Ramarao Kaza M.D., and Ramarao Kaza, M.D., PC, DAB CR5084

DECISION

I grant summary judgment sustaining the determinations of a Medicare contractor to reactivate the Medicare billing privileges of Petitioners Ramarao Kaza, M.D. (Petitioner Kaza) and Ramarao Kaza, M.D., P.C. (Petitioner Kaza, P.C.). I sustain the reactivation date of August 13, 2017, that the contractor determined for Petitioner Kaza, P.C. and the date of August 20, 2017, that the contractor determined for Petitioner Kaza.

I. Background

Petitioners requested a hearing in order to challenge the effective dates of reactivation of their Medicare billing privileges. The Centers for Medicare & Medicaid Services (CMS) moved for summary judgment, filing a brief and 24 proposed exhibits that are identified

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as CMS Ex. 1-CMS Ex. 24. Petitioners opposed the motion, filing a written statement and six proposed exhibits that are identified as P. Ex. 1-P. Ex. 6.

It is unnecessary that I rule on the admissibility of the parties’ exhibits inasmuch as there are no disputed issues of material fact. I cite to some of these exhibits in this decision but only to illustrate facts that are not in dispute.

II. Issue, Findings of Fact and Conclusions of Law

A. Issue

The issue is whether the contractor properly established August 13, 2017, and August 20, 2017, to be the effective dates of reactivation of Petitioners’ Medicare billing privileges.

B. Findings of Fact and Conclusions of Law

This case is governed by a regulation, 42 C.F.R. §424.540. In relevant part, the regulation states:

(a) Reasons for deactivation. CMS may deactivate the Medicare billing privileges of a provider or supplier for any of the following reasons: . . .

(3) The provider or supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information.

(b) Reactivation of billing privileges.

(1) When deactivated for any reason other than nonsubmission of a claim, the provider or supplier must complete and submit a new enrollment application to reactivate its Medicare billing privileges or, when deemed appropriate, at a minimum, recertify that the enrollment information currently on file with Medicare is correct.

A contractor’s decision to deactivate a provider’s reimbursement privileges is not a determination that gives hearing rights to the affected individual or entity.  See 42 C.F.R. §§ 498.3(b) and (d). Consequently, a provider or supplier whose Medicare billing privileges are deactivated may not challenge the contractor’s decision to deactivate. I have no authority to decide that challenge.

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CMS has published guidance to its contractors concerning what effective participation date to assign to a supplier or provider that seeks to reactivate its participation. That date shall be the date when the contractor receives a re-enrollment application that it processes to completion. Medicare Program Integrity Manual, § 15.27.1.2. That guidance is consistent with regulatory requirements governing the effective date of participation of newly participating suppliers and providers. 42 C.F.R. § 424.520(d); Willie Goffney, Jr., M.D., DAB No. 2763 (2017).

Given that, the only question I may consider is whether the contractor (or, in this case, a reconsideration hearing officer) properly assigned an effective reactivation date to a provider or a supplier whose billing privileges are deactivated. The propriety of the contractor’s action in determining to reactivate is governed by 42 C.F.R. § 424.520(d). The regulation states that:

The effective date for billing privileges for physicians, . . . physician and non-physician practitioner organizations . . . is the later of . . . [t]he date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or . . . [t]he date that the supplier first began furnishing services at a new practice location.

The earliest possible effective reactivation date that a contractor may assign to a provider or supplier whose billing privileges are deactivated is the date that the provider or supplier files a new enrollment application with the contractor that the contractor subsequently approves. The contractor has no authority to assign a retroactive reactivation date to a provider or a supplier whose billing privileges were deactivated on a date prior to the date when the provider or supplier submits a new enrollment application for the purpose of reactivating his or her billing privileges. Moreover, I do not have authority to order a contractor to assign a retroactive reactivation date.

The undisputed facts of this case establish that Petitioners made several unsuccessful attempts to reactivate their Medicare billing privileges before finally submitting applications that the contractor subsequently approved.

On May 22, 2017, Petitioner Kaza submitted a Medicare reenrollment application to the contractor. CMS Ex. 2. He submitted this application in response to three notices that the contractor had sent to him on March 6, 2017, requesting that he revalidate his and Petitioner Kaza, P.C.’s Medicare enrollment. CMS Ex. 1. These notices informed Petitioners that the contractor could deactivate their billing privileges if Petitioners failed timely to revalidate their enrollments. Id.

On June 27, 2017, the contractor rejected the application and deactivated Petitioners’ billing privileges because it found that Petitioners had not responded to requests that they

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supplement the information that they supplied with their May 22, 2017 reenrollment application and that they had not revalidated their enrollment. CMS Ex. 4; CMS Ex. 5.

Petitioner Kaza submitted a second enrollment application to the contractor on July 5, 2017. CMS Ex. 6. On August 4, 2017, Petitioner Kaza additionally submitted an application for reassignment of his individual billing privileges to Petitioner Kaza, P.C. CMS Ex. 11. The contractor found these applications to be unacceptable. On August 11, 2017, the contractor sent letters to Petitioner Kaza rejecting the July 5 and August 4 applications. CMS Ex. 12; CMS Ex. 13.

On August 14, 2017, Petitioner Kaza submitted a new enrollment application on behalf of Petitioner Kaza, P.C. CMS Ex. 14 at 5. On August 21, 2017, Petitioner Kaza submitted a reenrollment application on his own behalf. CMS Ex. 17. The contractor subsequently approved the applications. It reactivated Petitioner Kaza, P.C.’s billing privileges effective August 13, 2017 and Petitioner Kaza’s billing privileges effective August 20, 2017. CMS Ex. 20; CMS Ex. 21.

August 13, 2017 is the earliest date on which Petitioner Kaza, P.C.’s billing privileges may be reactivated. August 20, 2017 is the earliest date on which Petitioner Kaza’s billing privileges may be reactivated.1 Petitioners have no right to challenge the contractor’s decisions to reject applications that they filed prior to August 14 and August 21, 2017. I may only decide whether the contractor based its determinations to reactivate Petitioners’ billing privileges based on applications that the contractor subsequently approved. The undisputed facts establish that it was the August 14 and August 21 applications that the contractor subsequently approved. Therefore, these applications are the basis for the reactivation dates.

Petitioners challenge the initial and reconsidered determinations in this case by asserting that the contractor erred – on multiple occasions – in the manner in which it processed Petitioners’ various applications. Petitioners’ argument is not one that I have authority to hear and decide. Petitioners effectively appeal the contractor’s rejection of applications that they submitted prior to August 14, 2017. As I note above, a decision by a contractor to deactivate a participating provider or supplier’s billing privileges is not appealable.

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Finally, I note that there is an equitable aspect to Petitioners’ argument. Effectively, they assert that it is unfair that they be penalized for what they characterize as errors by the contractor. This is also an argument that I have no authority to hear and decide inasmuch as equitable challenges to CMS’s determinations are not appealable.U.S. Ultrasound, DAB No. 2302 at 8 (2010).

1. Technically, the earliest possible reactivation date for Petitioner Kaza, P.C. is August 14, the date on which Petitioner Kaza submitted the application that the contractor subsequently approved. August 21 is the earliest possible reactivation date for Petitioner Kaza, because that is the date on which he submitted an application on his own behalf for reenrollment that the contractor subsequently approved. However, I will not adjust the August 13 and August 20 reactivation dates in this case to reflect the actual submission dates of the reenrollment applications that the contractor subsequently approved, given that CMS evidently does not dispute those reactivation dates.
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