Thomas Trancik, M.D., LLC and Thomas Trancik, M.D., DAB CR5467 (2019)

DECISION

Petitioner Thomas Trancik, M.D., LLC, is an Indiana medical practice that participates in the Medicare program. Petitioner Thomas Trancik, M.D., is a physician, specializing in orthopedics, who owns the practice. After their Medicare billing privileges were deactivated, they applied to reenroll in the program. The Centers for Medicare & Medicaid Services (CMS) granted the application, effective December 1, 2016. Petitioner now challenges that effective date.

Because Petitioner filed their subsequently-approved enrollment application on December 1, 2016, I find that December 1 is the correct effective date for their 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 30, 2016, the Medicare contractor, Wisconsin Physicians Service Insurance Corporation, advised Petitioners that it approved their Medicare enrollments. The notice letter is confusing because it refers to a January 27, 2004

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effective date, with a note that the effective date "reflects a gap in coverage from 10/20/2016 to 11/30/2016." CMS Ex. 10 at 1.1 Petitioners requested reconsideration.

In a reconsidered determination, dated February 22, 2017, a Medicare hearing officer affirmed the gap in coverage – from October 20 through November 30, 2016 – but, for reasons that have not been explained, stopped short of specifying the effective date of reenrollment following Petitioners' deactivations. CMS Ex. 12. CMS does not explain this omission.

Nevertheless, at this level of review, CMS finally articulates Petitioners' effective date of reenrollment – December 1, 2016. CMS Br. at 1, 5, 13.

Although CMS moves for summary judgment, I find that this matter may be decided on the written record, without considering whether the standards for summary judgment are satisfied. In my initial order, I instructed the parties to list their proposed witnesses (if any) and to submit their written direct testimony. Acknowledgment and Pre-hearing Order at 3, 5 (¶¶ 4, 8) (May 10, 2017). I also directed each party to state, affirmatively, whether it intended to cross-examine any proposed witness. Order at 5 (¶ 9). An in-person hearing is necessary "only if a party files admissible, written direct testimony, and the opposing party asks to cross-examine." Order at 5 (¶ 10). Neither party lists any witnesses. An in-person hearing would therefore serve no purpose, and I may decide the case based on the written record.

With its motion and brief, CMS submits eleven exhibits, labeled CMS Exs. 2-12 (with CMS Ex. 1 intentionally omitted). Petitioners submit their opposition to CMS's motion (P. Br.) with six exhibits (P. Exs. 1-6). In the absence of any objections, I admit into evidence CMS Exs. 2-12 and P. Exs. 1-6.

Discussion

Petitioners filed their subsequently-approved application on December 1, 2016, and their Medicare reenrollments can be no earlier than that date. 42 C.F.R. § 424.520(d).2

Enrollment. Petitioners participate in the Medicare program as "suppliers" of services. Social Security Act § 1861(d); 42 C.F.R. § 498.2. To receive Medicare payments for the

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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. § 424.502.3 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 or physician organization, the effective date for billing privileges "is the later of the 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).

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. Urology Grp., DAB No. 2860 at 7; Goffney, DAB No. 2763 at 7.

Petitioners' deactivation and reenrollment. In notice letters dated July 6, 2016, the contractor directed Petitioners to revalidate their Medicare enrollments by updating or confirming the information in their records. The letters directed Petitioners to the PECOS website and explained that a supplier could revalidate through the PECOS

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system or by mailing to the contractor a completed CMS-855 Medicare enrollment application. CMS Ex. 2. The letters also warned that Petitioners had to revalidate by September 30, 2016, or risk their Medicare enrollments being deactivated; the letters explained that, during the period of deactivation, Medicare would not pay for the services rendered. CMS Ex. 2 at 1, 3, 5, 7.

In response, Petitioners submitted an enrollment application, which the contractor received on September 20, 2016.4 CMS Ex. 3. In a letter dated September 21, 2016, the contractor directed Petitioners to revise a section of their application and to submit a certification statement. The letter directed them to respond within 14 days and warned that their Medicare billing privileges would be deactivated if they failed to do so within 30 days. CMS Ex. 4. Petitioners did not respond, and, in notices dated October 21, 2016, the contractor advised them that their application was rejected and their Medicare billing privileges were stopped on October 20, 2016. The contractor would not pay for any claims after that date. CMS Ex. 6. I have no authority to review that determination. Ark. Health Grp., DAB No. 2929 at 7-9 (2019) and cases cited therein.

On December 1, 2016, the contractor received Petitioners' reenrollment application, which, after some further development, it subsequently approved. CMS Ex. 7 at 43; CMS Ex. 10. Thus, pursuant to section 424.520(d), the date Petitioners filed their subsequently-approved enrollment application – December 1, 2016 – is the correct effective date of enrollment. Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

Conclusion

Because Petitioners filed their subsequently-approved reenrollment application on December 1, 2016, CMS properly granted their Medicare reenrollments effective that date.

1. Inasmuch as December 1, 2016, is the effective date for Petitioners' reenrollments, the gap in coverage was from October 20 through November 30, 2016. The reconsidered determination corrects the error. CMS Ex. 12 at 2.
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2. I make this one finding of fact/conclusion of law.
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3. CMS's electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
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4. Medicare contractors stamp paper applications with a "Julian date stamp," which counts the days of the year consecutively. Here, the first two digits stamped on the application indicate the year – 2016. The next three digits indicate the date – the 263rd day of 2016 or September 20, 2016.
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