Daniel J. Kachman, Ed. D., P.C., DAB CR5448 (2019)

DECISION

Petitioner, Daniel J. Kachman, Ed. D., P.C., is a group practice that provides counseling services in Lapeer, Michigan.1  After the practice’s Medicare billing privileges were deactivated, it applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective September 21, 2016.  Petitioner now challenges that effective date. 

Because Petitioner filed its subsequently-approved enrollment application on September 21, 2016, I find that September 21 is the correct effective date of its enrollment.  Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).

Background

In a letter dated November 4, 2016, the Medicare contractor, Wisconsin Physicians Service, advised Petitioner Kachman that it approved its Medicare enrollment effective September 21, 2016.  CMS Ex. 5.  Petitioner sought reconsideration, asking that the effective date be changed to August 9, 2016.  CMS Ex. 6 at 2-3.  In a reconsidered

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determination, dated January 23, 2017, the contractor denied Petitioner an earlier effective date.  CMS Ex. 2.   

Petitioner appealed. 

Although the parties have filed cross-motions for summary judgment, I find that this matter may be decided on the written record, without considering whether the standards for summary judgment are satisfied.  In my initial order, I instructed the parties to list their proposed witnesses (if any) and to submit their written direct testimony.  Acknowledgment and Pre-hearing Order at 3, 5 (¶¶ 4, 8) (April 7, 2017).  I also directed each party to state, affirmatively, whether it intended to cross-examine any proposed witness.  Order at 5 (¶ 9).  An in-person hearing is necessary “only if a party files admissible, written direct testimony, and the opposing party asks to cross-examine.”  Order at 5 (¶ 10).  Neither party lists any witnesses.  An in-person hearing would therefore serve no purpose, and I may decide the case based on the written record. 

With its motion and brief, CMS submits eight exhibits (CMS Exs. 1-8).  Petitioner submits its motion and brief with two exhibits (P. Exs. 1-2).  CMS responded to Petitioner’s submissions.  I admit into evidence CMS Exs. 1-8 and P. Exs. 1-2.

Discussion

Petitioner filed its subsequently-approved application on September 21, 2016, and its Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).2

Enrollment.  Petitioner Kachman 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 it furnishes 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. § 424.502.3   When CMS determines that a

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prospective supplier meets the applicable enrollment requirements, it grants Medicare billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  The effective date for its 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).

Deactivation.  To maintain its billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of its 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 its 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 its enrollment information, CMS may deactivate its billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3), 424.555(b).  To reactivate its 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.  Urology Grp., DAB No. 2860 at 7; Goffney, DAB No. 2763 at 7.

Petitioner’s deactivation and reenrollment.  In a notice letter dated April 7, 2016, the contractor directed Petitioner to revalidate its Medicare enrollment by updating or confirming the information in its 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.  CMS Ex. 1.  The notice warned that the supplier had to revalidate by June 30, 2016, or risk its Medicare enrollment being deactivated and explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Ex. 1 at 1. 

Petitioner apparently thought that it had responded to the contractor’s notice letter, although the parties’ explanations of Petitioner’s interactions with the contractor are confusing.  In any event, it did not revalidate its Medicare enrollment, and, in a notice dated August 8, 2016, the contractor advised Petitioner that its Medicare billing privileges were stopped on August 8.  The contractor would not pay for any claims after that date.  CMS Ex. 3.  No matter how compelling the circumstances, I have no authority to review that determination.  Ark. Health Grp., DAB No. 2929 at 7-9 (2019) and cases cited therein.

On September 21, 2016, the contractor received Petitioner’s reenrollment application, which it subsequently approved.  CMS Exs. 4, 5.  Thus, pursuant to section 424.520(d),

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the date Petitioner filed his subsequently-approved enrollment application – September 21, 2016 – is the correct effective date of enrollment.  Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on September 21, 2016, CMS properly granted his Medicare reenrollment effective that date.

• 1.Dr. Daniel J. Kachman is a clinical psychologist and the president of the practice; his individual enrollment is not an issue. CMS Ex. 8.
• 2.I make this one finding of fact/conclusion of law.
• 3.CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).