Douglas J. Weckstein, DAB CR5502 (2019)

DECISION

The Centers for Medicare & Medicaid Services (CMS), through a CMS contractor, determined that the effective date for reactivation of the Medicare billing privileges for Douglas J. Weckstein (Dr. Weckstein or Petitioner) was July 3, 2018.  Petitioner requested an administrative law judge (ALJ) hearing to dispute this effective date.  Because the CMS contractor received Petitioner’s revalidation enrollment application (CMS-855I) on July 3, 2018, and the CMS contractor later approved that application, the CMS contractor correctly determined that the effective date for the reactivation of billing privileges was July 3, 2018.  Therefore, I affirm CMS’s determination.

I. Background and Procedural History

Dr. Weckstein has been enrolled in the Medicare program as a supplier since 1998.  Petitioner Exhibit (P. Ex.) 2 at 1; see CMS Ex. 2 at 1-2.  In a February 9, 2018 notice, a CMS contractor informed Dr. Weckstein that he needed to revalidate his Medicare enrollment record by April 30, 2018.  CMS Ex. 1 at 8; CMS Ex. 3 at 1.  This notice also stated that failure to respond to the notice could result in deactivation of his Medicare enrollment, causing a “gap in [his] reimbursement” during the period of deactivation.

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CMS Ex. 1 at 8; CMS Ex. 3 at 1.  In a follow-up notice, dated May 2, 2018, the CMS contractor stated that Dr. Weckstein had yet to revalidate his Medicare enrollment and again warned that he could be subject to deactivation.  CMS Ex. 1 at 10; CMS Ex. 3 at 3.  Finally, in a July 10, 2018 notice, the CMS contractor informed Dr. Weckstein that it had stopped his Medicare billing privileges as of June 30, 2018, because he had not successfully revalidated his enrollment.  The notice stated that “[w]e will not pay any claims after this date.”  CMS Ex. 1 at 12; CMS Ex. 3 at 5.    

On July 3, 2018, or a few days after the deactivation date, the CMS contractor received an electronic application to revalidate Dr. Weckstein’s Medicare enrollment (CMS-855I) and to reassign his billing privileges to Dana Farber Cancer Institute (CMS-855R).  CMS Ex. 1 at 14.  On July 16, 2018, the CMS contractor received a separate electronic application to reassign Dr. Weckstein’s billing privileges to a second group practice, New Hampshire Oncology (CMS-855R).  CMS Ex. 1 at 21.

In an August 24, 2018 initial determination, the CMS contractor reactivated Dr. Weckstein’s billing privileges and approved the reassignment to New Hampshire Oncology.  CMS Ex. 1 at 27.  The initial determination noted that Dr. Weckstein’s effective date was July 16, 2018, which resulted in a billing gap from June 30, 2018, through July 15, 2018.  CMS Ex. 1 at 27. 

Dr. Weckstein timely submitted a request for reconsideration.  CMS Ex. 1 at 30.  Dr. Weckstein, through the billing manager for New Hampshire Oncology, explained that there was “confusion” when the office switched to a new “EMR” and billing system, which contributed to Dr. Weckstein’s failure to timely revalidate and resulted in deactivation.  CMS Ex. 1 at 30.  The billing manager also claimed that she was unable to locate any revalidation notice sent by the CMS contractor.  CMS Ex. 1 at 30.  She also added that she was under the impression that Dr. Weckstein’s next revalidation would not be needed until August 26, 2018, or five years from his last revalidation on August 26, 2013.  CMS Ex. 1 at 30. 

On October 1, 2018, the CMS contractor issued a partially unfavorable reconsidered determination.  CMS Ex. 1 at 1-5.  In the notice, the CMS contractor stated that Dr. Weckstein did not timely respond to the February 9, 2018 revalidation request and so he was deactivated on June 30, 2018.  CMS Ex. 1 at 3.  The CMS contractor nevertheless adjusted Dr. Weckstein’s effective date to July 3, 2018, finding that Dr. Weckstein’s three applications, one revalidation and two reassignment applications, were approved together, and that the revalidation application (CMS-855I) was originally received on July 3, 2018.  CMS Ex. 1 at 3-4; see also CMS Ex. 1 at 6-7, 20, 26.  The adjustment also reduced the billing gap accordingly, but the contractor explained it was unable to remove the gap entirely as Dr. Weckstein did not timely respond to the request for revalidation.  CMS Ex. 1 at 4. 

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Petitioner timely requested an ALJ hearing to dispute the reconsidered determination.  On November 7, 2018, Judge Keith W. Sickendick issued an Acknowledgment and Prehearing Order (Order), which established a schedule for prehearing exchanges.  In response, CMS filed a brief, which included a motion for summary judgment, and four exhibits (CMS Exs. 1-4).  Petitioner submitted a letter in response (P. Br.) and three exhibits (P. Exs. 1-3).

On November 20, 2018, this case was transferred to me.

II. Decision on the Written Record

I admit all of the proposed exhibits into the record because neither party objected to the admission of the other side’s exhibits.

The Order required each party to include with its prehearing exchange a list of any witnesses that it proposed to call at an oral hearing.  Order § II(D)(1), (2); Civil Remedies Division Procedures (CRDP) § 16(a).  Neither party submitted a witness list.  Therefore, I issue this decision based on the written record because “the parties d[id] not identify any proposed witnesses.”  CRDP § 19(d).

III. Issue

Whether CMS had a legitimate basis to assign July 3, 2018, as the effective date for the reactivation of Petitioner’s Medicare billing privileges.

IV. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R § 498.3(b)(15); Victor Alvarez, M.D., DAB No. 2325 at 8-12 (2010); see also 42 U.S.C. § 1395cc(j)(8).

V. Findings of Fact, Conclusions of Law, and Analysis

My findings of fact and conclusions of law are set forth in italics and bold font.

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.  “Enroll/Enrollment means the process that

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Medicare uses to establish eligibility to submit claims for Medicare-covered items and services . . . .”  42 C.F.R. § 424.502.  A supplier seeking billing privileges under the Medicare program must “submit enrollment information on the applicable enrollment application.  Once the . . . supplier successfully completes the enrollment process . . . CMS enrolls the . . . supplier into the Medicare program.”  42 C.F.R. § 424.510(a).  CMS then establishes an effective date for billing privileges under the requirements stated in 42 C.F.R. § 424.520(d) and may permit limited retrospective billing under 42 C.F.R. § 424.521.

To maintain Medicare billing privileges, suppliers must revalidate their enrollment information at least every five years; however, CMS reserves the right to require revalidation at any time.  42 C.F.R. § 424.515.  When CMS notifies suppliers that it is time to revalidate, the suppliers must submit the appropriate enrollment application, accurate information, and supporting documents within 60 calendar days of CMS’s notification.  42 C.F.R. § 424.515(a)(2).

CMS can deactivate an enrolled supplier’s Medicare billing privileges if the enrollee fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates a supplier’s Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b).  If CMS deactivates a supplier’s billing privileges due to an untimely response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by completing a new enrollment application or, if deemed appropriate, recertifying its enrollment information that is on file.  42 C.F.R. § 424.540(b)(1).

1. Petitioner electronically submitted a revalidation enrollment application (CMS-855I) on July 3, 2018, to the CMS contractor via the Provider Enrollment, Chain, and Ownership System (PECOS).  The CMS contractor received the enrollment application on July 3, 2018, and ultimately approved that enrollment application. 

Petitioner submitted his revalidation enrollment application (and a reassignment application) electronically via PECOS on July 3, 2018.  CMS Ex. 1 at 14.  Petitioner confirmed July 3, 2018, as the date of submission.  CMS Ex. 1 at 30.  CMS later approved this revalidation enrollment application, together with Petitioner’s two reassignment applications.  CMS Ex. 1 at 27; see also CMS Ex. 1 at 6-7, 20, 26. 

1. The effective date for Petitioner’s Medicare billing privileges is July 3, 2018. 

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” of a Medicare enrollment application that is subsequently approved or the

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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” a signed 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 7-8 (2016).  The Departmental Appeals Board has applied these effective date provisions to reactivation cases, and its decisions doing so are consistent with § 424.555(b)’s prohibition on reimbursing services while a provider or supplier is deactivated.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6-7 (2019).

In the present case, the CMS contractor initially determined that Petitioner’s effective date for reactivation of its Medicare billing privileges was July 16, 2018.  CMS Ex. 1 at 27.  However, on reconsideration, the CMS contractor modified the effective date of reactivation to July 3, 2018.  CMS Ex. 1 at 3-4.  The CMS contractor correctly applied the regulations in the reconsidered determination.  

Although a July 3, 2018 reactivation effective date significantly reduces the gap in billing privileges, Petitioner seeks to remove the gap in Medicare billing privileges entirely.  In a letter, Petitioner’s billing manager asserts that she had not seen the revalidation notices before CMS submitted copies of them for this case.  P. Br. at 1.  She also explains again that, based on the date for Petitioner’s last revalidation, she was expecting Petitioner’s next revalidation to be in August, not April, 2018.  P. Br. at 1.  Finally, the billing manager adds that the “key” person responsible for revalidations in Petitioner’s office was on leave during the relevant dates “due to a death in her family as well as illness and vacation time.”  P. Br. at 1. 

These arguments are, unfortunately, related to Petitioner’s deactivation.  I do not have the authority to review CMS’s decision to deactivate Petitioner’s Medicare billing privileges because deactivation is not an “initial determination” subject to appeal, and deactivation decisions have a separate review process involving the submission of a rebuttal to CMS.  See 42 C.F.R. §§ 424.545(b), 498.3(b); see also Willie Goffney, Jr., M.D., DAB No. 2763 at 4-5 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).  As stated above in the Issue and Jurisdiction sections of this decision, I only have authority to decide whether the date of reactivation of Petitioner’s billing privileges is correct based on the facts in this case and the law.  Ark. Health Grp., DAB No. 2929 at 12 (2019) (“Where, as here, the contractor deactivated Petitioner’s billing privileges, the issue for us (and the ALJ) is the effective date of reactivation.”).  For the reasons already explained above, I conclude that Petitioner’s reactivation date is correct.

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VI.  Conclusion

I affirm CMS’s determination that Petitioner’s effective date for Medicare billing privileges is July 3, 2018.