Michael Lalezarian, M.D., DAB CR5672 (2020)

DECISION

Petitioner, Michael A. Lalezarian, M.D., is a physician practicing in California.  He applied to reassign his Medicare billing privileges to a group practice, Southern California Vascular and Vein Center, Inc.  The Centers for Medicare & Medicaid Services (CMS) granted his application with a retrospective billing date of August 15, 2017 (and, by inference, an effective date of September 14, 2017).  Petitioner now challenges that effective date.  Acknowledging “employee error” and complaining of “huge financial hardship,” Petitioner asks that his billing date be changed to July 1, 2017. 

Because Petitioner filed his subsequently-approved enrollment application on September 14, 2017, I find that September 14 is the correct effective date for the enrollment.

Background

In a letter dated October 20, 2017, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that it approved his Medicare enrollment with an “effective date” of August 15, 2017.  CMS Ex. 5.  In fact, as explained below, the contractor was granting Petitioner a billing date of August 15, 2017; the effective date of Petitioner’s enrollment was September 14, 2017 (see discussion below).

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Petitioner sought reconsideration, asking that the effective date of his enrollment be changed to July 1, 2017.  CMS Ex. 6 at 9-10.  In a reconsidered determination, dated December 19, 2017, the contractor denied Petitioner an earlier effective date, concluding that he filed his subsequently-approved application on September 14 and that CMS appropriately allowed a retrospective billing date 30 days prior (August 15).  CMS Ex. 7. 

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) (February 26, 2018).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.

With its motion and brief, CMS submits eight exhibits (CMS Exs. 1-8).  Petitioner submits two exhibits (P. Exs. 1-2).  In the absence of any objections, I admit into evidence CMS Exs. 1-8 and P. Exs. 1-2.  

Discussion

On September 14, 2017, Petitioner filed his subsequently-approved application to reassign his billing privileges, and his Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).1

Enrollment.  Petitioner Lalezarian 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. 

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.  The effective date for its 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).

If a physician meets all program requirements, CMS may allow it to bill retrospectively for up to 30 days prior to the effective date “if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.”  42 C.F.R. § 424.521(a)(1).

Some Medicare contractors have created confusion because they are inclined to conflate the effective date with the retrospective billing date, as the contractor did in this case.  CMS Ex. 5.  The distinction is important; I have the authority to review “[t]he effective date of . . . supplier approval.”  42 C.F.R. § 498.3(b)(15).  But nothing in the regulations gives me the authority to review CMS’s determinations regarding retrospective billing.  Although it mischaracterizes August 15 as the “effective date,” the reconsidered determination here is somewhat more accurate than the initial notice, finding that Petitioner filed his enrollment application on September 14, 2017, and was granted 30-days retrospective billing under section 424.521.  CMS Ex. 7 at 2.

Here, on September 14, 2017, the Medicare contractor received Petitioner’s enrollment application (CMS 855R), which the contractor subsequently approved.  CMS Ex. 1.3  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – September 14, 2017 – is the correct effective date of enrollment.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 at 7-9 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).

Petitioner, however, complains that he attempted to enroll in April 2017, but, in error, the employee responsible for completing his application advised him that his reassignment had been approved at that time.  Based on that employee representation, Petitioner had

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been providing covered services and, without an earlier effective date, he and the practice would suffer severe financial hardship.  P. Ex. 1.  

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

Conclusion

Because Petitioner filed his subsequently-approved enrollment application on September 14, 2017, CMS properly granted his Medicare enrollment effective that date.  CMS is authorized to allow him to bill retrospectively for 30 days prior to that date.