Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

C. JACK FRIEDMAN, PH.D. & ASSOCS., P.C. v. PENNSYL

September 22, 1993

C. JACK FRIEDMAN, Ph.D. & ASSOCIATES, P.C.
v.
PENNSYLVANIA BLUE SHIELD



The opinion of the court was delivered by: LOUIS C. BECHTLE

 BECHTLE, J.

 SEPTEMBER 22, 1993

 Presently before the court is defendant United States' ("the government") motion to dismiss or, in the alternative, for summary judgment, plaintiff C. Jack Friedman & Associates' ("Friedman & Associates" or "plaintiff") response, and the government's reply filed thereto. For the reasons set forth below, the court will dismiss counts I and II of the Complaint pursuant to Fed. R. Civ. P. 12(b)(1) for lack of subject matter jurisdiction.

 I. Background

 A. Procedural History

 This action originated on December 17, 1987, when plaintiff filed a praecipe for a writ of summons in the Court of Common Pleas of Philadelphia County, Pennsylvania. A writ of summons was issued the same day and apparently served on Pennsylvania Blue Shield ("Blue Shield"), the named defendant. (Document No. 14, Pltff.'s Ans. to Def.'s M. To Dismiss., ex. B.) Plaintiff, however, did not file a complaint in the Court of Common Pleas until December 14, 1992. The United States, as the real party in interest, *fn1" removed the complaint to federal court on January 19, 1993. The United States has filed a motion to dismiss pursuant to Fed. R. Civ. P. 12(b)(1) and 12(b)(6), or, in the alternative, for summary judgment.

 B. The Medicare Act

 For background purposes, this case involves issues dealing with the administration of the Medicare statute. Title XVIII of the Social Security Act, "Health Insurance for Aged and Disabled," 42 U.S.C. §§ 1395-1395ccc (known as the "Medicare Act"), is administered by the Health Care Financing Administration ("HCFA"), a component of the United States Department of Health and Human Services.

 The Medicare Act consists of two distinct programs. Part A, titled "Hospital Insurance Benefits for Aged and Disabled," provides insurance coverage for hospital services and related post-hospital home health services, and hospice care. 42 U.S.C. §§ 1395c-1395i-4. Part B, titled "Supplementary Medical Insurance Benefits for Aged and Disabled," is a federally subsidized, voluntary health insurance system, whereby individual Medicare enrollees may assign their right to reimbursement for medical care to their medical service providers. 42 U.S.C. §§ 1395j-1395w-4. Part B supplements Part A's coverage by providing insurance for a portion of some medical expenses, such as certain physician services and X-rays, that are excluded from the Part A program.

 Eligible individuals pay monthly premiums if they choose to enroll in Part B. These premiums, together with contributions from the Federal Government, are deposited in the Federal Supplementary Medical Insurance Trust Fund ("Trust Fund") which finances the Part B program. *fn2"

 Under contractual agreements with the HCFA, private health insurance carriers, such as Blue Shield, and defined as "carriers" (for Part B), are charged with the responsibility of administering the benefit provisions of the supplementary insurance programs of Part B. Part of the carrier's responsibility includes determining the amount of payments due to Medicare providers, and auditing the records of providers as may be necessary to insure that payments are made for services actually rendered. See 42 U.S.C. §§ 1395h, 1395u; 42 C.F.R. § 421.200.

 The Secretary of Health and Human Services administers the Medicare program, including the task of paying Part B claims from the Trust Fund to private insurance carriers experienced in such matters. After Part B enrollees receive medical care, they (or, after their assignment, their medical providers) bill the private insurance carrier. If the carrier determines that a claim meets all of Part B coverage criteria, such as medical necessity and reasonable cost, the carrier pays the claim out of the Trust Fund. See 42 U.S.C. § 1395u. If the carrier decides that reimbursement in full is not warranted, the statute and the regulations designate an appeal procedure available to dissatisfied claimants.

 A dissatisfied claimant may request a "review determination" which is a de novo written review hearing before a carrier employee different from the one who initially decided the claim. Claimants who remain dissatisfied and whose appeal involves more than $ 100.00 may then petition for an oral hearing before a hearing officer designated by the carrier. See 42 U.S.C. § 1395u(b)(3)(C). Unless the carrier or the hearing officer decides to reopen the proceeding, the hearing officer's decision is "final and binding upon all parties to the hearing . . . ." 42 C.F.R. § 405.835 (1980). Neither the statute nor the Secretary's regulations make ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.