Michael Sackman, M.D., DAB CR5583 (2020)

DECISION

Petitioner, Michael Sackman, M.D., is a physician, licensed in Michigan, who participates in the Medicare program as a supplier of services.  After his Medicare billing privileges were deactivated, he applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective July 27, 2017, resulting in an eight-week coverage gap.  Petitioner now challenges that effective date and asks that the lapse in coverage be eliminated. 

Because Petitioner filed his subsequently-approved reenrollment application on July 27, 2017, I find that July 27 is the correct effective date for his reenrollment.  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 7 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019). 

Background

In a notice letter dated August 7, 2017, the Medicare contractor, Wisconsin Physicians Service, advised Petitioner that it approved his revalidated Medicare enrollment

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application, effective July 27, 2017, with a gap in coverage from June 1 “to” July 26, 2017.1  CMS Ex. 9.  Petitioner requested reconsideration.  CMS Ex. 10. 

In a reconsidered determination, dated October 17, 2017, the contractor determined that July 27, 2017, was the correct effective date and that the lapse in coverage could not be changed.  CMS Ex. 11.  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) (November 9, 2017).  I may therefore decide the case based on the written record without considering whether the standards for summary judgment are satisfied.

CMS submits its motion and brief (CMS Br.) with 11 exhibits (CMS Exs. 1-11).  Petitioner filed no brief and no exhibits but rests his case on the arguments presented in his hearing request.  In the absence of any objections, I admit into evidence CMS Exs. 1-11.

Discussion

Petitioner filed his subsequently-approved reenrollment application on July 27, 2017, and his reactivated 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 he 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.

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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.  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 that it is able to process to approval.  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).

Revalidation and Deactivation.  To maintain his billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of his 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 his 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 receiving 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 his enrollment information, CMS may deactivate his billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3); 424.555(b).  To reactivate his 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.  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). 

Petitioner’s deactivation and reenrollment.  In notice letters, dated January 9, 2017, the contractor directed Petitioner Sackman to revalidate his Medicare enrollment by updating or confirming the information in his record.  The letters directed Petitioner 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.  The letters warned that Petitioner had to revalidate by March 31, 2017, or risk his Medicare enrollment being deactivated; the letters also explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Exs. 1, 2.

The contractor sent the notices to the addresses it had on file for Petitioner and the group to which he assigned his benefits, but Petitioner did not respond.  CMS Br. at 2.4  In a follow-up letter, dated April 5, the contractor reminded Petitioner that he should revalidate his enrollment, noting that he’d missed the March 31, 2017 deadline.  The letter encouraged him to revalidate and again warned that he would not be paid for services rendered during any period of deactivation.  CMS Exs. 3. 

In a letter dated June 2, 2017, the contractor advised Petitioner that his Medicare enrollment was deactivated, effective June 1, 2017.  The contractor would not pay for any claims after that date.  CMS. Ex. 4.

Petitioner filed a revalidation application on June 12, 2017.  CMS Ex. 5.  The contractor deemed the application insufficient and requested additional development.  The contractor’s requests were not met, and, in a notice dated July 17, 2017, it advised Petitioner that it rejected the application and explained how to submit a new one.  CMS Ex. 6.  I have no authority to review a rejected application.  42 C.F.R. § 424.525(d).

On July 27, 2017, Petitioner again submitted Medicare reenrollment applications (CMS forms 855I and 855R), which the contractor subsequently approved.  CMS Exs. 7, 8.  Thus, pursuant to section 424.520(d), July 27, 2017, is the correct effective date of reenrollment.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

Petitioner nevertheless asks for Medicare reenrollment retroactive to June 1, 2017, the date of his deactivation, because he was not aware of the deactivation, and, as soon as he learned about it, he “began working on the process.”  Hearing request (October 28, 2017).  Although he now suggests that he did not receive the notices, in his request for reconsideration he said that he did not respond due to a “miscommunication within our office.”  CMS Ex. 10.  Why he did not timely reactivate his enrollment is irrelevant, however, because I have no authority to review a deactivation.  Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9.

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Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on July 27, 2017, CMS properly granted his Medicare reenrollment effective that date.

• 1. Because the contractor determined July 27, 2017, was Petitioner’s reenrollment effective date, the gap in coverage was actually from June 1 through July 26, 2017.  The contractor clarified the correct coverage lapse in its reconsidered determination.  See CMS Ex. 11. 
• 2. I make this one finding of fact/conclusion of law.
• 3. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
• 4. In his hearing request, Petitioner suggested that he did not receive the notices (see discussion).