JEAN C. HAMILTON, District Judge.
This matter is before the Court on the Motion of Defendant Sylvia Burwell, Secretary of the United States Department of Health and Human Services ("HHS") to Dismiss Plaintiff's First Amended Complaint, filed October 28, 2015. (ECF No. 30). The motion is fully briefed and ready for disposition.
Plaintiff Triple A Home Care Agency, Inc. is a provider of home healthcare services to Medicare beneficiaries. (Plaintiff's First Amended Complaint ("FAC"), ¶ 1). Defendant Burwell, the Secretary of HHS, administers the Medicare program through the Centers for Medicare and Medicaid Services ("CMS"). Palomar Medical Center v. Sebelius, 693 F.3d 1151, 1153 (9
There are four levels of appeal from an adverse HHS/CMS decision, and Plaintiff alleges that it has exhausted the first two levels. (See 42 U.S.C. § 1395ff; FAC, ¶ 9).
On June 29, 2015, Defendant Burwell moved to dismiss Plaintiff's original Complaint. (ECF No. 8). On September 28, 2015, former United States Magistrate Judge Thomas C. Mummert, III,
In its First Amended Complaint, Plaintiff asserts this Court has jurisdiction in this case pursuant to 28 U.S.C. § 1331. (FAC, ¶ 3). Defendant counters this Court does not have subject matter jurisdiction over Plaintiff's claims, as they arise under the Medicare program.
To determine this question, the Court turns to 42 U.S.C.§ 405(h)
The Eighth Circuit has explained that although section 405(h) appears to be a conclusive bar of jurisdiction over Medicare claims, "section 405(g), after requiring exhaustion of administrative avenues of relief, limits the preclusive effect of section 405(h)." Clarinda Home Health, 100 F.3d at 529. Section 405(g) in turn states in relevant part as follows:
Taken together, 42 U.S.C.§§ 405(g) and (h) thus provide that judicial review of claims arising under the Medicare Act is precluded under § 1331, and may only be had under §405(g) after there has been a final decision by the Secretary. Great Rivers Home Care, Inc. v. Thompson, 170 F.Supp.2d 900, 903-004 (E.D. Mo. 2001).
Although the statutory framework does not provide relief to Plaintiff, as it admittedly has not exhausted its administrative remedies, the Eighth Circuit previously has recognized a constitutional exception to the statutory exhaustion requirement. Clarinda Home Health, 100 F.3d at 530. "This exception applies where the litigant: (1) raises a colorable constitutional claim collateral to his substantive claim of entitlement; (2) shows that irreparable harm would result from exhaustion; and (3) shows that the purposes of exhaustion would not be served by requiring further administrative procedures." Id. at 530-31 (internal quotations and citations omitted). See also Great Rivers Home Care, 170 F.Supp.2d at 905 (citations omitted) ("Specifically, courts must weigh the following factors in determining if waiver of the requirement of administrative exhaustion is appropriate: 1) whether the claim is collateral to a demand for benefits; 2) whether exhaustion would be futile; and 3) whether the plaintiff would suffer irreparable harm if required to exhaust its administrative remedies before obtaining relief.").
Upon consideration, the Court finds Plaintiff here fails to establish entitlement to the statutory exhaustion exception, for several reasons. First, the Court agrees with Defendant that Plaintiff's claims are not collateral to its substantive claim of entitlement; rather, Plaintiff seeks review of the Medicare contractor's determination that it overbilled the program, relief "`inextricably intertwined' with [Plaintiff's] claims for benefits." Heckler v. Ringer, 466 U.S. 602, 614, 104 S.Ct. 2013, 80 L.Ed.2d 622 (1984). See also Great Rivers Home Care, 170 F.Supp.2d at 905 ("Further, the Court disagrees with plaintiff's characterization of its request to enjoin the recoupment process pending appeal of the overpayment decisions as being merely collateral to a claim for benefits.").
Second, the Court finds Plaintiff fails to show that irreparable harm would result from exhaustion, as the Medicare statute itself provides an escalation remedy designed to provide either an expeditious resolution of claims or access to judicial review in a timely manner. For example, 42 U.S.C. § 1395ff(d)(1)(A) requires the ALJ to render a decision within ninety days of the date the request for hearing is timely filed. If the ALJ fails to render such decision, "the party requesting the hearing may request a review by the Departmental Appeals Board of the Department of Health and Human Services, notwithstanding any requirements for a hearing for purposes of the party's right to such a review." 42 U.S.C. § 1395ff(d)(3)(A). Furthermore, the Departmental Appeals Board is required to make a decision or remand the case to the ALJ for reconsideration within ninety days of the date a request for review is timely filed, see 42 U.S.C. § 1395ff(d)(2)(A), and if it fails to do so, "the party requesting the hearing may seek judicial review, notwithstanding any requirements for a hearing for purposes of the party's right to such judicial review." 42 U.S.C. § 1395ff(d)(3)(B).
Finally, Plaintiff fails to show "that the purposes of exhaustion would not be served by requiring further administrative procedures," Clarinda Home Health, 100 F.3d at 531, as it is entirely possible that the Departmental Appeals Board would reverse prior decisions and rule in Plaintiff's favor. Under these circumstances, Plaintiff is required to exhaust its administrative remedies, and Defendant's Motion to Dismiss must be granted. See Schoolcraft v. Sullivan, 971 F.2d 81, 85 (8th Cir. 1992) (waiver of administrative remedies is the exception to the general rule, warranted only under exceptional circumstances), cert. denied, 114 S.Ct. 902 (1994).