Sullivan County Auditor, DAB CR5648 (2020)

DECISION

Petitioner, Sullivan County Auditor, operates the Sullivan County Ambulance Service in Sullivan County, Indiana.  The ambulance service participates in the Medicare program as a supplier of services.  After its Medicare billing privileges were deactivated, it applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective June 16, 2017, resulting in a two-week coverage lapse.  Petitioner now challenges that effective date and asks that the lapse in coverage be eliminated.

Because Petitioner filed its subsequently-approved reenrollment application on June 16, 2017, June 16 is the earliest possible effective date for its reactivation.  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 Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

Background

In a notice dated August 10, 2017, the Medicare contractor, Wisconsin Physicians Service, advised Petitioner that it approved the supplier’s revalidated Medicare

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enrollment with a lapse in coverage from June 2 through 15, 2017.  CMS Ex. 7 at 1.  Petitioner requested reconsideration.  See CMS Ex. 8.

In a reconsidered determination dated October 16, 2017, the contractor affirmed the effective date and the coverage lapse.  CMS Ex. 8.  Petitioner appealed.

CMS moves 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, 5 (¶¶ 4, 10) (December 21, 2017).  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.) with eight exhibits (CMS Exs. 1-8).  Petitioner submits its written response and an additional copy of its hearing request with attached documents, which are not marked as exhibits.  In the absence of any objections, I admit into evidence CMS Exs. 1-8.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).  I decline to sort out Petitioner’s documents, although I have reviewed them.  Some duplicate CMS’s exhibits, and the rest address the deactivation, which, as discussed below, I have no authority to review.

Discussion

Petitioner filed its subsequently-approved enrollment application on June 16, 2017, and its Medicare reactivation enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).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 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. § 424.502.2  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 ambulance suppliers, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (emphasis added).

Revalidation and deactivation.  To maintain its billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of its 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 its enrollment information.  42 C.F.R. § 424.515(d)-(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 receipt of 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 its enrollment information, CMS may deactivate its billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3), 424.555(b).  To reactivate its 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 a notice letter, dated February 7, 2017, the contractor directed Petitioner to revalidate its Medicare enrollment by updating or confirming the information in its record.  The letter directed Petitioner to the PECOS website and explained that a supplier could revalidate through the PECOS system or by mailing to the contractor a completed CMS-855 Medicare enrollment application.  The letter warned that Petitioner had to revalidate by April 30, 2017, or risk losing its Medicare billing privileges; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Ex. 1.

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On May 1, 2017, via PECOS, Petitioner submitted its reenrollment application.  CMS Ex. 2 at 1.

In a letter, dated May 2, 2017, the contractor acknowledged that it received Petitioner’s enrollment application, but the application did not include some required documentation (vehicle registrations and a letter certifying that the county was legally and financially responsible for Medicare payments).  The letter warned that, if Petitioner failed to submit the requested information within 30 days, its application would be rejected.  CMS Ex. 3.

Petitioner responded on May 31, 2017, providing the vehicle registration materials.  CMS Ex. 4 at 8-10.  It did not provide certification of the county’s responsibilities.  CMS Ex. 4.

By letter, dated June 7, 2017, the contractor advised Petitioner that its Medicare billing privileges were stopped, effective June 2, 2017, because the ambulance service did not revalidate its enrollment application and did not respond to the contractor’s request for more information.  The letter directed Petitioner to submit a new Medicare enrollment application that included the missing information.  CMS Ex. 5.

Petitioner maintains that it did not receive the contractor’s May 2 development letter until May 31, and that it responded within 30 days of that date, so it should not have been deactivated.  Petitioner’s Response.  Regardless of the merits of Petitioner’s argument, I have no authority to review a deactivation.  Ark. Health Grp., DAB No. 2929 at 7-9 and cases cited therein.3

On June 16, 2017, Petitioner filed, via PECOS, a new application that included the previously missing certification of responsibility.  CMS Ex. 6.4  In a letter dated August 10, 2017, the contractor approved the revalidated application, with a lapse in coverage from June 2 through 15, 2017.  CMS Ex. 7.  Thus, pursuant to section 424.520(d), the date Petitioner filed its subsequently-approved enrollment application – June 16, 2017 – is the correct effective date of enrollment.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

I have no authority to grant Petitioner an earlier effective date based on any equitable or policy arguments.  Sokoloff, DAB No. 2972 at 9.

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Conclusion

Because Petitioner filed its subsequently-approved reenrollment application on June 16, 2017, CMS properly granted its Medicare reenrollment effective that date. 

• 1. I make this one finding of fact/conclusion of law.
• 2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
• 3. CMS makes a compelling argument that Petitioner, in fact, timely received the May 2 notice, but the issue is irrelevant because I have no authority to review the deactivation.
• 4. CMS did not submit a copy of the June 16 application; however, Petitioner does not dispute that it filed a reenrollment application on that date.