Vakula Atthota, M.D., DAB CR5545 (2020)

DECISION

Petitioner Vakula Atthota, M.D., is a New Jersey physician who participates in the Medicare program as a supplier of services.  After her Medicare billing privileges were deactivated, she applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective December 20, 2016.  Petitioner now challenges that effective date. 

Because Petitioner filed her subsequently-approved enrollment application on December 20, 2016, I find that December 20 is the correct effective date for her enrollment.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 3-5 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

Background

In a letter dated February 3, 2017, the Medicare contractor, Novitas Solutions, advised Petitioner that it approved her Medicare enrollment effective December 20, 2016.  CMS Ex. 1 at 14; P. Ex. 7.  Petitioner requested reconsideration.

In a reconsidered determination, dated May 5, 2017, a contractor hearing specialist determined that December 20, 2016 was the correct effective date because that was the

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date Petitioner Atthota filed her subsequently-approved revalidation application.  P. Ex. 10.  Petitioner appealed. 

CMS moves to dismiss or for summary judgment.  I decline to dismiss because the regulations that govern these proceedings authorize review of a reconsidered determination as to the effective date of a supplier’s Medicare approval.  42 C.F.R. § 498.3(b)(15); 498.5; Sokoloff, DAB No. 2972 at 5-6.

Because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre-hearing Order at 3, 5 (¶¶ 4, 10) (June 26, 2017).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied. 

CMS submits its motion and brief (CMS Br.) with two exhibits (CMS Exs. 1-2).  Petitioner submits its brief in opposition (P. Br.) with 13 exhibits (P. Exs. 1-13).  In the absence of any objections, I admit into evidence CMS Exs. 1-2 and P. Exs. 1-13.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

Petitioner filed her subsequently-approved enrollment application on December 20, 2016, and her Medicare reactivation enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Atthota participates in the Medicare program as a “supplier” of services.  Social Security Act § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a prospective supplier must enroll in the program.  42 C.F.R. § 424.505.  “Enrollment” is the process by which CMS and its contractors: 1) identify the prospective supplier; 2) validate the supplier’s eligibility to provide items or services to Medicare beneficiaries; 3) identify and confirm a supplier’s owners and practice location; and 4) grant the supplier Medicare billing privileges. 42 C.F.R. § 424.502.

To enroll, a prospective supplier must complete and submit an enrollment application.  42 C.F.R. §§ 424.510(d)(1), 424.515(a).  An enrollment application is either a CMS-approved paper application or an electronic process approved by the Office of Management and Budget.  42 C.F.R. § 424.502.2  When CMS determines that a prospective supplier meets the applicable enrollment requirements, it grants Medicare

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billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  For a physician, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (emphasis added).

Revalidation and Deactivation.  To maintain her billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of her enrollment information, a process referred to as “revalidation.”  42 C.F.R. § 424.515.  In addition to periodic revalidations, CMS may, at other times and for its own reasons, ask a supplier to recertify the accuracy of her enrollment information.  42 C.F.R. § 424.515(d) and (e).  Within 60 days of receiving CMS’s notice to recertify, the supplier must submit an appropriate enrollment application with complete and accurate information and supporting documentation.  42 C.F.R. § 424.515(a)(2).

If, within 90 days from receipt of CMS’s notice, the supplier does not furnish complete and accurate information and all supporting documentation or does not resubmit and certify the accuracy of her enrollment information, CMS may deactivate her billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3); 424.555(b).  To reactivate her billing privileges, the supplier must complete and submit a new enrollment application.  42 C.F.R. § 424.540(b)(1).  It is settled that, following deactivation, section 424.520(d) governs the effective date of reenrollment.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7; Goffney, DAB No. 2763 at 7.

I have no authority to review a deactivation.  Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9 (2019).

Petitioner’s deactivation and reenrollment.  In a notice letter, dated June 15, 2016,
the contractor directed Petitioner Atthota to revalidate her Medicare enrollment by updating or confirming the information in her record.  The letter directed Petitioner to the PECOS website and explained that a supplier could revalidate through the PECOS system or by mailing to the contractor a completed CMS-855 Medicare enrollment application.  The letter warned that Petitioner had to revalidate by August 31, 2016, or risk her Medicare enrollment being deactivated; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered.  The contractor addressed this notice to Petitioner Atthota at the address Petitioner had filed with the contractor.  CMS Ex. 1 at 1-2.

The contractor received no response.

Petitioner agrees that the contractor sent the letter to the appropriate address but complains that, because the mail delivery to her building is unreliable, she did not receive the notice.  Hearing Request at 1; P. Br. at 1-2; P. Ex. 1.

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In a second letter, dated November 4, 2016, the contractor reminded Petitioner that she had not revalidated her Medicare enrollment as requested and again warned that, if she failed to do so, her Medicare enrollment would be deactivated and she would not be paid for services rendered during the period of deactivation.  CMS Ex. 1 at 10-11; P. Exs. 2, 3.

By letter dated December 2, 2016, the contractor advised Petitioner that her billing privileges were stopped, effective December 2, because she had not revalidated her enrollment record.  CMS Ex. 1 at 12-13; P. Ex. 4.

On December 20, 2016, Petitioner submitted, by PECOS, a Medicare enrollment application, which the contractor subsequently approved.  CMS Ex. 1 at 17-21; P. Ex. 6.

Petitioner challenges the deactivation, arguing that she did not receive the original (June 15) revalidation notice.  She concedes that her office received the November 4 notice on November 17, but, because her staff resources were insufficient, she was unable to respond until December 5, 2016, when her staff called the contractor.  By that time, her enrollment had been deactivated.  P. Br. at 2.  She asks that her reenrollment be made retroactive to eliminate any billing gap.

On December 20, 2016, the contractor received, via PECOS, Petitioner’s reenrollment application, which it subsequently approved.  CMS Ex. 1 at 17-21; P. Ex. 6.  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment application – December 20, 2016 – is the correct effective date of enrollment.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

I have no authority to grant Petitioner an earlier effective date based on her equitable and policy arguments.  Sokoloff, DAB No. 2972 at 9.

Conclusion

Because Petitioner filed her subsequently-approved reenrollment application on December 20, 2016, CMS properly granted her Medicare reenrollment effective that date.

• 1. I make this one finding of fact/conclusion of law.
• 2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).