What Happened?Kenneth Benjamin (the Debtor or Benjamin) was the designated beneficiary of his sister’s disability benefits.

elieve that the Administrator has complete discretion regarding the amount of time she may take to acknowledge her discretionary decision to review the CMS hearing officer’s decision, which discretionary decision by the Administrator then triggers a right to submit additional briefing before the Administrator issues a ruling on the merits. See §422.311(c)(8)(iii), (iv)(A).In short, the administrative remedies CMS has established in the RADV context appear to be both incomplete and prone to significant delay.Section 405(g)-Based ExhaustionMany, if not most, Medicare-related cases reach court only after the plaintiffs have presented their legal arguments to CMS and have exhausted their administrative remedies. The primary reason for that phenomenon is not patience on the part of the plaintiffs. Most such plaintiffs would prefer to be in court as quickly as possible. Instead, such delays often are required as a matter of law based on the interaction between three different subsections of 42 U.S.C. § 405: namely, subsections (b), (g), and (h).Those subsections state, in relevant part:(b) Administrative determination of entitlement to benefits; findings of fact; hearings....(1) The Commissioner of Social Security is directed to make findings of fact, and decisions as to the rights of any individual applying for a payment under this subchapter. Any such decision by the Commissioner of Social Security which involves a determination of disability and which is in whole or in part unfavorable to such individual shall contain a statement of the case, in understandable language, setting forth a discussion of the evidence, and stating the Commissioner’s determination and the reason or reasons upon which it is based. Upon request by any such individual ... the Commissioner shall give such applicant ... reasonable notice and opportunity for a hearing with respect to such decision, and, if a hearing is held, shall, on the basis of evidence adduced at the hearing, affirm, modify, or reverse the Co

of certain MA coverage determinations satisfying an amount-in-controversy requirement). And the Medicare Act even goes so far as to expressly prohibit judicial review of particular MA issues. See, e.g., 42 U.S.C. §1395w-23(l)(8) (prohibiting judicial review of certain determinations related to meaningful use of electronic health records).So if the Medicare Act does not expressly provide for judicial review in the RADV context, what about using the so-called “federal-question statute,” 28 U.S.C. §1331? That statute provides that federal district courts “shall have original jurisdiction of all civil actions arising under the Constitution, laws, or treaties of the United States.” And the Administrative Procedure Act provides that “[a] person suffering legal wrong because of agency action ... is entitled to judicial review thereof.” 5 U.S.C. §702.Reliance on the federal-question statute is potentially complicated in this instance by a statutory provision outside the Medicare Act: namely, 42 U.S.C. §405(h). Section405(h)’s third sentence states that “[n]o action against the United States, the Commissioner of Social Security, or any officer or employee thereof shall be brought under section 1331 ... of title 28 [i.e., the federal-question statute] to recover on any claim arising under this subchapter [i.e., subchapter II, 42 U.S.C. §§401–434].”But wait? What’s this about the “Commissioner of Social Security” and claims arising under subchapter II? I thought we were talking about Medicare.Well, the Medicare Act states that the “provisions of ... subsections (a), (d), (e), (h), (i), (j), (k), and (l) of section 405 of this title, shall also apply with respect to this subchapter [i.e., the Medicare Act] to the same extent as they are applicable with respect to subchapter II, except that, in applying such provisions with respect to [the Medicare Act], any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secr

Global Rescue Jets, LLC, 30 F.4th at 911-12. Under Part A and B, if a provider remains dissatisfied, the provider may seek review from the Secretary of Health and Human Services pursuant to 42 U.S.C. § 405(b). See id. at 912 (citing Heckler v. Ringer, 466 U.S. 602 (1984)).

The legal challenge was brought by the American Hospital Association, the Association of American Medical Colleges, America’s Essential Hospitals as well as three public and not-for-profit hospitals. The District Court found that it lacked subject matter jurisdiction to hear the plaintiffs’ challenge because plaintiffs had failed to present their claims through the administrative review process as required by 42 U.S.C. § 405(g).Background: The 340B Drug Pricing Program Since 1992, the 340B Program allows eligible hospitals and certain other healthcare providers, otherwise referred to as “covered entities,” to purchase covered outpatient drugs at discounted rates from pharmaceutical manufacturers.

Introduction In an opinion dated June 26, 2015, the U.S. District Court for the Middle District of Florida ruled that the bankruptcy court administering the Bayou Shores SNF, LLC (“Debtor” or “Bayou Shores”), chapter 11 proceeding lacked subject matter jurisdiction to enjoin the termination of the Debtor’s Medicare and Medicaid provider agreements or to order the assumption of the provider agreements.[1] Specifically, the district court held that the Medicare jurisdictional bar under 42 U.S.C. § 405(h) limits the authority of the bankruptcy court to interfere with efforts by the Centers for Medicare & Medicaid Services (“CMS”) to terminate the provider agreements except to provide judicial review under section 405(g) after administrative remedies have been exhausted. Bayou Shores has expressed its intention to appeal the district court’s decision, but if the decision is affirmed, it could have broad implications for health care bankruptcies by limiting the ability of health care businesses in bankruptcy to reorganize or sell their assets on a going-concern basis.Background Bayou Shores operates a skilled nursing facility in Florida serving patients with neurological disorders and psychiatric conditions.

nal agency decision in a Medicare claims appeal ordered the Government to complete the administrative record. Specifically, the judge ordered the Government to produce the missing target universe of claims, including adjudicated claims issued zero payment (zero-paid claims) that were excluded by a Medicare auditor in calculating an extrapolated overpayment levied against a health care provider. The provider in this case had fought through the labyrinth of the Medicare appeals process for over a decade and finally received a measure of vindication for arguments raised throughout.What is Required to “Complete” the Administrative RecordThis ruling is significant for a number of reasons: namely, it represents the first time a federal district court has held that:A provider was entitled to zero-paid claims data, the routine exclusion of which often drastically increases an auditor’s extrapolated overpayment assessment;The administrative record for a Medicare Act claims appeal brought under 42 U.S.C. § 405(g) must include anything that any agency decision-maker—not just the Administrative Law Judge—relied upon, either directly or indirectly;The administrative record for a Medicare Act claims appeal must include all information supporting any recalculation of an extrapolated overpayment demand, even if not reviewed by the final agency decision-maker, because such recalculations are “effectuations” and properly reviewable under 42 U.S.C. § 405(g);Contractors for the Centers for Medicare and Medicaid Services (CMS)1 acted on behalf of the agency and relied on information missing from the administrative record (i.e., zero-paid claims data) in performing their statistical sampling and extrapolation; andBecause CMS (through its contractors) relied on this missing information, the administrative record before the court must include this missing information in order to create a complete record for the court’s ultimate review.The court also recognized and set forth a helpful delineation between “co

A domino has fallen, but the question remains whether there are more to come. On February 12, 2024, the U.S. District Court for the Western District of Texas dismissed a challenge to the Department of Health and Human Services (HHS) over the controversial Medicare Drug Price “Negotiation” (yes, in quotes) Program passed under the Inflation Reduction Act (IRA). This dismissal is a win for the government, with eight other cases pending in various district courts across the nation. Although the government may find this dismissal to be a cause for celebration, it will be interesting to see if it has a significant impact on the other pending lawsuits because the dismissal did not reach the merits of the case.The case before the Western Texas District Court was dismissed due to a procedural issue relating to the exhaustion of administrative remedies and the unique circumstances of two out-of-state plaintiffs, which raised a venue issue. As to the first issue, evaluating 42 U.S.C. § 405, the Court found that the claims advanced by Plaintiff National Infusion Center Association (NICA) arose under the Medicare Act and thus required exhaustion of administrative remedies before HHS prior to a federal litigation being filed. Although NICA contended that the case at hand did not fall under Section 405 because it is a “constitutional challenge” to the IRA, Judge Ezra pointed to U.S. Supreme Court and Fifth Circuit precedent to find otherwise. The case also did not qualify for the narrow, recognized exception to the exhaustion doctrine, and therefore the Court found that there was no subject matter jurisdiction over the case.The Court then granted defendants’ motion to dismiss the case for improper venue as to the other plaintiffs in the case – the Pharmaceutical Research and Manufacturers of America (PhRMA) and the Global Colon Cancer Association. The only reason why venue was proper in the Western District of Texas was because NICA resided there. With NICA dismissed as a p

Justice Alito dissented, joined by Chief Justice Roberts, Justice Gorsuch, and Justice Kavanaugh.The Court's decision is available here.Smith v. Berryhill, No. 17-1606: The Social Security Act permits judicial review only of “any final decision of the [agency] made after a hearing.” 42 U.S.C. §405(g). This normally requires claimants to first seek an initial decision as to their eligibility; second, seek reconsideration; third, request a hearing by an administrative law judge (“ALJ”); and fourth, seek review by the Appeals Council, before being able to pursue judicial review in federal district court.

The ALJ denied Biestek’s application, basing the conclusion on the expert’s testimony. While an agency’s factual findings in such a proceeding are “conclusive” in judicial review so long as they are supported by “substantial evidence,” 42 U.S.C. §405(g), Biestek argued on appeal that the expert’s testimony could not be deemed “substantial evidence” given that the expert refused to provide the underlying data relied upon when specifically requested. The District Court rejected that argument, and the Sixth Circuit affirmed.