Essex Physicians Group LLC, DAB CR5049 (2018)

Department of Health and Human Services
Civil Remedies Division

Docket No. C-18-292
Decision No. CR5049


I enter summary judgment sustaining the determination of a Medicare contractor, as affirmed on reconsideration, to assign an effective date of enrollment of Petitioner, Essex Physicians Group, LLC, and 25 individual practitioners associated with Petitioner, of June 15, 2017.1

I. Background

The Centers for Medicare & Medicaid Services (CMS) moved for summary judgment.  Petitioner opposed the motion but also cross-moved for summary judgment.  In support of its motion CMS offered 34 exhibits, identified as CMS Ex. 1-CMS Ex. 34.  Petitioner filed four exhibits, identified as P. Ex. 1-P Ex. 4.

I find no dispute as to the material facts of this case.  Consequently, there is no need for me to admit the parties’ exhibits into evidence.  I cite to some exhibits in this decision but only to illustrate material facts that are not in dispute.

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II. Issue, Findings of Fact and Conclusions of Law

A. Issue

At issue is whether a Medicare contractor properly assigned an effective participation date to Petitioner and its individual practitioners of June 15, 2017.

B. Findings of Fact and Conclusions of Law

Two regulations govern this case.  First, 42 C.F.R. § 424.525 governs the circumstances under which CMS or a contractor with delegated authority from CMS may reject a Medicare enrollment application.  One of those reasons is failure by a prospective enrollee to respond to an information request from CMS or a contractor within 30 days of the date of the request.  42 C.F.R. § 424.525(a)(1).

A rejected enrollment application is not appealable.  42 C.F.R. § 424.525(d).  I have no authority to hear a challenge to an enrollment application rejection.  I may not entertain evidence or arguments concerning the propriety of a contractor’s decision to reject an application.

Second, 42 C.F.R. § 424.520(d) establishes the effective date on which an applicant for participation in Medicare may participate.  As a general rule, the earliest effective participation date for any newly enrolled Medicare supplier is the date on which that individual or entity submits an application that a Medicare contractor subsequently approves.2

The undisputed facts of this case establish that the contractor charged with processing Petitioner’s Medicare enrollment application approved a participation application from Petitioner that it received on June 15, 2017.  CMS Ex. 34.3   June 15 is the earliest participation date that the contractor could have assigned to Petitioner and its practitioners.  Consequently, the contractor’s determination to assign June 15 to Petitioner and its practitioners as the effective date of their Medicare participation is consistent with regulatory requirements.

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Petitioner argues that the contractor erred in assigning June 15 as the effective participation date, contending that it should receive an effective participation date of May 1, 2017. Petitioner bases this argument on its contention that the contractor mishandled a participation application that Petitioner filed on May 1. As support, Petitioner recites a series of communications between its representative and an employee of the contractor that it asserts took place between May 15 and June 5, 2017. Petitioner’s motion for summary judgment and response in opposition to CMS’s motion for summary judgment at 2-3; see P. Ex. 1-P. Ex. 4. It contends that, by virtue of Petitioner’s responses to the contractor’s information requests, the contractor had all of the information that it needed to process Petitioner’s May 1 application to completion and that it improperly rejected it.

I may not consider these arguments. They do not relate to the propriety of the contractor’s determination to accept the application that Petitioner completed on June 15, but rather, they address the propriety of the contractor’s decision to reject Petitioner’s May 1 application. As I have stated, that rejection is not appealable.

  • 1. As a consequence of the contractor’s determination and this decision Petitioner and its practitioners may file claims for Medicare services delivered on or after May 16, 2017.
  • 2. As a matter of administrative discretion, contractors may allow newly enrolled suppliers to file claims for services provided up to 30 days prior to the effective dates of their participation.
  • 3. Petitioner began filing this application on June 5, 2017, but did not complete its filing until June 15. CMS Ex. 34.