Ashlesha Pandhre, DPT, DAB CR5661 (2020)

DECISION

I affirm the determination of Noridian Healthcare Solutions (Noridian), a contractor for the Centers for Medicare & Medicaid Services (CMS), that the effective date for Petitioner’s Medicare billing privileges and the reassignment of Medicare benefits to Petitioner’s practice, is June 12, 2019, with retrospective billing privileges commencing May 13, 2019. 

I.  Procedural History

On November 22, 2019, Noridian issued a reconsidered determination related to the effective date of Petitioner’s Medicare billing privileges and the reassignment of Medicare benefits from Petitioner to Petitioner’s practice.  Petitioner timely requested a hearing to dispute the reconsidered determination.  On January 17, 2020, the Civil Remedies Division (CRD) issued an acknowledgment of the hearing request and my Standing Prehearing Order.  In response, CMS filed a motion for summary judgment with a brief in support of the motion (CMS Br.) and seven exhibits (CMS Exs. 1-7).  Petitioner then filed a brief (P. Br.) and three exhibits (P. Exs. 1-3).

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II.  Decision on the Written Record

I admit all of the proposed exhibits into the record without objection.  Standing Prehearing Order ¶ 10; CRD Procedures § 14(e).

The Standing Prehearing Order advised the parties to submit written direct testimony for each witness and that an in-person hearing would only be held if a party requested to cross-examine a witness.  Standing Prehearing Order ¶¶ 10-13; CRD Procedures §§ 16(b), 19(b).  Neither party has offered any written direct testimony.  Therefore, I issue this decision based on the written record.  Standing Prehearing Order ¶ 14; CRD Procedures § 19(d).

III.  Issue

Whether CMS had a legitimate basis to assign June 12, 2019, as the effective date for Petitioner’s Medicare billing privileges and reassignment of Medicare benefits, with a retrospective billing period commencing on May 13, 2019.

IV.  Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R §§ 498.3(b)(15), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8).

V. Findings of Fact and Conclusions of Law

1. Noridian received a Medicare enrollment application (Form CMS-855I) from Petitioner on December 26, 2018.  CMS Ex. 1; P. Ex. 2.
2. On January 29, 2019, Noridian sent Petitioner a request for information (i.e., revisions and additional documentation) related to the enrollment application.  Noridian requested that Petitioner furnish the requested information by February 13, 2019.  Noridian also advised Petitioner that a failure to provide “complete information” within 30 calendar days from the date of the letter may result in rejection of the enrollment application.  CMS Ex. 2 at 1; P. Ex. 1 at 1.
3. Noridian received Petitioner’s response to its request for information, as well as an application (Form CMS-855R) to reassign Petitioner’s Medicare benefits to Fernley Physical Therapy, Inc., on February 12, 2019.  See CMS Exs. 3, 4.
4. In a May 24, 2019 letter, Noridian rejected Petitioner’s enrollment and reassignment applications because Petitioner failed to provide all of the requested information.  CMS Ex. 4 at 1; P. Ex. 2. 

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5. On June 12, 2019, Noridian received from Petitioner new enrollment and reassignment applications.  CMS Ex. 5 at 13, 15.
6. On August 28, 2019, Noridian notified Petitioner that her effective date for billing privileges and reassignment of Medicare benefits was May 13, 2019.  CMS Ex. 5 at 1.
7. On August 30, 2019, Petitioner requested reconsideration of Noridian’s determination to reject her December 26, 2018 enrollment application, and attached the rejection letter to her reconsideration request.  CMS Ex. 6 at 5-7.  In Petitioner’s reconsideration request, she sought an effective date of January 2, 2019, which is the date Petitioner purportedly began treating Medicare beneficiaries.  CMS Ex. 6at 7; see P. Ex. 3.
8. Noridian issued an unfavorable reconsidered determination, affirming a June 12, 2019 effective date with retrospective Medicare billing privileges commencing on May 13, 2019.  See CMS Ex. 7.
9. Based on the enrollment and reassignment applications that Noridian approved, the effective date for Medicare enrollment/billing privileges, and the reassignment of Medicare benefits is the date the approved applications were received (i.e., June 12, 2019), and the date that Petitioner’s retrospective billing period commences is 30 days before the effective date (i.e., May 13, 2019).  42 C.F.R. §§ 424.520(d), 424.521(a).     

VI.  Analysis

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A “supplier” is “a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services” under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u).

A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The term “Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.  The process includes . . . [i]dentification and confirmation of the . . . supplier’s practice location(s) and owner(s).”  42 C.F.R. § 424.502 (emphasis in original).  A supplier seeking Medicare billing privileges must “submit enrollment information on the applicable enrollment application.  Once the . . .

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supplier successfully completes the enrollment process . . . CMS enrolls the . . . supplier into the Medicare program.”  42 C.F.R. § 424.510(a).

When enrolling a non-physician practitioner, CMS establishes an effective date for billing privileges.  The effective date for Medicare billing privileges for physicians, non-physician practitioners, and physician or non-physician practitioner organizations is the later of the “date of filing” or the date the supplier first began furnishing services at a new practice location.  42 C.F.R. § 424.520(d).  The “date of filing” is the date that the Medicare contractor “receives” an enrollment application that the Medicare contractor is able to process to approval.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).  These effective date rules also apply to the effective date of the reassignment of Medicare benefits.  Gaurav Lakhanpal, MD, DAB No. 2951 at 6 (2019).

When CMS assigns an effective date, CMS may permit a retrospective billing period of up to 30 days.  42 C.F.R. § 424.521.

In the present case, there is no dispute that Noridian received Petitioner’s enrollment and reassignment applications on June 12, 2019, which Noridian subsequently approved.  CMS Ex. 5 at 13, 15.  Therefore, Noridian properly established June 12, 2019, as the effective date for Petitioner’s billing privileges and for the reassignment of her Medicare benefits.  Further, Noridian properly exercised its authority to permit a 30-day retrospective billing period starting on May 13, 2019.

Petitioner argues that her enrollment application filed on December 26, 2018, should not have been rejected, but should have been approved because her practice “submitted all of [the] requested information.”  P. Br. at 2.  Petitioner asserts that “section 4F was not requested in the original letter [requesting additional information] dated January 29, 2019” and her practice “did not at any time receive a request for section 4F of the [855I].”  P. Br. at 2.

Petitioner’s arguments are related to the rejection of Petitioner’s originally filed enrollment and reassignment applications.  However, the decision to reject an application is not subject to further appeal.  42 C.F.R. § 424.525(d).  I only have authority to decide whether the effective date assigned to the second set of applications is correct because those applications were ultimately approved.1

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VII.  Conclusion

I affirm CMS’s determination that Petitioner’s effective date for Medicare enrollment/billing privileges and the reassignment of Medicare benefits is June 12, 2019, with a retrospective billing period commencing on May 13, 2019.

• 1. Petitioner is correct that Noridian’s January 29, 2019 letter did not request that Petitioner complete section 4F, and yet Noridian indicated that Petitioner’s failure to complete that section was a basis for rejecting Petitioner’s original enrollment application.  CMS Ex. 2 at 1; CMS Ex. 4 at 1.  In the reconsidered determination, Noridian specified that Noridian “found that section 4F was still missing the correct group NPI [National Provider Identifier].”  CMS Ex. 7 at 3.  This statement does not address Petitioner’s concern that she was never requested to complete section 4F of the enrollment application.  Noridian did request that Petitioner complete section 4B of the enrollment application and provide the “Name of the Group,” the “Group’s Medicare Identification Number (PTAN),” and the “Group’s National Provider Identifier (NPI).”  CMS Ex. 2 at 1.  Section 4F of the enrollment application, and not section 4B, has a place to provide the requested information.  CMS Ex. 3 at 18, 21.  Further, Petitioner attempted to provide the requested information in section 4F.  CMS Ex. 3 at 21.  However, as stated in the reconsidered determination, this information was not considered “correct” because the Group NPI that Petitioner provided in section 4F was missing a digit.  The Group PTAN is also missing a digit.  Compare CMS Ex. 3 at 21 with CMS Ex. 3 at 31 and CMS Ex. 5 at 1, 14, 18.