Joycelyn Parish, Ph.D., DAB CR5408 (2019)

DECISION

The effective date of Medicare enrollment and billing privileges of Petitioner, Joycelyn Parish, Ph.D., is June 19, 2017, with retrospective billing allowed beginning June 16, 2017.  

I. Background and Procedural History

Petitioner, a clinical psychologist, submitted a Form CMS-855I enrollment application and supporting documents by mail on June 16, 2017, that was received on June 19, 2017.  Centers for Medicare & Medicaid Services (CMS) Exhibit (Ex.) 2 at 36; see CMS Ex. 8 at 5.  Wisconsin Physicians Service Insurance Corporation (WPS), a Medicare administrative contractor, denied Petitioner’s enrollment application on June 26, 2017.  CMS Ex. 3.  Following an appeal to the Departmental Appeals Board (DAB), an administrative law judge (ALJ) granted a motion for remand filed by CMS.  CMS Ex. 7. 

On January 30, 2018, CMS’s Provider Enrollment & Oversight Group “overturned the denial of [Petitioner’s] Medicare application” and approved her enrollment as a clinical psychologist.  CMS Ex. 8 at 5.  Thereafter, WPS informed Petitioner, in a letter dated

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February 27, 2018, that it had likewise approved her application, effective June 16, 2017.  CMS Ex. 9 at 1.  On March 12, 2018, Petitioner requested reconsideration of the effective date of her Medicare enrollment and billing privileges.  CMS Ex. 10.  Petitioner explained that she “began seeing Medicare patients in 2016 and request[s] that the effective date of [her] enrollment be corrected to October 23, 2016, so that [she] may be paid for these earlier claims.”  CMS Ex. 10 at 1. 

WPS issued a reconsidered determination on April 24, 2018, in which it maintained the June 16, 2017 effective date of Petitioner’s enrollment and billing privileges.  CMS Ex. 1 at 2.  WPS explained that it “did not make a processing error to Dr. Parish’s enrollment.”  CMS Ex. 1 at 2.  WPS determined that it “would not be permitted to issue an October 23, 2016, effective date on an application received on June 19, 2017.”  CMS Ex. 1 at 2. 

Petitioner submitted a request for an ALJ hearing that was received on July 26, 2018.  ALJ Carolyn Cozad Hughes issued an Acknowledgment and Pre-Hearing Order (Pre-Hearing Order) on August 13, 2018, at which time she directed the parties to file their respective pre-hearing exchanges.1   CMS filed a motion for summary judgment and pre-hearing brief (CMS Br.), along with 10 proposed exhibits (CMS Exs. 1-10).  Petitioner filed a one-page letter that I construe as a response to CMS’s motion for summary judgment and brief (P. Br).  In the absence of any objections, I admit CMS Exs. 1-10 into the evidentiary record.

A hearing for the purpose of cross-examination is unnecessary because neither party has submitted written direct testimony.  Pre-Hearing Order §§ 8-10.  I consider the record in this case to be closed, and the matter is ready for a decision on the merits.2

II. Issue

Whether the effective date of Petitioner’s Medicare enrollment and billing privileges is June 19, 2017, with retrospective billing beginning June 16, 2017.

III. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R § 498.3(b)(15); Victor Alvarez, M.D., DAB No. 2325 at 8-12 (2010); see also 42 U.S.C. § 1395cc(j)(8).

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IV. Findings of Fact, Conclusions of Law, and Analysis3

Pursuant to 42 C.F.R. §§ 424.520(d) and 424.521(a)(1), Petitioner’s Medicare enrollment and billing privileges were effective June 19, 2017, with retrospective billing beginning on June 16, 2017, which is the date she mailed the enrollment application that was processed to approval. 

As a clinical psychologist, Petitioner is a “supplier” for purposes of the Medicare program.  See CMS Ex. 8 at 5; see also 42 U.S.C. § 1395x(d); 42 C.F.R. §§ 400.202 (definition of supplier); 498.2.  A “supplier” furnishes items or services under Medicare and the term applies to physicians or other practitioners who are not included within the definition of the phrase “provider of services.”  42 U.S.C. § 1395x(d).  A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The regulations at 42 C.F.R. Part 424, subpart P, establish the requirements for a supplier to enroll in the Medicare program.  42 C.F.R. §§ 424.510-424.516; see also 42 U.S.C. § 1395cc(j)(1)(A) (authorizing the Secretary of the U.S. Department of Health and Human Services to establish regulations addressing the enrollment of providers and suppliers in the Medicare program).  A supplier who seeks billing privileges under Medicare “must submit enrollment information on the applicable enrollment application.”  42 C.F.R. § 424.510(a)(1).  “Once the provider or supplier successfully completes the enrollment process . . . CMS enrolls the provider or supplier into the Medicare program.”  Id.; see also 42 C.F.R. § 424.510(d) (listing enrollment requirements).  When the contractor approves an enrollment application, it sets the effective date for approval of billing privileges.  See Alexander C. Gatzimos, MD, JD, LLC,DAB No. 2730 at 2 (2016).  “The effective date of a physician’s or physician organization’s enrollment in Medicare is ‘the later of the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor or the 
date [the supplier] first began furnishing services at a new practice location.’”  Id. at 2-3, citing 42 C.F.R. 424.520(d).

The DAB has explained that “[t]he governing law on how CMS (and its Medicare contractors) determine the effective date for [suppliers] applying for Medicare billing privileges is set by regulation” at 42 C.F.R. § 424.520(d).  Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).  Even though Petitioner argues that she began seeing patients in October 2016, she did not submit an enrollment application to WPS until June 16, 2017, that was received on June 19, 2017.  P. Br.; CMS Ex. 2.  Therefore, the earliest possible effective date for Petitioner’s enrollment and billing privileges is the later date of

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June 19, 2017,4 with retrospective billing beginning on June 16, 2017.  42 C.F.R. §§ 424.520(d), 424.521(a)(1).  Accordingly, I conclude that Petitioner’s billing privileges began no earlier than June 16, 2017.  Cf. Urology Grp. of NJ, LLC,DAB No. 2860 at 7 (2018) (“The governing authority to determine the effective date for reactivation of Petitioner’s Medicare billing privileges is 42 C.F.R. § 424.520(d).”) (italics omitted).

Petitioner does not contend that she submitted an enrollment application prior to the application that was received on June 19, 2017.  Rather, Petitioner explains that she began submitting claims to Novitas Solutions, and later WPS, prior to submitting the June 2017 enrollment application.  P. Br.  Petitioner also reports that WPS denied her claims in April 2017 because she was not enrolled as a Medicare supplier.  P. Br.  Petitioner argues that she received misinformation during the enrollment process, and based on this purported misinformation, she “should not be denied payment for the services [she has] rendered to [her] Medicare patients.”  P. Br.  The simple fact is that Petitioner mailed her application to enroll as a Medicare supplier on June 16, 2017; WPS received it on June 19, 2017; therefore, WPS correctly determined that the effective date of her enrollment is June 19, 2017, with retrospective billing privileges beginning June 16, 2017.  To the extent that Petitioner’s request for relief is based on principles of equitable relief, I cannot grant such relief.  US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither the ALJ nor the [DAB] is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”).  Petitioner points to no authority by which I may grant her relief from the applicable regulatory requirements, and I have no authority to declare statutes or regulations invalid or ultra vires.  1866ICPayday.com, L.L.C., DAB No. 2289 at 14 (2009) (“An ALJ is bound by applicable laws and regulations and may not invalidate either a law or regulation on any ground . . . .”).

WPS had a legitimate basis to assign a June 19, 2017 effective date for Petitioner’s Medicare enrollment and billing privileges, with retrospective billing privileges beginning June 16, 2017.  See 42 C.F.R. §§ 424.520(d), 424.521(a)(1).

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V. Conclusion

For the foregoing reasons, June 19, 2017, is the effective date of Petitioner’s Medicare enrollment and billing privileges, with retrospective billing beginning June 16, 2017.

1. This case was reassigned to me on March 8, 2019.
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2. Because a hearing is unnecessary, I need not address whether summary judgment is appropriate.
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3. Findings of fact and conclusions of law are in italics and bold font.
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4. Based on the date of receipt, the effective date of enrollment and billing privileges should have been June 19, 2017.  42 C.F.R. § 424.520(d).  CMS contended that, based on 42 C.F.R. § 424.521(a)(1), the effective date of billing privileges is June 16, 2017.  In more precise terms, the effective date of billing privileges is June 19, 2017, with retrospective billing privileges beginning June 16, 2017.  42 C.F.R. §§ 424.520(d), 424.521(a)(1).
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