Heckler v. Ringer - 466 U.S. 602, 104 S. Ct. 2013 (1984)

Rule:

A "final decision" is rendered on a Medicare claim only after the individual claimant has pressed his claim through all designated levels of administrative review. First, the Medicare Act authorizes the Secretary to enter into contracts with fiscal intermediaries providing that the latter will determine whether a particular medical service is covered by Part A, and if so, the amount of the reimbursable expense for that service. 42 U.S.C. S. § 1395h; 42 C.F.R. § 405.702 (1983). If the intermediary determines that a particular service is not covered under Part A, the claimant can seek reconsideration by the Health Care Financing Administration in the Department of Health and Human Services. 42 C.F.R. §§ 405.710-405.716 (1983).

Facts:

Individual Medicare claimants brought suit in the United States District Court for the Central District of California raising various challenges to the policy of the Secretary of Health and Human Services as to the payment of Medicare benefits for a surgical procedure known as bilateral carotid body resection (BCBR). The District Court dismissed the action for lack of jurisdiction, finding that in essence the parties were claiming entitlement to benefits for the BCBR procedure and therefore must exhaust their administrative remedies pursuant to 42 USCS 405(g). The Court of Appeals for the Ninth Circuit reversed, concluding that the thrust of the claim was that the Secretary's presumptive rule that the BCBR operation was not reasonable and necessary was an unlawful administrative mechanism for determining awards of benefits, and that to the extent that the parties sought to invalidate the Secretary's procedure for determining entitlement to benefits, those claims were cognizable without the requirement of administrative exhaustion under the federal question statute and the mandamus statute.

Issue:

Could the Medicare claimants bring actions in a Federal District Court under federal question jurisdiction or mandamus jurisdiction without exhausting their administrative remedies?

Answer:

No.

Conclusion:

The Court held that both the claims of persons who had had BCBR surgery prior to the Secretary's ruling, and the claim of an individual who had not yet had BCBR surgery but who wished to have it, were essentially claims arising under the Medicare Act, with the result that the claimants could not bring an action in a Federal District Court under federal question jurisdiction or mandamus jurisdiction but had to proceed under 42 USCS 405(g), which was the exclusive remedy for claims under the Medicare Act and which required exhaustion of administrative remedies prior to bringing a court action. The Court noted that Congress, in 42 U.S.C.S. § 405(g), (h), refused declaratory relief and required that administrative remedies be exhausted before judicial review was allowed.