Oluwaseun Opelami, MD, DAB CR5497 (2019)

DECISION

Petitioner Oluwaseun Opelami, MD, is an Ohio physician, specializing in nephrology and internal medicine, who participates in the Medicare program. After his Medicare billing privileges were deactivated, he applied to reenroll in the program. The Centers for Medicare & Medicaid Services (CMS) granted enrollment, effective December 9, 2016. Petitioner now challenges that effective date.

Because Petitioner filed his subsequently-approved enrollment application on December 9, 2016, I find that December 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 7 (2017).

Background

In a letter dated December 21, 2016, the Medicare contractor, CGS, advised Petitioner that it approved his Medicare enrollment effective December 19, 2016. CMS Ex. 5. Petitioner requested reconsideration.

In a reconsidered determination, dated March 23, 2017, a contractor hearing officer determined that December 9, 2016, was the correct effective date because that was the

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date Petitioner Opelami filed his revalidation application. CMS Ex. 7. 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) (June 14, 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 eight exhibits (CMS Exs. 1-8). Petitioner submits his brief in opposition (P. Br.) with three exhibits (P. Exs. 1-3). In the absence of any objections, I admit into evidence CMS Exs. 1-8 and P. Exs. 1-3. See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

Petitioner filed his subsequently-approved enrollment application on December 9, 2016, and his Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Opelami 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 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).

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Revalidation and Deactivation.  To maintain his billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of his 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 his 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 his enrollment information, CMS may deactivate his billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3), 424.555(b).  To reactivate his 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.

I have no authority to review a deactivation.  Ark. Health Grp., DAB No. 2929 at 7-9 (2019) and cases cited therein. 

Petitioner’s deactivation and reenrollment.  In a notice letter, dated April 7, 2016, the contractor directed Petitioner Opelami 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.  The letter warned that Petitioner had to revalidate by June 30, 2016, or risk his Medicare enrollment being deactivated; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered.  The contractor addressed this notice to Petitioner Opelami at a street address in Euclid, Ohio, which was one of two correspondence addresses Petitioner had filed with the contractor.  CMS Ex. 1; CMS Ex. 8 at 2.

The contractor received no response. 

In a follow-up letter, dated July 21, 2016, the contractor reminded Petitioner that he had not revalidated his Medicare enrollment as requested and again 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.  The contractor addressed this notice to Petitioner Opelami at a post office box in Cincinnati, Ohio.  CMS Ex. 2.   

Again, the contractor received no response.

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By letter dated September 8, 2016, the contractor advised Petitioner that his billing privileges were stopped, effective September 8, because he had not revalidated his enrollment record.  CMS Ex. 3. 

On December 9, 2016, Petitioner submitted, by PECOS, a Medicare enrollment application, which the contractor subsequently approved.  CMS Exs. 4-5. 

Petitioner challenges the deactivation, arguing that he did not receive the original (April 7) revalidation notice.  He concedes that he received the July 21 notice on August 1, 2016, and claims his “credentialing specialist” thereafter attempted to submit an electronic application but was not able to access PECOS because her username and password were no longer valid.  She then mailed in an application, according to Petitioner.  P. Ex. 3.  Petitioner offers no reliable evidence – such as a copy of the application or some proof of mailing or delivery.  Instead, he submits an after-the-fact (January 11, 2017) email from the credentialing specialist, in which she makes the claim.  Even then, she provides no details, such as when she purportedly sent in the application or to whom she addressed it.  P. Ex. 1.  No evidence suggests that the contractor received Petitioner’s enrollment application until December 9, 2016.  See P. Ex. 2.

On December 9, 2016, the contractor received, via PECOS, Petitioner’s reenrollment application, which it subsequently approved.  CMS Ex. 4.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – December 9, 2016 – is the correct effective date of enrollment.  Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on December 9, 2016, CMS properly granted his Medicare enrollment effective that date. 

1. I make this one finding of fact/conclusion of law.
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2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
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