91 F.Supp.3d 400
ART OF HEALING MEDICINE, P.C., Plaintiff
v.
Sylvia Mathews BURWELL, in her official capacity as Secretary of Health and Human Services, Defendant.
No. 14–CV–4001.
United States District Court, E.D. New York.
Signed March 10, 2015.
Filed March 11, 2015.
91 F.Supp.3d 401
Martin Bienstock, Weisbrod Matteis & Copley PLLC, Washington, DC, for Plaintiff.
91 F.Supp.3d 402
Layaliza K. Soloveichik, Margaret M. Kolbe, United States Attorney's Office, Eastern District of New York, Civil Division, Brooklyn, NY, for Defendant.
MEMORANDUM & ORDER
JACK B. WEINSTEIN, Senior District Judge.
| Table of Contents |
| I. | Introduction | 402 |
| II. | Facts | 403 |
| A. | Medicare Payment Process Regarding Supplemental Health Insurance Benefits | 403 |
| 1. | Requirements for Documenting Psychiatric Services | 403 |
| 2. | MACs and Initial Medicare Payment Determinations | 404 |
| 3. | RACs and the Medicare Integrity Program | 405 |
| B. | Challenging an Audit Finding: Five–Stage Appeals Process | 405 |
| 1. | MAC Redetermination Request | 406 |
| 2. | QIC Reconsideration | 406 |
| a. | Procedural Dismissal | 406 |
| b. | Substantive Redetermination | 406 |
| 3. | Administrative Law Judge Hearing | 407 |
| 4. | Appeals Council Review | 407 |
| 5. | Judicial Review | 407 |
| C. | Denial of Plaintiff's Medicare Reimbursement Claims | 408 |
| 1. | Dr. Pinkusovich's Psychiatric Practice | 408 |
| 2. | SafeGuard Services Audits Dr. Pinkusovich's Billing Records | 408 |
| 3. | Art of Healing Appeals the Audit Findings | 409 |
| a. | MAC Dismisses Art of Healing's Appeal for Failure to Identify Beneficiaries Whose Claims Had Been Denied | 409 |
| b. | Plaintiff Resubmits Redetermination Request to MAC | 410 |
| c. | Plaintiff Initiates Concurrent Action with QIC to Appeal MAC Dismissal | 410 |
| d. | MAC Issues Merits Decision Adverse to Plaintiff | 410 |
| e. | QIC Vacates Dismissal But Still Issues Unfavorable Merits Determination | 410 |
| f. | Plaintiff Unsuccessfully Appeals MAC's Merits Redetermination to QIC | 411 |
| g. | Plaintiff Exercises Its Right to Present Its Case to Appeals Council, Which Upholds Overpayment Determination | 412 |
| D. | Timeline of Events | 413 |
| III. | Law | 415 |
| A. | Administrative and Judicial Review Under the Medicare Act | 415 |
| 1. | Relevant Statutory Authority | 415 |
| 2. | Section 405(g) Sixth Sentence Remands | 416 |
| B. | The Accardi Doctrine | 417 |
| C. | The Administrative Procedure Act | 418 |
| IV. | Application of Facts to Law | 419 |
| V. | Conclusion | 419 |
I. Introduction
Plaintiff Art of Healing, P.C. (“Art of Healing”) brings this action pursuant to the...
