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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Insurance Expert May Not Testify to Speculative and Contains Unsupported Conclusions.
Posted on September 18, 2026 by Barry Zalma
See the full video at and at https://rumble.com/v7fmifw-expert-may-only-testify-to-what-experience-supports.html
In Michele A. Over, and The Estate Of Paul R. Over v. State Farm Mutual Automobile Insurance Company, and State Farm Fire And Casualty Company, Civil Action No. 23-cv-02243-PAB-STV, United States District Court, D. Colorado (September 14, 2026) Michele and Paul Over sued State Farm Fire and State Farm Auto over hail-damage and stolen-vehicle claims.
The operative dispute concerned State Farm Auto’s motion to exclude or limit opinions from plaintiffs’ insurance-industry expert, Aaron Castillo. Castillo.
Law
The proponent of expert testimony must establish by a preponderance of the evidence that an expert is qualified and that the opinions are helpful, sufficiently grounded, and reliably derived and applied. Experience-based opinions must explain how the...
150 Months in Prison for Tax Fraud
Post 4846
Posted on September 17, 2026 by Barry Zalma
See the full video at https://lnkd.in/g8rh3JBX and https://lnkd.in/gmkdy-9C, In United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
In United States Of America v. Thomas Addaquay, United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
Thomas Addaquay controlled United Consolidated Accounting and Business Services (UC), nominally a check-cashing business.
The government proved a three-stage tax-refund scheme that converted the resulting refund checks into usable funds through ...
Major Fraud Perpetrator Asserts Fifth Amendment Privilege to Avoid Prosecution
Post 5489
Posted on September 14, 2026 by Barry Zalma
Fraudster Refuses to Answer Questions About His Alleged Fraud
See the full video at https://lnkd.in/gvicAMDr and at https://lnkd.in/gvicAMDr
In Great American Insurance Co. v. Gemstone Property Management, LLC, et al., No. 23-cv-9100 (LJL), United States District Court, S.D. New York (September 8, 2026) Great American Insurance Company alleged that it was defrauded through a scheme in which Subin Associates, LLP recruited individuals to stage construction-site injuries, arranged unnecessary medical treatment and litigation funding, and pursued fraudulent personal-injury claims.
Luis Manuel Garcia Salcedo, resulted in a $6 million settlement. Non-party Jose Hernandez allegedly worked as an assistant manager at Subin, operated Hernandez Associates, and owned litigation-funding companies that shared office space with Subin and provided services to its clients.
After Great American ...
Payment of Fines & Completion of Probation Reinstates Right to Vote
Post 4576
Posted on November 5, 2026 by Barry Zalma
To Restore Voting Rights The Felon Must Pay Fines of $546.00
In Florida Supreme Court Mediator Ethics Advisory Committee, ETH F-26-377, No. F-26-377 (October 29, 2026) citizen unnamed and to Ron Desantis Governor, Cord Byrd the Secretary of State Florida Division of Elections provided an advisory opinion to a convicted felon about his right to vote:
To: [redacted] We received your request for an advisory opinion. You indicate that you have one or more felony convictions and request whether you are eligible to vote, including whether you have any outstanding legal financial obligations under section 98.0751, Florida Statutes, and, if so, a statement of the amount that must be paid to make you eligible to vote, and an explanation of how the amount was calculated.
The Division hereby responds to your request pursuant to its legal authority under section 106.23(2), Florida Statutes, and Florida ...
Administrative Review Permits the Agency to Apply its Expertise
Post 4574
In Erwin Jordan Castro Valdez v. Warden, Otay Mesa Detention Center, No. 26-cv-06147-BAS-JLB, United States District Court, S.D. California (October 30, 2026) Castro Valdez, a Cuban national paroled into the United States, was arrested on June 23, 2026, for alleged insurance fraud, grand theft, and making a false report to law enforcement. In his first habeas action, the district court ordered a bond hearing within fourteen days to determine whether the changed circumstances justified revoking his parole.
An Immigration Judge subsequently denied bond because of his pending state criminal case. Castro Valdez filed a second petition under 28 U.S.C. § 2241, challenging that determination and requesting immediate release without first appealing to the Board of Immigration Appeals (BIA).
LAW
According to the supplied text, § 2241 does not expressly require administrative exhaustion, but courts impose exhaustion as a prudential requirement. ...
Insured’s Ordered to Pay Insurer for Fraud by the Insureds
Post 4573
Posted on November 3, 2026 by Barry Zalma
In The Prudential Insurance Company Of America v. Carol Gardina and George Gardina, No. 6:23-cv-1125-JSS-DCI, United States District Court, M.D. Florida, Orlando Division (October 22, 2026).
THE JURY TRIAL AND VERDICT
Plaintiff sued Defendants for numerous causes of action stemming from its allegations that Defendants fraudulently collected benefits under their long-term care insurance policies. Plaintiff's case proceeded to a nine-day jury trial, after which the jury found Defendants liable for fraudulent misrepresentation, fraudulent concealment, and civil conspiracy.
The jury also found Defendant Carol Gardina liable to Plaintiff for $1,930,129 in compensatory damages and Defendant George Gardina liable to Plaintiff for $12,496 in compensatory damages and $20 in punitive damages. Thereafter, the court entered judgment in Plaintiff's favor and awarded Plaintiff $1,930,129 in compensatory damages from...
