Padmaja Chalasani and Chalasani, M.D., Inc., DAB CR5801 (2021)

DECISION

CGS Administrators, LLC (CGS), an administrative contractor for Respondent, the Centers for Medicare & Medicaid Services (CMS), granted Medicare billing privileges to Petitioner Chalasani, M.D., Inc. (Chalasani, Inc.) effective May 8, 2018, with retrospective billing permitted from April 8, 2018.  CGS also determined June 11, 2018, to be the effective date of reassignment of Medicare billing privileges from Petitioner Padmaja Chalasani (Dr. Chalasani) to Chalasani, Inc., with retrospective billing permitted from May 12, 2018.  Petitioners requested a hearing before an administrative law judge to dispute these effective dates.  As explained herein, CGS correctly determined Petitioners' enrollment and reassignment effective dates to be May 8, 2018, and June 11, 2018, respectively.  I therefore affirm CMS's effective date determinations.

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I. Background

Dr. Chalasani signed and submitted a CMS-855I Medicare Enrollment Application form on November 21, 2017 to report "new ownership of office."  CMS Exhibit (Ex.) 3 at 4, 26.  Dr. Chalasani indicated Chalasani, Inc. was the new owner of her practice and expressed her intent to reassign her payments to that corporation.  Id. at 15-16.  She identified her practice location as St. Marys Family Practice in St. Marys, Ohio, which she described as a "private office."  Id. at 17.  Dr. Chalasani noted she was "still billing Ranga Inc . . . for new owners."  Id.  Petitioners also submitted a Form CMS-460 Medicare Participating Physician or Supplier Agreement on behalf of Chalasani, Inc. d/b/a St. Marys Family Practice.  Id. at 29-34.  Dr. Chalasani signed this form as the "owner" of Chalasani, Inc.  Id. at 29, 32.

On November 22, 2017, Amanda Rohrbach, the office manager for St. Marys Family Practice, mailed a Form CMS-855R Medicare Enrollment Application to CGS to terminate reassignment of St. Marys' billing to Dr. Ranga, Inc.  CMS Ex. 4 at 1, 3-4.  Ms. Rohrbach did not indicate which individual practitioner was terminating his or her reassignment.  Id. at 3.  Included with the reassignment termination was an undated and unsigned letter advising CGS that ownership of St. Marys Family Practice would change from Dr. Ranga, Inc. to Chalasani, Inc. after "the first of the new year."  Id. at 8.

On December 7, 2017, CGS wrote to Dr. Chalasani in care of Chalasani, Inc., and to the attention of Ms. Rohrbach, to request development of the November 21, 2017 enrollment application.  CMS Ex. 5 at 1.  CGS warned the application could be rejected if it did not receive all requested materials within 30 days.  Id.  CGS also wrote to Dr. Chalasani in care of Dr. Ranga, Inc., and to the attention of Ms. Rohrbach, to request Section 3 of the November 22, 2017 enrollment application be completed with the name of the practitioner whose reassignment was being terminated, and to have that individual sign the application.  CMS Ex. 6 at 3.  CGS also asked Dr. Chalasani to revise the National Provider Identifier in Section 2.  Id.  As with the request for development it sent on the same day, CGS warned Dr. Chalasani that it could reject the application if it did not receive all the requested materials within 30 days.  CMS Ex. 5 at 1; CMS Ex. 6 at 3.

CGS rejected Petitioner Dr. Chalasani's November 22, 2017 CMS-855R enrollment application on January 8, 2018, asserting it had not received a written response to the development letter within 30 days.  CMS Ex. 7.1

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On January 4, 2018, Chalasani, Inc. submitted a Form CMS-855B Medicare Enrollment Application by mail to CGS.  CMS Ex. 9.  Dr. Chalasani signed this application and identified herself as the owner of "Chalasani MD Inc d/b/a St. Marys Family Practice," a newly enrolling group practice.  Id. at 1, 5, 10, 41-42.  CGS acknowledged receipt of the CMS-855B application and sought further development.  CMS Ex. 10.  CGS again requested Form CMS-855R Medicare Enrollment Application(s) to identify physician(s) who intended to reassign their Medicare billing to the newly enrolled group practice.  Id. at 3.  As with the December 2017 development letters, CGS cautioned Petitioner Chalasani, Inc. it might reject the application if it did not receive all the requested materials within 30 days.  Id. at 1.  On February 27, 2018, CGS rejected Petitioner Chalasani, Inc.'s January 4, 2018 enrollment application, explaining Chalasani, Inc. had not filed a group enrollment application or submitted newly signed attestation statements with its responses to CGS's development request.  CMS Ex. 11 at 3.

On May 8, 2018, CGS received a new Form CMS-855B Medicare Enrollment Application from Chalasani, Inc.  CMS Ex. 12 at 60.  Dr. Chalasani identified both herself and her husband, Venkata Chalasani, M.D., as owners.  Id. at 28-33, 41-42.  CGS acknowledged receipt of this application in a May 16, 2018 letter to Ms. Rohrbach's attention, and again requested further development, attaching a detailed list of items needed.  CMS Ex. 13.

On May 25, 2018, a CGS employee e-mailed Ms. Rohrbach to acknowledge receipt of information faxed to CGS on May 18, 2018, and to identify additional information CGS needed to process the application, including Form CMS-855I and CMS-855R Medicare Enrollment Applications from those individuals practicing with the group, including Dr. Chalasani.  CMS Ex. 14 at 2.  On June 4, 2018, Dr. Chalasani signed and mailed a Form CMS-855R Medicare Enrollment Application reassigning her Medicare payments to Chalasani, Inc., which CGS received on June 11, 2018.  CMS Ex. 15 at 4; see DAB E-file Dkt No. C-18-1226, Doc. No. 1a at 2.

On June 21, 2018, CGS notified Chalasani, Inc. it had approved the May 8, 2018 enrollment application with retrospective billing permitted from April 8, 2018.  CMS Ex. 16.  CGS also notified Dr. Chalasani by separate letter that it had approved her reassignment of payments to Chalasani, Inc. as of June 11, 2018, the date she filed a Form CMS-855R Medicare Enrollment Application, and approved retrospective billing from May 12, 2018.  CMS Ex. 17.

Petitioners sought reconsideration of these effective date determinations.  CGS affirmed its effective date determinations in a reconsidered determination dated July 26, 2018.  DAB E-file Dkt No. C-18-1226, Doc. No. 1a.  Petitioners then timely sought a hearing in the Civil Remedies Division and I was designated to hear and decide this case.  On August 24, 2018, I issued an Acknowledgment and Prehearing Order (Pre-Hearing Order) that required each party to file a pre-hearing exchange and supporting documents.

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Pre-Hearing Order ¶ 4.  CMS timely filed a Combined Pre-Hearing Brief and Motion for Summary Judgment (CMS Br.), along with 17 exhibits (CMS Exs. 1-17).  Petitioners failed to file a timely pre-hearing exchange.  I therefore issued an Order to Show Cause, requiring Petitioners to explain why their case should not be dismissed for failure to comply with the directives and schedule set forth in my Pre-Hearing Order.  On December 6, 2018, CMS forwarded Petitioners' response to my office, which they erroneously mailed to CMS on November 28, 2018.

On December 17, 2018, I issued an Order Discharging Order to Show Cause, acknowledging Petitioners' wish to proceed and construing Petitioners' Letter Response as a request to treat their hearing request and attachments as Petitioners' pre-hearing exchange, which I granted.  I also waived the signature requirement with regard to Petitioners' Hearing Request and granted Petitioners' request for a waiver from the electronic filing system requirement.

II. Decision on the Written Record and Admission of Exhibits

Petitioners did not object to the exhibits offered by CMS.  I admit CMS Exs. 1-17 into evidence.  Neither party offered written direct testimony of a witness as part of its pre‑hearing exchange, meaning an in-person hearing is not necessary in this matter.  Pre‑Hearing Order ¶¶ 8-10; Civ. Remedies Div. P. §§ 16(b), 19(b).  I therefore decide this case on the record based on the parties' written submissions and arguments.  Civ. Remedies Div. P. § 19(d).  CMS's motion for summary judgment is denied as moot.

III. Issues

The issues in this case are whether CGS, acting on behalf of CMS, properly established May 8, 2018, as the effective date of enrollment for Medicare billing privileges for Chalasani, Inc., and June 11, 2018, as the effective date for reassignment of Dr. Chalasani's Medicare billing privileges.

IV. Jurisdiction

I have jurisdiction to decide this case.  42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2); see also Social Security Act (Act) § 1866(j)(8) (codified at 42 U.S.C. § 1395cc(j)(8)).

V. Findings of Fact, Conclusions of Law, and Analysis

A.  Applicable Law

The Act authorizes the Secretary of Health and Human Services to promulgate regulations governing the enrollment process for providers and suppliers.  Act §§ 1102, 1866(j) (42 U.S.C. §§ 1302, 1395cc(j)).  "[S]upplier[s]," like Petitioners, are defined as

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"a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services" under the Medicare provisions of the Act.  Act § 1861(d) (42 U.S.C. § 1395x(d)); see also Act § 1861(u) (42 U.S.C. § 1395x(u)).

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 define "Enrollment" as "the process that Medicare uses to establish eligibility to submit claims for Medicare‑covered items and services."  42 C.F.R. § 424.502.  A supplier seeking billing privileges under the Medicare program must "submit enrollment information on the applicable enrollment application.  Once the provider or supplier successfully completes the enrollment process . . . , CMS enrolls the provider or supplier into the Medicare program."  42 C.F.R. § 424.510(a)(1).  CMS then establishes an effective date for billing privileges under the requirements stated in 42 C.F.R. § 424.520(d) and may permit retrospective billing pursuant to 42 C.F.R. § 424.521(a).

The effective date for Medicare billing privileges for physicians, non-physician practitioners, and physician or non-physician practitioner organizations is the later of the "date of filing" or the date the supplier first began furnishing services at a new practice location.  42 C.F.R. § 424.520(d).  The "date of filing" is the date that the Medicare contractor "receives" a signed enrollment application that the Medicare contractor is able to process to approval.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).  The regulations allow suppliers to "retrospectively bill" Medicare, meaning CMS permits a supplier to bill Medicare for services occurring up to thirty days before the effective date of enrollment, if certain circumstances apply.  42 C.F.R § 424.521(a)(1).

For Medicare Part B claims, a beneficiary may assign his or her benefits to an enrolled physician or non‑physician supplier providing services to that beneficiary.  Act § 1842(b)(3)(B)(ii) (42 U.S.C. § 1395u(b)(3)(B)(ii)).  In certain circumstances, a supplier who has received an assignment of benefits may reassign those benefits to an employer, or to an individual or entity with which the supplier has a contractual arrangement.  Act § 1842(b)(6) (42 U.S.C. § 1395u(b)(6)); 42 C.F.R. § 424.80(b)(1)‑(2).  CMS applies the effective date rules at 42 C.F.R. §§ 424.520(d) and 424.521(a)(1) to reassignments of Medicare benefits.  See Medicare Program Integrity Manual (MPIM) (CMS Pub. 100-08) §§ 15.5.20(E)(3), 15.17.

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B.  Analysis

1. The effective date of Chalasani, Inc.'s Medicare enrollment application is May 8, 2018, as that is the date CGS received the application it subsequently processed to approval.

On May 8, 2018, CGS received an enrollment application from Chalasani, Inc. that it ultimately processed to approval.  CMS Ex. 12 at 60.  The record before me reflects no earlier application submitted by Chalasani, Inc. that CGS subsequently approved.  Therefore, May 8, 2018, the date Chalasani, Inc. filed its subsequently approved enrollment application, is the correct effective date of enrollment for Chalasani, Inc.  Urology Grp. of NJ, LLC, DAB No. 2860 at 7-9 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).

2. The effective date of Dr. Chalasani's reassignment of Medicare billing privileges is June 11, 2018, as that is the date CGS received the application it subsequently processed to approval.

Dr. Chalasani submitted a reassignment application received by CGS on June 11, 2018 that the contractor ultimately processed to approval.  CMS Ex. 15.  The record before me reflects no earlier application submitted by Dr. Chalasani that CGS subsequently approved.  Therefore, the date Dr. Chalasani filed her subsequently approved reassignment application, June 11, 2018, is the correct effective date of reassignment for Dr. Chalasani's billing privileges.  Urology Grp. of NJ, LLC, DAB No. 2860 at 7-9; Willie Goffney, Jr., M.D., DAB No. 2763 at 7; MPIM §§ 15.5.20(E)(3), 15.17.

3. I have no authority to review CGS's decisions to reject Petitioners' earlier applications.

Petitioners have provided no basis in law or fact that would permit me to award Chalasani, Inc. an earlier effective date than that determined by CMS, or an earlier reassignment effective date for Dr. Chalasani.  While Petitioners did attempt to file enrollment and assignment applications in November 2017 and January 2018, CMS rejected both sets of applications because of Petitioners' failure to timely respond to CGS's requests for development. CMS Exs. 3, 4, 5, 6, 7.

Petitioners may have good-faith objections to the denial actions taken by CGS, but the regulations do not permit me to review CGS's application rejections as they are not initial determinations under 42 C.F.R. § 498.3(b).  Indeed, the regulations explicitly state that a rejected application may not be appealed.  42 C.F.R. § 424.525(d); see also James Shepard, M.D., DAB No. 2793 at 8 (2017) (providing 42 C.F.R. § 424.525(d) "plainly prohibits" ALJ review of a rejected application because there are no appeal rights for such a determination).

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Petitioners contend they never withdrew the November 21, 2017 CMS-855I enrollment application submitted for Chalasani, Inc., as CMS asserts, and as such believe there is a legal basis to award an earlier effective date based on that application.  CMS Ex. 3; P. Br. at 1.  That claim is without merit.  It is true CMS has failed to provide explicit evidence of the denial of that application, but ultimately, this earlier application is immaterial because it is clear it was never processed to approval.  As the regulations make plain, the effective date of enrollment derives from the date CMS receives an application it is able to successfully process to approval.  42 C.F.R. § 424.520(d); 73 Fed. Reg. at 69,769; Donald Dolce, M.D., DAB No. 2685 at 8.  There is no basis in the record before me to conclude that CGS continued to develop Petitioners' November 2017 applications.  The fact that Petitioners continued to submit applications of various types in January 2018 and May 2018 clearly suggests that Petitioners either abandoned the November 21, 2017 application or understood it to have been denied by CGS.  

4. I have no authority to consider Petitioners' equitable arguments.

Petitioners also complain of conflicting or bad information provided by CGS, and claim they were "[given] the run around on [sic] for months."  P. Br. at 1.  I am sympathetic to Petitioners' claims and do not find them implausible.  But Petitioners' request to modify their effective dates of enrollment and reassignment for that reason has no basis in law, and is therefore a plea for equitable relief, which I do not have the authority to grant.  See, e.g., US Ultrasound, DAB No. 2302 at 8 (2010) ("Neither the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements."); Pepper Hill Nursing & Rehab. Ctr., LLC, DAB No. 2395 at 11 (2011) (holding the ALJ and Board were not authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements).

My jurisdiction is instead limited to review of CMS's determinations of the effective dates of Petitioners' enrollment and reassignment applications under 42 C.F.R. § 424.520(d).  As I have explained, CGS properly determined, pursuant to the controlling regulations, that May 8, 2018 and June 11, 2018 are Petitioners' effective dates of enrollment and reassignment, respectively, as those are the dates CGS received applications that it was able to successfully approve.  The effective dates of May 8, 2018 and June 11, 2018 must stand.

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VI. Conclusion

For the foregoing reasons, I affirm CMS's determination of the effective date of Chalasani, Inc.'s Medicare enrollment to be May 8, 2018, with retrospective billing permitted from April 8, 2018.  I also affirm CMS's determination of the effective date of Dr. Chalasani's reassignment of Medicare billing privileges to be June 11, 2018, with retrospective billing permitted from May 12, 2018.

1. CMS explained CGS did not issue a similar letter to reject Petitioners' November 21, 2017 CMS‑855I Medicare Enrollment Application because CGS understood that application to have been withdrawn by Ms. Rohrbach after she was informed this form could not be used to enroll a group practice with more than one owner and that she needed to submit a Form CMS-855B Medicare Enrollment Application instead.  DAB E-file Dkt No. C-18-1226, Doc. No. 1a at 2; CMS Ex. 1.  Petitioners dispute this understanding.  P. Br. at 1.
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