## Facts

- Dr. M.M. Cassim, a surgeon in Oregon, participated in Medicare and derived about 40% of his income from Medicare patients.
- A federally contracted peer review organization, the Oregon Medical Professional Review Organization (OMPRO), conducted a quality-of-care review of Cassim’s Medicare surgical services and expanded the review to all surgeries in a prior six-month period.
- OMPRO reviewed 80 patient records and identified 13 cases it labeled “gross and flagrant” failures to meet professionally recognized standards.
- In conducting the review, OMPRO did not interview Cassim, contact patients or other care providers, consult the hospital quality assurance committee, or obtain complete related records.
- OMPRO notified Cassim of its findings and analysis and recommended that HHS suspend him from Medicare and publish notice of the suspension in a local newspaper.
- The governing scheme provided administrative review primarily on written submissions and the record, with post-suspension review mechanisms, rather than a pre-suspension, trial-type evidentiary hearing with live testimony and cross-examination.
- Cassim sought a preliminary injunction to block suspension and publication unless he first received a full evidentiary hearing; the district court denied relief.

## Issues

1. Whether Cassim showed entitlement to a preliminary injunction barring Medicare suspension and publication absent a pre-deprivation, trial-type evidentiary hearing under the Fifth Amendment.
2. Whether the district court abused its discretion in concluding Cassim failed to show likely success on the merits and that the balance of hardships and public interest supported denial of preliminary relief.

## Decision

- The Ninth Circuit affirmed the denial of the preliminary injunction.
- The court held Cassim did not make the required showing of likely success on his due process claim.
- The court held the balance of hardships did not tip sharply in Cassim’s favor and the public interest weighed against enjoining the Medicare quality-enforcement process.
- The court concluded existing notice, written-response opportunities, and post-deprivation review were sufficient safeguards at the preliminary injunction stage.

## Legal Principles

- A preliminary injunction may be denied absent (i) a strong likelihood of success and possible irreparable injury, or (ii) serious questions plus a sharply favorable balance of hardships, with consideration of the public interest.
- Due process requirements for timing and form of administrative hearings are assessed by weighing the private interest, risk of erroneous deprivation, value of additional safeguards, and the government’s interests in prompt action and administrative efficiency.
- Economic loss and reputational harm from an administrative sanction do not, by themselves, establish a constitutional right to a pre-deprivation, trial-type evidentiary hearing where meaningful administrative procedures and post-deprivation review are available.
- Courts are cautious about granting preliminary relief that would impede enforcement of federal program safeguards intended to protect beneficiaries and public funds.

## Conclusion

The Ninth Circuit upheld denial of preliminary injunctive relief because Cassim did not demonstrate a sufficient likelihood of success that due process required a full pre-suspension evidentiary hearing, and because patient-protection and program-integrity interests supported allowing HHS to proceed under existing administrative procedures.


Cassim v. Bowen, 824 F.2d 791 (9th Cir. 1987)