43 F. Supp. 3d 1329
S.D. Fla.2014Background
- Plaintiff Einhorn, a Medicare Advantage beneficiary under CarePlus, was injured in a 2009 slip-and-fall; CarePlus made conditional Medicare payments for her medical care.
- Einhorn settled her tort claim; CarePlus asserted a Medicare lien to recover conditional payments and initially demanded $49,983.87, later reducing the lien to $21,078.78, which was satisfied.
- Einhorn sued in Florida state court (removed to federal court) under the Florida Consumer Collection Practices Act (FCCPA), alleging CarePlus sought reimbursement in excess of the statutorily allowed amount (i.e., failed to apply Medicare’s procurement-cost reduction formula) and thus engaged in unlawful collection practices.
- CarePlus moved to dismiss, arguing (1) the court lacked jurisdiction because Einhorn failed to exhaust Medicare administrative remedies, (2) FCCPA claims are preempted by federal law, and (3) Einhorn failed to state an FCCPA claim.
- The district court focused on the jurisdictional issue: whether Einhorn’s challenge to the lien amount is a claim “arising under” the Medicare statutes that requires exhaustion of administrative remedies before judicial review.
- The court concluded Einhorn should have pursued the Medicare administrative appeals process when she first objected to the lien and therefore dismissed her FCCPA action with prejudice for lack of jurisdiction.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the court has jurisdiction when the plaintiff challenges the amount of a Medicare(like) lien without exhausting administrative remedies | Einhorn: claim is a state-law FCCPA action for unlawful collection, not a Medicare benefits claim, so no exhaustion required | CarePlus: challenge to lien amount is inextricably intertwined with Medicare/Medicare Secondary Payer law and requires exhaustion under the Medicare Act | Court: Lack of jurisdiction — plaintiff must exhaust Medicare administrative remedies; dismissal with prejudice |
| Whether a state-law FCCPA suit is preempted by federal Medicare law | Einhorn: FCCPA claim addresses state-law collection practices, not Medicare benefits or eligibility | CarePlus: federal law governs Medicare reimbursement and preempts conflicting state-law claims | Court: Did not decide preemption because jurisdictional dismissal rendered it unnecessary |
| Whether plaintiff stated a claim under FCCPA | Einhorn: alleged misrepresentation and seeking to collect amounts not owed under FCCPA | CarePlus: argued failure to state a claim (substantive defense) | Court: Did not reach merits after dismissing for lack of jurisdiction |
| Whether a litigant can avoid administrative review by recasting a Medicare challenge as a state-law damages claim | Einhorn: framed relief as damages under FCCPA rather than a benefits dispute | CarePlus: recharacterization cannot evade Medicare’s administrative-review requirement | Court: Recharacterization does not avoid exhaustion; collateral attack barred |
Key Cases Cited
- Cochran v. U.S. Health Care Financing Admin., 291 F.3d 775 (11th Cir.) (Medicare beneficiaries must exhaust administrative remedies for claims tied to Medicare reimbursement)
- United States v. Blue Cross & Blue Shield of Alabama, 156 F.3d 1098 (11th Cir.) (§ 405(h) bars judicial bypass of administrative review by reframing benefits claims)
- Heckler v. Ringer, 466 U.S. 602 (U.S. 1984) (broad interpretation of “claim arising under” Medicare statute; exhaustion requirement applies when claims are inextricably intertwined)
- Bodimetric Health Servs., Inc. v. Aetna Life & Cas., 903 F.2d 480 (7th Cir.) (parties cannot evade Medicare Act jurisdiction by styling benefits challenges as collateral damage/state claims)
- Potts v. Rawlings Co., LLC, 897 F. Supp. 2d 185 (S.D.N.Y.) (claims concerning reimbursement under Medicare Secondary Payer law are inextricably intertwined with Medicare benefits and require administrative exhaustion)