Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
Lee Snyder, MD,
Centers for Medicare & Medicaid Services.
Docket No. C-19-1139
Decision No. CR5966
Petitioner, Lee Snyder, MD, is a Maryland physician, specializing in ophthalmology. After her Medicare billing privileges were deactivated, she applied to reenroll in the program. The Centers for Medicare & Medicaid Services (CMS) granted her application, effective April 23, 2019, with a retrospective billing date of March 24, 2019, resulting in a coverage lapse from February 14, 2019, through March 23, 2019. Petitioner now challenges that effective date and asks that the lapse in coverage be eliminated.
Because Petitioner Snyder filed her subsequently-approved enrollment application on April 23, 2019, I find that April 23 is the earliest possible effective date for her enrollment. 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).
In a notice dated May 7, 2019, the Medicare contractor, Novitas Solutions, advised Petitioner that it approved her revalidated Medicare enrollment application, with a gap in billing privileges from February 14 through March 23, 2019. CMS Ex. 9. Petitioner requested reconsideration. CMS Ex. 10.
In a reconsidered determination, dated August 2, 2019, the contractor affirmed the April 23, 2019, reactivation date. CMS Ex. 11. 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 4, 6 (¶¶ 4(c)(iv), 10) (Oct. 4, 2019). 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 11 exhibits (CMS Exs. 1-11). Petitioner submits a brief (P. Br.) and four exhibits (P. Exs. 1-4). In the absence of any objections, I admit into evidence CMS Exs. 1-11 and P. Exs. 1-4. See Acknowledgment and Pre-hearing Order at 5 (¶ 7).
Petitioner filed her subsequently-approved enrollment application on April 23, 2019, and her reactivated Medicare enrollment can be no earlier than that date. 42 C.F.R. § 424.520(d).1
Enrollment. Petitioner Snyder 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
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 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).
If a physician meets all program requirements, CMS may allow her 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).
Revalidation and Deactivation. To maintain her billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of her 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 her 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 her enrollment information, CMS may deactivate her billing privileges, and no Medicare payments will be made. 42 C.F.R. §§ 424.540(a)(3); 424.555(b). To reactivate her 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 May 30, 2018, the contractor directed Petitioner to revalidate her Medicare enrollment no later than August 31, 2018, by updating or confirming the information in her record. The letter warned that, if Petitioner failed to respond to the notice, her Medicare enrollment could be deactivated; the letter explained that, during the period of deactivation, Medicare would not pay for the services rendered. CMS Ex. 1.
The contractor received no response.
In a second letter, dated January 14, 2019, the contractor reminded Petitioner that she had not revalidated her enrollment as requested and warned that, if she failed to do so, her Medicare enrollment would be deactivated and she would not be paid for services rendered during the period of deactivation. CMS Ex. 2.
In a letter dated February 14, 2019, the contractor advised Petitioner that her Medicare billing privileges were stopped, effective February 14, 2019, because she had not revalidated her enrollment record. CMS Ex. 3.
On February 21, 2019, Petitioner filed a reenrollment application (Form CMS-855I). CMS Ex. 4. However, she did not include a required reassignment-of-benefits application (Form CMS-855R).
In an e-mail, sent March 20, 2019, the contractor directed Petitioner to submit the required application, and reminded Petitioner that “[s]ignatures are required from the provider and the current Authorized Official.” The e-mail advised Petitioner that corrections “must be received by April 19, 2019.” CMS Ex. 5.
On April 5, 2019, Petitioner submitted the required Form CMS-855R. However, the application was not signed by an authorized official. CMS Ex. 6.
In a letter dated April 22, 2019, the contractor advised Petitioner that it rejected her February 21 application because she failed to submit, within 30 days of the contractor’s request, a CMS Form-855R with original signatures. CMS Ex. 7.
Petitioner objects to the rejection, maintaining that she was not wholly responsible for the delay in submitting an acceptable CMS-855R. She asserts that, on March 22, 2019, she attempted, unsuccessfully, to submit the Form CMS‑855R with the required signatures but was unable to attach it electronically to the February 21 application. Although she “tried to reach CMS daily to see how to submit this revised document,” she did not reach anyone from CMS until April 5, 2019, when she was advised to send the revised Form CMS‑855R via fax. P. Br. at 2 (¶ 4); P. Ex. 2. In an April 10 telephone call, CMS asked her to resend the application, which she did. P. Ex. 3; P. Br. at 2-3 (¶ 5).3 I simply have no authority to review a rejected application, notwithstanding the merits of Petitioner’s position. Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).
On April 23, 2019, Petitioner Snyder filed, via PECOS, her Medicare reenrollment applications (Forms CMS-855I and 855R), which the contractor subsequently approved. CMS Ex. 8. Thus, pursuant to section 424.520(d), the date Petitioner filed her
subsequently-approved enrollment applications – April 23, 2019 – is the correct effective date of enrollment. Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB 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.
Because Petitioner Snyder filed her subsequently-approved reenrollment application on April 23, 2019, CMS properly granted her Medicare reenrollment effective that date. CMS also had the authority to allow her to bill up to 30 days prior to that effective date.
Carolyn Cozad Hughes Administrative Law Judge
1. I make this one finding of fact/conclusion of law.
- back to note 1 2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
- back to note 2 3. Of course, ultimately, this was not an acceptable application. Petitioner implies that, had she been able to submit the unacceptable application earlier, she’d have known to correct earlier, and could have submitted it within the deadline for approval of her February 21 application.
- back to note 3