Christopher J. Magnifico, M.D., DAB CR5706 (2020)

DECISION

Petitioner, Christopher J. Magnifico, M.D., is a New York physician who participates in the Medicare program as a supplier of services.  After his Medicare billing privileges were deactivated, he applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted his application, effective November 6, 2017, resulting in a coverage lapse from June 21, 2017, through November 5, 2017.  Petitioner now challenges that effective date and asks that the lapse in coverage be eliminated.

Because Petitioner Magnifico filed his subsequently-approved reenrollment application on November 6, 2017, I find that November 6 is the earliest possible effective date for his reenrollment.  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 December 19, 2017, the Medicare contractor, National Government Services, advised Petitioner that it approved his revalidated Medicare enrollment, with an effective date of November 6, 2017.  CMS Ex. 14.  Petitioner requested reconsideration.  CMS Ex. 16.

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In a reconsidered determination, dated March 12, 2018, the contractor affirmed the gap in billing, although the determination incorrectly describes it as "June 21, 2017 through November 6, 2017."  CMS Ex. 19 at 3.  In fact, the gap is June 21 through November 5, 2017 (or June 21 to November 6), with an effective re-enrollment date of November 6, 2017.

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) (May 29, 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 19 exhibits (CMS Exs. 1-19).  Petitioner submits a brief (P. Br.), a PDF of chapter 15 of the Medicare Program Integrity Manual (CMS Pub. 100-08, Rev. 762, effective Jan. 29, 2018), and exhibits, marked P. Ex. 1-3 and 6-14.  In the absence of any objections, I admit into evidence CMS Exs. 1-19 and P. Exs. 1-3 and 6-14.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

Petitioner filed his subsequently-approved enrollment application on November 6, 2017, and his reactivated Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Magnifico 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

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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, 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 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.  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 notice letters, dated January 13, 2017, the contractor directed Petitioner to revalidate his Medicare enrollment no later than March 31, 2017, by updating or confirming the information in his record.  The letters 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 letters warned that, if Petitioner failed to respond to the notice, his Medicare enrollment could be deactivated; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Exs. 2, 3.  Petitioner did not respond.

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In follow-up letters, dated April 4, 2017, the contractor reminded Petitioner that he had not revalidated his enrollment as requested and warned that, if he failed to do so, his Medicare enrollment would be deactivated and he would not be paid for services rendered during the period of deactivation.  CMS Exs. 4, 5.  Petitioner did not respond.

In letters dated April 26, 2017, the contractor advised Petitioner that it was holding his Medicare payments because he had not revalidated and again warned that, if he did not respond, the contractor would deactivate his enrollment and he would not be paid for services provided during the period of deactivation.  CMS Exs. 7, 8.

On May 2, 2017, Petitioner submitted an enrollment application using the PECOS system.  CMS Ex. 6.  After requesting additional information (CMS Exs. 10, 11), the contractor rejected Petitioner's application.  In a letter dated June 22, 2017, it advised Petitioner that it stopped his Medicare billing privileges, effective June 21, 2017, because he hadn't revalidated his enrollment or hadn't responded to the contractor's requests for more information.  CMS Ex. 12.  I have no authority to review a rejected application, notwithstanding the merits of Petitioner's position.  Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).

On November 6, 2017, Petitioner Magnifico filed another Medicare reenrollment application (CMS-855I), which the contractor approved.  CMS Exs. 13 at 1, 14.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – November 6, 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.

Petitioner contends that the CMS contractor did not give him proper notice prior to deactivating his billing privileges because emails from the contractor were not marked "Urgent," and a contractor representative with whom he had discussed his revalidation did not follow up with him by telephone.  P. Br. at 1-5.  However, I have no authority to review a deactivation or to grant Petitioner an earlier effective date based on any equitable or policy arguments.  Sokoloff, DAB No. 2972 at 6, 9.

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Conclusion

Because Petitioner Magnifico filed his subsequently-approved reenrollment application on November 6, 2017, CMS properly granted his 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).