Edward Tremoulis, M.D., DAB CR5479 (2019)

DECISION

Petitioner, Edward Tremoulis, M.D., is an Ohio physician who participates in the Medicare program. 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 January 11, 2017. Petitioner now challenges that effective date.

Because Petitioner filed his subsequently-approved enrollment application on January 11, 2017, I find that January 11 is the correct effective date for his enrollment. Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).

Background

In a letter dated January 23, 2017, the Medicare contractor, CGS, advised Petitioner that it approved his Medicare enrollment effective January 11, 2017. CMS Ex. 10. Petitioner requested reconsideration.

In a reconsidered determination, dated April 25, 2017, a contractor hearing officer affirmed the January 11, 2017 effective date. CMS Ex. 12. Petitioner appealed.

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Although CMS moves for summary judgment, I find that this matter may be decided on the written record, without considering whether the standards for summary judgment are satisfied. In my initial order, I instructed the parties to list proposed witnesses (if any) and to submit their written direct testimony. Acknowledgment and Pre-hearing Order at 3, 5 (¶¶ 4, 8) (May 26, 2017). I also directed each party to state, affirmatively, whether it intended to cross-examine any proposed witness. Order at 5 (¶ 9). An in-person hearing is necessary “only if a party files admissible, written direct testimony, and the opposing party asks to cross-examine.” Order at 5 (¶ 10). CMS lists no witnesses. Petitioner lists one witness, himself, and provides a written declaration. P. Ex. A. CMS has not asked to cross-examine him. An in-person hearing would therefore serve no purpose, and I may decide the case based on the written record.

With its motion and brief, CMS submits twelve exhibits, CMS Exs. 1-12. With his response (P. Br.), Petitioner submits one exhibit, P. Ex. A. In the absence of any objections, I admit into evidence CMS Exs. 1-12 and P. Ex. A.

Discussion

Petitioner filed his subsequently-approved enrollment application on January 11, 2017, and his Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Tremoulis 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 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

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from Medicare for covered services provided to program beneficiaries.  For a physician, 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 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 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 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.  Urology Grp., DAB No. 2860 at 7; Goffney, DAB No. 2763 at 7.

Petitioner’s deactivation and reenrollment.  In a notice letter dated August 15, 2016, the contractor directed Petitioner Tremoulis to revalidate his Medicare enrollment by updating or confirming the information in his 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 October 31, 2016, or risk his Medicare enrollment being deactivated; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered.  CMS Ex. 1 at 2.

In response, on November 2, 2016, Petitioner submitted, by Federal Express, an enrollment application.  CMS acknowledges that the contractor received it on November 3, 2016.3  In a letter dated November 17, 2016, the contractor directed Petitioner to provide additional information and signatures.  The letter encouraged him to respond within ten days and warned that his Medicare billing privileges would be deactivated if he failed to do so within 30 days.  CMS Ex. 6.  Petitioner did not respond within 30 days.  On December 22, his office faxed at least some of the requested

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information, but it was apparently too late, was improperly submitted, or was incomplete.  CMS Ex. 7; see CMS Br. at 8 n.3.  In any event, in a notice dated December 28, 2016, the contractor advised Petitioner that his Medicare billing privileges were stopped on December 27, 2016, because he had not responded to the request for more information.  The contractor would not pay for any claims after that date.  CMS Ex. 8. 

Petitioner challenges the deactivation, arguing that he did not receive the notice letters – which doesn’t explain how or why he submitted the November 2 enrollment application or the December 22 fax.  In any event, I have no authority to review the deactivation.  Ark. Health Grp., DAB No. 2929 at 7-9 (2019), and cases cited therein. 

On January 11, 2017, the contractor received Petitioner’s reenrollment application, which it subsequently approved.  CMS Ex. 9.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – January 11, 2017 – is the correct effective date of enrollment.  Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.

Conclusion

Because Petitioner filed his subsequently-approved reenrollment application on January 11, 2017, CMS properly granted his Medicare reenrollment effective that date.