Mark Pluym, M.D., DAB CR5945 (2021)

DECISION

This decision affirms the determination of Wisconsin Physicians Service (WPS), a contractor for the Centers for Medicare & Medicaid Services (CMS), that the effective date for revalidation/reactivation of Petitioner’s Medicare enrollment and billing privileges is April 5, 2019, with a retroactive billing date of March 6, 2019.

I. Background and Procedural History

On July 23, 2019, Dr. Mark Pluym (Petitioner or Dr. Pluym) timely requested a hearing before an administrative law judge (ALJ) to contest the effective date of the reactivation of his Medicare enrollment.  On August 1, 2019, at Judge Leslie Weyn’s direction, the Civil Remedies Division (CRD) issued an acknowledgment letter and Judge Weyn’s standing prehearing order (Standing Order), along with a non-discrimination notice and the CRD Procedures.  

On August 8, 2019, Petitioner authorized Michael Dean Ohmart to serve as his representative.  On September 5, 2019, CMS filed a Motion for Summary Judgment 

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(CMS Br.), along with nine exhibits (CMS Exs. 1-9), and a statement indicating that the agency would not present witnesses if the matter proceeded to a hearing.  

On October 9, 2019, Petitioner filed a Brief and a Cross Motion for Summary Judgment (P. Br.) along with 13 exhibits (P. Exs. 1-13).1 Petitioner also filed a statement indicating that he would not call witnesses should this matter proceed to a hearing.  On May 14, 2021, this matter was transferred from Judge Wynn to the undersigned.  

Although both parties moved for summary judgment, both indicated that they would not call witnesses if a hearing were held.  Therefore, I will decide this matter on the written record, without considering whether the standards for summary judgment are satisfied.  Standing Order §§ 8-10.  Furthermore, in the absence of objections, all proposed exhibits are admitted into evidence.  Standing Order § 7.

II. Findings of Fact

The following Findings of Fact are undisputed.  

1. Dr. Pluym joined the Western Missouri Medical Center (WMMC) on July 1, 2017, where he served as the only pulmonologist in the local area.  CMS Ex. 6 at 1.  He applied for Medicare enrollment and billing privileges and listed WMMC as his practice location.  The enrollment application and the reassignment of Medicare benefits to WMMC were approved and Dr. Pluym was given an effective date of July 6, 2017. CMS Ex. 8.

2. In June 2018, WMMC attempted to revalidate its enrollment in the Medicare program as a supplier.  P. Exs. 2-4.  In a July 26, 2018 notice, WPS informed WMMC that WMMC had failed to revalidate its enrollment as a Medicare supplier and, as a result, WMMC’s Medicare billing privileges would be deactivated effective August 31, 2018.  CMS Ex. 7.  From July through September 2018, WMMC submitted additional documents concerning revalidation.  CMS Ex. 6; P. Exs. 5-7.

3. Dr. Pluym’s reassignment of benefits ended as a result of WMMC’s deactivation, per CMS policy that requires WPS to “end-date all reassignment and employment relationship Provider Transaction Numbers (PTANs) linked to an organization’s enrollment record that is -- 1) deactivated; 2) revoked; or 3) voluntarily withdraws, within fourteen (14) calendar days of the organization’s related enrollment action 

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in the Provider Enrollment Chain and Ownership System (PECOS).”  CMS Ex. 9 at 3.

4. On April 5, 2019, a Medicare Enrollment Application for the Reassignment of Benefits (CMS-855R form), was received by WPS.  CMS Ex. 2 at 7.  In that reassignment application, Petitioner requested that the Medicare program approve Petitioner’s reassignment of benefits to WMMC with an effective date of July 20, 2018.  CMS Ex. 2 at 3.  

5. In an April 12, 2019 letter, WPS acknowledged receipt of the reassignment application and requested that Petitioner submit a form CMS-855I (application for enrollment in the Medicare program) and supporting documentation within 30 calendar days.  CMS Ex. 3.  WMMC submitted a CMS-855I form, seeking the reactivation of Dr. Pluym’s Medicare enrollment, which WPS received on April 16, 2019.  CMS Ex. 4.  

6. In a May 15, 2019 initial determination, WPS approved Dr. Pluym’s revised application and provided April 5, 2019 as the revalidation effective date, with a retroactive billing date of March 6, 2019.  CMS Ex. 5.  

7. Dr. Pluym’s Medicare billing privileges were inactive from August 31, 2018, to March 5, 2019.  CMS Exs. 1, 5, 7.  

8. WMMC submitted a request for reconsideration explaining that Dr. Pluym’s reassignment of benefits and enrollment with Medicare was deactivated on July 20, 2018, and WMMC was unaware of the inactivation. CMS Ex. 6.  WMMC requested that the activation date be changed to July 20, 2018 or July 1, 2017.  CMS Ex. 6.  

9. On June 21, 2019, WPS issued a decision clarifying that Petitioner’s billing privileges were deactivated on August 31, 2018.  The decision also denied Petitioner’s request to change the effective date of his reactivation.  CMS Ex. 1. 

III. Jurisdiction

This tribunal has jurisdiction to hear and decide this case.  42 C.F.R §§ 498.3(b)(15), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8).

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IV. Legal Authorities

The Social Security Act (the Act) establishes the enrollment process for providers and suppliers participating in Medicare or Medicare related programs.  42 U.S.C. §§ 1302, 1395cc(j).  Under the Act, “suppliers” are physicians or other practitioners, a facility or other entity (other than a provider of services) that furnishes items or services under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u). Providers include hospitals, skilled nursing facilities, and home health agencies.  42 U.S.C. § 1395x(u).  Dr. Pluym is a “supplier.”  42 U.S.C. § 1395x(d); 42 C.F.R. § 400.202. 

A provider or supplier must be enrolled in the Medicare program in order to receive payment for covered items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary.  42 C.F.R. § 424.505. Once enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered.  42 C.F.R. § 424.505.

CMS can deactivate an enrolled supplier’s Medicare billing privileges if the supplier fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates a supplier’s Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b).  If CMS deactivates a supplier’s billing privileges due to an untimely response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by completing a new enrollment application or, if deemed appropriate, recertifying its enrollment information that is on file.  42 C.F.R. § 424.540(b)(1).

The regulations provide that the effective date of enrollment for a physician or nonphysician practitioner may only be the later of two dates:  the date when the practitioner filed an application for enrollment that was subsequently approved by a Medicare contractor charged with reviewing the application on behalf of CMS; or, the date when the practitioner first began providing services at a new practice location.  42 C.F.R. § 424.520(d).  An enrolled physician or nonphysician practitioner may retrospectively bill Medicare for services provided to Medicare-eligible beneficiaries up to 30 days prior to the effective date of enrollment, if circumstances precluded enrollment before the services were provided.  42 C.F.R. § 424.521(a)(1).

V. Analysis

Dr. Pluym joined WMMC on July 1, 2017.  The initial request to have Dr. Pluym’s benefits reassigned to WMMC was approved with an effective date of July 6, 2017.  P. Ex. 1.  On July 26, 2018, WPS issued a letter to WMMC indicating that its billing

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privileges would cease on August 31, 2018, because WMMC failed to revalidate its enrollment.  CMS Ex. 7.  WMMC asserts that it never received the letter.  P. Br. at 2.  On August 31, 2018, WMMC’s billing privileges were deactivated due to failure to revalidate their enrollment record.  Dr. Pluym’s billing privileges were deactivated as a result of WMMC’s deactivation and remained inactive from August 31, 2018, through March 5, 2019.  P. Br. at 3; see CMS Ex. 1 at 2.  

WMMC submitted a new reassignment application on April 4, 2019, and a Medicare enrollment application on behalf of Petitioner on April 15, 2019.  CMS Exs. 2, 4.  Dr. Pluym’s enrollment was approved by CMS with a retroactive billing date of March 6, 2019.  CMS Exs. 2, 5.  WMMC requested reconsideration and asked that Dr. Pluym’s reactivation date be changed to July 20, 2018, or July 1, 2017.  CMS Ex. 6.  CMS denied the request and WMMC appealed.  CMS Ex. 1. 

It is undisputed that after deactivation, Dr. Pluym applied for reassignment of Medicare benefits on April 5, 2019, and, after also completing a reactivation application, WPS processed those applications to completion.  CMS Exs. 2, 5.  Based on the regulations, CMS correctly determined that the effective date of Petitioner’s reenrollment was April 5, 2019, the date the application for reassignment was submitted; and an allowance for 30 days of retroactive billing allowed Petitioner to bill beginning March 6, 2019.

Petitioner argues that WMMC attempted to complete the enrollment process by submitting online revalidation documents on June 1, 2018, June 5, 2018, June 28, 2018, August 1, 2018, August 20, 2018, and September 18, 2018.  P. Br. at 2; P. Exs. 2-7.  Neither party provides an explanation for what happened with the June 2018 requests for revalidation, but Petitioner submits that CMS has traditionally presented barriers to effective communication in the enrollment process.  P. Br. at 3. Additionally, Dr. Pluym asserts that he is the only pulmonologist in the local area and was unable to stop seeing patients during the time that he was deactivated. P. Br. at 3.  Petitioner requested an earlier effective date based on the aforementioned factors.  

However, there is no legal basis that allows me to grant Dr. Pluym’s request.  Dr. Pluym’s arguments regarding communication with CMS and being the only local pulmonologist amount to a request for equitable relief.  The regulations do not provide this tribunal with the authority to grant equitable relief, thus Petitioner’s effective date cannot be changed based upon the reasons provided.  US Ultrasound, DAB No. 2302 at 8 (2010) (“[n]either 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.”).  For the reasons explained above, I have concluded that Petitioner’s revalidation/reactivation date is correct.

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VI. Conclusion

CMS correctly determined that Petitioner’s effective date for reactivation of Medicare enrollment and billing privileges is April 5, 2019, with retroactive billing allowed beginning on March 6, 2019. Therefore, CMS’s determination is AFFIRMED.

1. Petitioner inadvertently filed his proposed exhibit 7 twice. See E-File Document Nos. 30, 31.
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