Sunnyside Family Medicine PC, DAB CR5651 (2020)

DECISION

Petitioner, Sunnyside Family Medicine PC, is a Washington State group medical practice that participates in the Medicare program.  After its Medicare billing privileges were deactivated, the practice group applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective December 12, 2016, resulting in a significant coverage lapse.  Petitioner now challenges that effective date and asks that it be made retroactive to September 1, 2016.

Because Petitioner filed its subsequently-approved enrollment application on December 12, 2016, I find that December 12 is the earliest possible effective date for its Medicare 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 sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

Background

In a notice dated January 23, 2017, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that it approved the practice’s revalidated Medicare enrollment, effective December 12, 2016.  CMS Exs. 17, 18; P. Ex. 1.  Petitioner requested reconsideration.  P. Ex. 2.

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In a reconsidered determination, dated October 24, 2017, the contractor affirmed the December 12, 2016 effective date.  CMS Ex. 21; P. Ex. 8.  Petitioner appealed.

The parties have filed cross-motions for summary judgment.  However, 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) (January 10, 2018).  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 22 exhibits (CMS Exs. 1-22).  Petitioner submits a motion and brief (P. Br.) with nine exhibits (P. Exs. 1-9).  In the absence of any objections, I admit into evidence CMS Exs. 1-22 and P. Exs. 1-9.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

Petitioner filed its subsequently-approved enrollment application on December 12, 2016, and its Medicare reactivation enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Sunnyside Family Medicine PC 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 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 physician

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and non-physician practitioner organizations, the effective date for billing privileges “is the later of [t]he date of filing” a subsequently-approved enrollment application or “[t]he 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 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)-(e).  Within 60 calendar 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 calendar 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.  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 review a deactivation.  Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9 (2019).

Petitioner’s deactivation and reenrollment.  Although the record does not indicate when Petitioner’s Medicare enrollment was deactivated, it seems that, by September 2016, it had been deactivated “for some time.”  CMS Ex. 4 at 1.

Petitioner apparently made several attempts to reactivate its enrollment, filing reenrollment applications on March 9, 2016, August 17, 2016, and September 1, 2016.  All were incomplete, and the contractor rejected them because Petitioner failed to submit timely the additional information that the contractor requested.  CMS Exs. 1, 2, 3, 4, 5; CMS Ex. 21 at 2.

Petitioner filed another application on December 12, 2016.  It also was incomplete; however, after Petitioner responded to the contractor’s requests for additional information, the contractor approved it.  CMS Exs. 12, 13, 14, 16, 17.  Pursuant to section 424.520(d), the date Petitioner filed its subsequently-approved enrollment application – December 12, 2016 – 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.

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Petitioner nevertheless complains about the effective date and suggests that its September 1, 2016 application should not have been rejected.  Petitioner asks for a September 1 effective date.  P. Ex. 9.  Regardless of the merits of Petitioner’s argument (and I’m hard-pressed to find any), I have no authority to review rejection of an enrollment application.  42 C.F.R. § 424.525(d); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).  Nor may I grant Petitioner an earlier effective date based on any equitable or policy arguments.  Sokoloff, DAB No. 2972 at 9.

Conclusion

Because Petitioner filed its subsequently-approved reenrollment application on December 12, 2016, CMS properly granted its 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).