Joseph R. Treadwell, DPM, DAB CR5449 (2019)

DECISION

Petitioner, Joseph R. Treadwell, DPM, is a podiatrist who practices in Plainville, Connecticut. After his Medicare billing privileges were deactivated, he applied to reenroll in the program. The Centers for Medicare & Medicaid Services (CMS) granted the application, effective January 9, 2017. Petitioner now challenges that effective date.

Because Petitioner filed his subsequently-approved enrollment application on January 9, 2017, I find that January 9 is the correct effective date for his enrollment. Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 3-5 (2017).

Background

In a letter dated February 7, 2017, the Medicare contractor, National Government Services, advised Petitioner Treadwell that it approved his Medicare enrollment. Curiously, the letter does not mention the effective date of enrollment, and CMS has not even mentioned, much less explained, this omission. CMS Ex. 2 at 5. Even more disturbing, the reconsideration determination, dated March 16, 2017, reviews the contractor’s determination to deactivate Petitioner’s enrollment, but does not specify the

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effective date of enrollment nor explain why that date is correct.  CMS Ex. 3 at 7-10.1   Again, in its submissions, CMS ignores these significant omissions. 

Nevertheless, at this level, CMS finally identifies Petitioner’s effective date of re-enrollment – January 9, 2017.  CMS Br. at 10-11.

Although CMS moves 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 four exhibits (CMS Exs. 1-4).  Petitioner submits his opposition to CMS’s motion (P. Br.).  In the absence of any objections, I admit into evidence CMS Exs. 1-4.

Discussion

Petitioner filed his subsequently-approved application on January 9, 2017, and his Medicare enrollment can be no earlier than that date. 42 C.F.R. § 424.520(d).2

Enrollment.  Petitioner Treadwell 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 he 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.

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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 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.  For a physician, the effective date for his billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that [he] 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 July 15, 2016, the contractor directed Petitioner to revalidate his Medicare enrollment by updating or confirming the information in his 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 at 1-2.  The letter warned that Petitioner had to revalidate by September 30, 2016, or risk his Medicare enrollment being deactivated; it explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Ex. 1 at 1.

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The contractor apparently sent the notice letter to the address it had on file, which Petitioner himself had provided.  CMS Ex. 1; CMS Ex. 4 at 6.  However, Petitioner was not at that address and did not receive the letter.  P. Hearing Request (DAB e-file #1).  Unsurprisingly, he did not revalidate his enrollment.  The contractor sent a second letter to Petitioner, using a different address.  Again, the letter told him to revalidate his enrollment records and warned that he would not be paid for services rendered during a period of deactivation.  CMS Ex. 1 at 3-4.

Petitioner did not then revalidate his enrollment, and, in a notice dated December 13, 2016, the contractor advised him that his Medicare billing privileges were stopped on December 7.  The contractor would not pay for any claims after that date.  CMS Ex. 1 at 5-6.  I have no authority to review that determination.  Ark. Health Grp., DAB No. 2929 at 7-9 (2019), and cases cited therein.

On January 9, 2017, the contractor received Petitioner’s reenrollment application, which it subsequently approved.  CMS Ex. 2.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – January 9, 2017 – is the correct effective date of enrollment.  Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB 2763 at 7.

Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on January 9, 2017, CMS properly granted his Medicare reenrollment effective that date.

• 1.Because the determination affirms the billing gap (12/07/16-01/08/17), one can figure out the effective date of re-enrollment.
• 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).