Pain Care Providers Services to Medicare are not Unlimited
See the full video at https://rumble.com/v6zb2a8-it-doesnt-pay-to-cheat-medicare.html and at https://youtu.be/b1924Ki2GQs, and at https://zalma.com/blog plus more than 5150 posts.
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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See the full video at https://lnkd.in/gkEJm3qy and at https://lnkd.in/gkiZASeT, and at https://zalma.com/blog, plus more than 5150 posts.
"Barry Zalma, Esq., CFE presents blog posts and videos so you can learn how insurance fraud is perpetrated and what is necessary to deter or defeat insurance fraud. This Video Blog of a True Crime Story of Insurance Fraud with the names and places changed to protect the guilty is based upon investigations conducted by me and fictionalized to create a learning environment for claims personnel, SIU investigators, insurers, police, and lawyers better understand insurance fraud and weapons that can be used to deter or defeat a fraudulent insurance claim."
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Post 5185
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See the full video at https://lnkd.in/gePN7rjm and at https://lnkd.in/gzPwr-9q
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See the full video at https://lnkd.in/gePN7rjm and at https://lnkd.in/gzPwr-9q
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See the full video at and at
This is a Fictionalized True Crime Story of Insurance Fraud from an Expert who explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is designed to help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the Perpetrators than any Other Crime.
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© 2025 Barry Zalma, Esq., CFE
When I finished my three year enlistment in the US Army as a Special Agent of US Army Intelligence in 1967, I sought employment where I could use the investigative skills I learned in the Army. After some searching I was hired as a claims trainee by the Fireman’s Fund American Insurance Company. For five years, while attending law school at night while working full time as an insurance adjuster I became familiar with every aspect of the commercial insurance industry.
On January 2, 1972 I was admitted to the California Bar. I practiced law, specializing in insurance claims, insurance coverage and defense of claims against people insured and defense of insurance companies sued for breach of contract and breach of the implied covenant of good faith and fair dealing. After 45 years as an active lawyer, I asked that my license to practice law be declared inactive ...
