Debra L. Anderson, PhD, DAB CR5824 (2021)

DECISION

Petitioner, Debra L. Anderson, PhD, is a clinical psychologist, licensed and practicing in Maryland, who participates in the Medicare program as a supplier of services.  Until March 7, 2018, she assigned her Medicare billing privileges to a group practice, JB Mealy and Associates, LLC.  When the sole owner of that practice, Dr. John Mealy, died, the Medicare contractor deactivated her reassignment.  Thereafter, Petitioner Anderson applied to reenroll in the program.  The Centers for Medicare and Medicaid Services (CMS) granted the application, effective July 23, 2018, and allowed her a 30-day retrospective billing period.  Petitioner now challenges the July 23 effective date. 

Because Petitioner filed her subsequently-approved enrollment application on July 23, 2018, that is the correct effective date for her enrollment.

Background

The Medicare contractor, Novitas Solutions, deactivated Petitioner’s Medicare program participation as of March 7, 2018, because the sole owner of the practice for which she worked had died.  CMS Ex. 2.  Petitioner reapplied on her own behalf, and, in a letter dated September 6, 2018, the contractor advised her that it approved her reactivated

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Medicare enrollment with a retroactive billing date of June 23, 2018.  This resulted in a coverage lapse of approximately three and a half months.  CMS Ex. 6. 

On September 25, 2018, Petitioner requested reconsideration, asking for a March 6, 2018 effective date.  She explained that she had not known that the practice’s enrollment would end with Dr. Mealy’s death and had continued to treat patients throughout the period of deactivation.  CMS Ex. 7 at 5.

In a reconsidered determination, dated November 21, 2018, the Medicare contractor upheld the July 23 effective date and the June 23 billing date.  CMS Ex. 8.  

In a letter dated December 16, 2018 (received January 2, 2019), Petitioner appealed the reconsidered determination.  She asks that her effective date of enrollment be changed to March.  The appeal explains that she continued to treat patients following Dr. Mealy’s death.  Although she acknowledges that contractor employees advised her staff to “hold off sending any claims” until her application process was completed, she thought that she could file those claims after her application was accepted. 

CMS has moved for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre‑Hearing Order at 3, 6  (¶¶ 4(c)(iv), 10) (January 17, 2019).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied. 

CMS submits its motion and brief (CMS Br.), along with eight exhibits (CMS Exs. 1-8). 
In the absence of any objections, I admit into evidence CMS Exs. 1-8.  Petitioner submitted no exhibits and no additional arguments. 

Discussion

Petitioner filed her subsequently-approved enrollment application on July 23, 2018, and her Medicare reactivation enrollment can be no earlier than that date, although she may retrospectively bill for services provided up to thirty days prior to her enrollment if certain criteria are met.  42 C.F.R. §§ 424.520(d), 424.521(a)(1).1

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 furnished to program beneficiaries, a prospective supplier must enroll in the

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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. § 424.502.2   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 nonphysician practitioner, 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); Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 3-5 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

Petitioner’s deactivation.  Deactivation means that a supplier’s billing privileges are stopped but can be restored.  42 C.F.R. § 424.502.  Here, because Dr. Mealy was the sole owner of the medical practice, its billing privileges were deactivated at the time of his death.  The Medicare contractor notified Petitioner of the deactivation in a March 19, 2018 letter.  CMS Ex. 2.  To reactivate its billing privileges, a 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.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7; Goffney, DAB No. 2763 at 7.  I have no authority to review a deactivation.  Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9 (2019). 

Effective date.  Here, on July 23, 2018, Petitioner submitted her enrollment application (CMS-855I), which the contractor subsequently approved.  CMS Exs. 3, 6.  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment application – July 23, 2018 – is the correct effective date of enrollment.  Sokoloff, DAB No. 2972; Urology Grp., DAB No. 2860; Goffney, DAB No. 2763 at 7.

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Pursuant to its authority under section 424.521(a)(1), CMS allowed Petitioner to bill retrospectively, back to June 23, 2018.

I may not grant Petitioner an earlier effective date based on any equitable or policy arguments.  Sokoloff, DAB No. 2972 at 9.

Conclusion

Because Petitioner filed her subsequently-approved enrollment application on July 23, 2018, CMS properly granted her Medicare enrollment effective that date.  CMS was also authorized to allow her to bill 30 days retrospectively.

1. I make this one finding of fact/conclusion of law.
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2.  CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
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