Tina Siridakis, ARNP, DAB CR5567 (2020)

DECISION

Petitioner Tina Siridakis, ARNP, is a nurse practitioner, practicing in Gig Harbor, Washington, 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 March 20, 2017.  Petitioner now challenges that effective date.

Because Petitioner filed her subsequently-approved enrollment application on March 20, 2017, I find that March 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 7 (2017), aff’d, Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

Background

In a letter dated April 17, 2017, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that it approved her Medicare enrollment effective March 20, 2017.  CMS Ex. 4 at 1.  Petitioner requested reconsideration.

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In a reconsidered determination, dated June 29, 2017, the contractor affirmed the March 20 effective date.  CMS Ex. 1.  Petitioner appealed. 

CMS moves for summary judgment.

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) (August 9, 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 ten exhibits (CMS Exs. 1-10).  Petitioner submits five exhibits (P. Exs. 1-5).  In the absence of any objections, I admit into evidence CMS Exs. 1-10 and P. Exs. 1-5.  See Acknowledgment and Pre-hearing Order at 4-5 (¶ 7).

Discussion

Petitioner filed her subsequently-approved enrollment application on March 20, 2017, and her Medicare reactivation enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Siridakis 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 billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  For a

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non‑physician practitioner, 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 October 14, 2016, the contractor directed Petitioner Siridakis 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 December 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 sent copies of this notice to Petitioner Siridakis at the addresses she had filed with the contractor.  CMS Exs. 9, 10.

The contractor received no response.

The contractor sent follow-up letters on January 26, 2017, reminding 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 Exs. 7, 8.

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Again, the contractor received no response.

Petitioner complains that she did not receive any of these notices because the contractor sent them to the addresses of her prior practice.  When Petitioner changed practices, the new practice submitted a new enrollment application on her behalf but did not otherwise notify the contractor of the change.  The contractor granted her enrollment with the new practice, and assigned her a new provider transaction access number (PTAN); her old number (to which the revalidation request applied), had not been deactivated.  P. Ex. 1.

By letter dated March 17, 2017, the contractor advised Petitioner that her billing privileges were stopped, effective March 2, because she had not revalidated her enrollment record.  CMS Ex. 6.

Petitioner challenges the deactivation, arguing that she did not receive any of the revalidation notices nor any other communication advising her to revalidate.  She learned of the deactivation when the contractor started denying her claims.  P. Ex. 1 at 1.  She asks that her re-enrollment be made retroactive to eliminate any billing gap.

On March 20, 2017, Petitioner filed a Medicare enrollment application, which the contractor subsequently approved.  CMS Ex. 5.  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment application – March 20, 2017 – 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 March 20, 2017, 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).