Pain Care Providers Services to Medicare are not Unlimited
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In the People Of The State Of California ex rel. San Diego Comprehensive Pain Management Center, Inc. v. Jaysen Eisengrein and Sandra Love, No. 24-cv-01481-BAS-BJC, United States District Court, S.D. California (September 17, 2025) Defendants Jaysen Eisengrein and Sandra Love’s (“Defendants”) moved the USDC to Dismiss Plaintiff San Diego Comprehensive Pain Management Center, Inc.’s (“SDCPMC” or “Plaintiff”) Complaint.
Plaintiff is a medical provider located in San Diego County that treats Medicare beneficiaries with chronic pain, and this is the third action stemming from a suspension of its Medicare payments. Previously the USDC dismissed Plaintiff’s suit for lack of subject matter jurisdiction because it did not show that it had exhausted administrative remedies or show that the exhaustion requirement should be judicially waived.
BACKGROUND
Administrative Remedies
Although providers cannot appeal a temporary payment suspension, a suspension “may culminate in an appealable determination . . . if [reimbursement] claims are subsequently denied.” Before filing suit in court, a Medicare beneficiary must proceed through five levels of administrative review, described in regulations issued by the controlling agency, CMS, as follows:
1 an initial determination by the Medicare administrative contractor;
2 a redetermination by the Medicare administrative contractor;
3 reconsideration by a qualified independent contractor;
4 a hearing before an administrative law judge . . .; and
5 review by the Medicare Appeals Council.
If the beneficiary is dissatisfied with the Appeals Council’s decision, he or she may then seek judicial review.
The Prior Actions
In late 2021, Plaintiff and two related medical practices sued, among others, HHS and Qlarant Integrity Solutions, LLC (“Qlarant”) to remove the suspension and receive payments for their outstanding claims. The Court analyzed whether waiving the exhaustion requirement was appropriate and found waiver was not warranted. The Court consequently dismissed Plaintiffs’ action in SDCPMC I and SDCPMC II for lack of subject matter jurisdiction.
The Present Action
Ultimately, Plaintiff’s Complaint in this present action is nearly identical to its Complaint in SDCPMC II.
MOTION TO DISMISS
Defendants move to dismiss pursuant to Rule 12(b)(1) because this ground is decisive.
Defendants Mount Facial and Factual Challenges to Subject Matter Jurisdiction
As a threshold matter, the Court concluded that Defendants’ motion presents both a facial and a factual attack to subject matter jurisdiction. Defendants mount a factual attack. The Court recognizes that Defendants have raised a factual attack on subject matter jurisdiction.
Plaintiff’s Complaint Recycles Allegations from SDCPMC II
First and foremost the subject matter jurisdiction analysis conducted in SDCPMC II does not change simply because Plaintiff now alleges that Medicare has terminated the suspension of payments in effect at the time.
Plaintiff may not seek judicial review without first obtaining a final agency decision subject to administrative appeal, and failure to exhaust one’s administrative remedies deprives federal courts of subject matter jurisdiction over claims arising under the Medicare Act. Plaintiff cannot circumvent this Court’s prior ruling by characterizing the termination of a payment suspension as a final agency decision.
The Court granted Defendants’ Rule 12(b)(1) motion due to the plaintiff’s failure to establish subject matter jurisdiction. The court emphasized that even if diversity jurisdiction could be established, the Medicare Act’s provisions would still preclude subject matter jurisdiction without a final decision issued by the Secretary. Consequently, the case was dismissed without prejudice.
ZALMA OPINION
Health care providers who improperly bill Medicare find CMS refuses to pay their claims for payment for services to Medicare patients. The law allows – indeed – requires that the provider seek administrative remedies before they can sue. The Defendants – health care providers – attempted three time to circumvent the need to fulfill administrative remedies only to find their attempts failed and the USDC dismissing their attempt three time by attempting recycle previous litigation. It didn’t work.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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ZIFL – Volume 29, Issue 21
THE SOURCE FOR THE INSURANCE FRAUD PROFESSIONAL
Post 5220
Read the full article at https://lnkd.in/gRMJpi4s, see the video at https://lnkd.in/gwGSd6ZA & at https://lnkd.in/gbDiuFJy, and at https://zalma.com/blog plus more than 5200 posts.
See the video at & at https://rumble.com/v711hr0-zalmas-insurance-fraud-letter-november-1-2025.html
See the full 18 page issue of ZIFL at ZIFL-11-01-2025
Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/
Conviction for Health Insurance Fraud Upheld
Physician Conspired with Bonavilla to Effect Health Insurance Fraud
Dennis Davin Bonavilla was involved in an insurance fraud scheme as an executive of Free Choice Healthcare. The scheme targeted indigent patients, often on ...
The Professional Claims Handler
Post 5218
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-8-barry-zalma-esq-cfe-zdwsc, see the full video at https://rumble.com/v70zl4s-the-zalma-philosophy-of-claims-handling-part-8.html and at https://youtu.be/MIYcF71ffRQ, and at https://zalma.com/blog plus more than 5200 posts.
Claims Commandment X – Thou Shall Not Pretend to be a Lawyer
Some experienced and professional claims people know the law in their area of expertise better than most lawyers.
Adjusters should be adjusters and leave lawyering to lawyers. Similarly, lawyers should be lawyers and never try to be adjusters.
Claims Commandment XI – Thou Shall Empathize With the Claimant
Everyone presenting a claim is unhappy, disturbed, shocked, injured and needs help.
Empathy is identification with and understanding of another’s situation, feelings, and motives. It is the ability to understand another person’s circumstances, point of view, thoughts, and feelings....
HOW TO CREATE AN EXCELLENCE IN CLAIMS HANDLING PROGRAM
See the full video at https://rumble.com/v70wb2i-the-zalma-philosophy-of-claims-handling-part-6.html and at https://youtu.be/tL5nDKPEs40 and at https://zalma.com/blog plus more than 5200 posts.
Post 5217
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry.
An Excellence in Claims Handling program begins with a statement in the insurer’s claims manual or statement of professionalism that it is dedicated to providing excellence in claims handling to every insured who presents a claim.
The excellence in claims handling program should include, at a minimum:
A series of lectures supported by text materials explaining:
A definition of insurance.
How to read and understand an insurance policy.
How to interview an insured, witness, or claimant.
How to assist an insured in the insured’s obligation to ...
The Professional Claims Handler
Post 5219
Posted on October 31, 2025 by Barry Zalma
An Insurance claims professionals should be a person who:
Can read and understand the insurance policies issued by the insurer.
Understands the promises made by the policy.
Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
Are competent investigators.
Have empathy and recognize the difference between empathy and sympathy.
Understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
Understand how to repair damage to real and personal property and the value of the repairs or the property.
Understand how to negotiate a fair and reasonable settlement with the insured that is fair and reasonable to both the insured and the insurer.
How to Create Claims Professionals
To avoid fraudulent claims, claims of breach of contract, bad faith, punitive damages, unresolved losses, and to make a profit, insurers ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
