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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Detail Charging Defendant for Fraud is Sufficient
Post 5242
Read the full article at https://lnkd.in/g_HVw36q, see the video at https://lnkd.in/gpBd-XTg and at https://lnkd.in/gzCnBjgQ and at https://zalma.com/blog plus more than 5200 posts.
Charges that Advises the Defendant of the Crime Cannot be Set Aside
In United States Of America v. Lourdes Navarro, AKA Lulu, No. 25-661, United States Court of Appeals, Ninth Circuit (December 4, 2025) Lourdes Navarro appealed the district court’s denial of her motion to dismiss the indictment and enter final judgment was in error.
FACTUAL BACKGROUND
The indictment alleged that insurers reimburse only for medically necessary services. Navarro performed unnecessary respiratory pathogen panel (RPP) tests on nasal swabs collected from asymptomatic individuals for COVID-19 screening.
Navarro billed over $455 million to insurers for those additional RPP tests that she knew to be medically unnecessary. These allegations constituted a plain, concise, and definite written ...
Louisiana Statute Prevents Enforcement of Contract Term Requiring Arbitration of Disputes
Post 5241
Read the full article at https://www.linkedin.com/pulse/international-convention-requiring-enforcement-award-barry-sttdc, see the video at and at and at https://zalma.com/blog plus more than 5200 posts.
In Town of Vinton v. Indian Harbor Insurance Company, Nos. 24-30035, 24-30748, 24-30749, 24-30750, 24-30751, 24-30756, 24-30757, United States Court of Appeals, Fifth Circuit (December 8, 2025) municipal entities including the Town of Vinton, et al sued domestic insurers after dismissing foreign insurers with prejudice. The insurers sought arbitration under the Convention on the Recognition and Enforcement of Foreign Arbitral Awards (the “Convention”) but the court held Louisiana law — prohibiting arbitration clauses in such policies—controls, as the Convention does not apply absent foreign parties who ...
Refusal to Provide Workers’ Compensation is Expensive
Post 5240
Read the full article at https://lnkd.in/guC9dnqA, see the video at https://lnkd.in/gVxz-qmk and at https://lnkd.in/gUTAnCZw, and at https://zalma.com/blog plus more than 5200 posts.
In Illinois Department of Insurance, Insurance Compliance Department v.USA Water And Fire Restoration, Inc., And Nicholas Pacella, Individually And As Officer, Nos. 23WC021808, 18INC00228, No. 25IWCC0467, the Illinois Department of Insurance (Petitioner) initiated an investigation after the Injured Workers’ Benefit Fund (IWBF) was added to a pending workers’ compensation claim. The claim alleged a work-related injury during employment with the Respondents who failed to maintain workers’ compensation Insurance.
Company Overview:
USA Water & Fire Restoration, Inc. was incorporated on January 17, 2014, and dissolved on June 14, 2019, for failure to file annual reports and pay franchise taxes. It then operated under assumed names including USA Board Up & Glass Co. and USA Plumbing and Sewer. The business ...
Zalma’s Insurance Fraud Letter
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ZIFL Volume 29, Issue 24
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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/
Zalma’s Insurance Fraud Letter
Merry Christmas & Happy Hannukah
Read the following Articles from the December 15, 2025 issue:
Read the full 19 page issue of ZIFL at ...
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 ...
