Ahmed Ali, M.D., DAB CR5575 (2020)

DECISION

Petitioner, Ahmed Ali, M.D., is a Missouri physician who participates in the Medicare program.  He applied to reassign his Medicare billing privileges to Florissant Medical Rehab Group, LLC.  The Centers for Medicare & Medicaid Services (CMS) granted his application with a retrospective billing date of January 11, 2017 (and, by inference, an effective date of February 10, 2017).  Petitioner now challenges that effective date.

Because Petitioner filed his subsequently-approved enrollment application on February 10, 2017, I find that February 10 is the correct effective date of Petitioner's enrollment.  CMS had the authority to grant Petitioner a January 11, 2017 retrospective billing date.

Background

In a letter dated February 16, 2017, the Medicare contractor, Wisconsin Physician Services, advised Petitioner Ali that it approved his application with an "effective date" of January 11, 2017.  CMS Ex. 6.  In fact, as explained below, the contractor was granting Petitioner a billing date of January 11; the effective date of Petitioner's enrollment was February 10, 2017 (see discussion below).

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Petitioner sought reconsideration, asking that the effective date of his enrollment be made retroactive to November 12, 2016, suggesting that the contractor may have mishandled his original application, submitted on December 12, 2016.  CMS Ex. 7 at 1-2.  In a reconsidered determination, dated June 16, 2017, the contractor denied Petitioner an earlier effective date.  CMS Ex. 8.1

Petitioner appealed.

Although CMS has moved for summary judgment, neither party proposes any witnesses, so an in-person hearing would serve no purpose.  See Acknowledgment and Pre-hearing Order at 3, 5 (¶¶ 4(c)(iv), 8-10) (August 31, 2017).  I may therefore decide the case based on the written record without considering whether the standards for summary judgment are satisfied.

With its motion and brief (CMS Br.), CMS submits eight exhibits (CMS Exs. 1-8).  Petitioner submits a written brief (P. Br.).  In the absence of any objections, I admit into evidence CMS Exs. 1-8.

Discussion

Petitioner filed his subsequently-approved application on February 10, 2017, and his Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).2

Enrollment.  Petitioner 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 it furnishes 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

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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.  The effective date for its billing privileges "is the later of the date of filing" a subsequently-approved enrollment application or the date the individual began furnishing services at a new practice location.  42 C.F.R. § 424.520(d) (emphasis added).  The date of filing is the date the Medicare contractor receives an application.  Karthik Ramaswamy, M.D., DAB No. 2563 at 3 (2014), aff'd sub nom. Ramaswamy v. Burwell, 83 F. Supp. 3d 846 (E.D. Mo. 2015).

If a physician meets all program requirements, CMS may allow him to bill retrospectively for up to 30 days prior to the effective date "if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries."  42 C.F.R. § 424.521(a)(1).

The Medicare contractors have created much confusion because they are inclined to conflate the effective date with the retrospective billing date, as the contractor did in this case.  CMS Exs. 6, 8.  The reconsidered determination acknowledges that the contractor received Petitioner's application on February 10, 2017, but it nevertheless mischaracterizes the "effective date" as January 11, 2017.  CMS Ex. 8 at 2.  In fact, January 11 is the retrospective billing date.  The distinction is important; I have the authority to review "the effective date of . . . supplier approval."  42 C.F.R. § 498.3(b)(15).  But nothing in the regulations gives me the authority to review CMS's determinations regarding retrospective billing.

Here, on February 10, 2017, the Medicare contractor received Petitioner's enrollment application, which the contractor subsequently approved.  CMS Exs. 5, 6.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – February 10, 2017 – is the correct effective date of enrollment.

The rejected application.  Petitioner, however, complains that the contractor improperly rejected his earlier (December 12, 2016) application.  The regulations authorize the contractor to reject an application if the supplier fails to furnish complete information within 30 days of the date requested.  42 C.F.R. § 424.525(a)(1).  According to Petitioner, on December 12, 2016, Florissant filed enrollment applications on behalf of two physicians:  Petitioner and Dr. Saima Ahmad.  P. Br. at 2; see CMS Ex. 7 at 25-44.  The practice subsequently received a development letter, requesting additional submissions, addressed to Dr. Ahmad, but did not receive a similar letter for Petitioner.  CMS Ex. 7

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at 49.  As a result, Florissant completed Dr. Ahmad's application, but it (and Petitioner) assumed that Petitioner's was complete.  Until the contractor began denying his claims, they did not learn that his December 12 application had been rejected.  P. Br. at 2.

CMS disputes Petitioner's assertion and maintains that the contractor sent Petitioner a development letter, dated December 14, 2016.  See CMS Ex. 3.  I need not resolve this conflict.  Although it is possible that the contractor did not send Petitioner Ali a development letter after receiving his December 12 enrollment application, I have no authority to review a rejected application.  42 C.F.R. § 424.525(d); see Guarav Lakhanpal, MD, DAB No. 2951 at 7 (2019); Ark. Health Grp., DAB No. 2929 at 7-9 (2019), and cases cited therein.

Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on February 10, 2017, CMS properly granted his Medicare enrollment effective that date.

1. The reconsidered determination also inaccurately refers to January 11, the retrospective billing date, as the "effective date."
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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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