Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
Louise Knudson, CRNA
(NPI: 1538551080 / PTAN: Q49688B),
Centers for Medicare & Medicaid Services.
Docket No. C-21-1006
Decision No. CR5980
The effective date for the reassignment of Medicare benefits from Petitioner to Atlantic Anesthesia, Inc. (Atlantic) is May 20, 2021.
The Center for Medicare & Medicaid Services (CMS) contractor that issued the initial and reconsidered determinations in this matter incorrectly provided Petitioner with a retrospective reassignment period commencing on January 19, 2021. Although the CMS contractor exceeded its authority under the regulations to give Petitioner a more generous retrospective period, this retrospective period is not within my jurisdiction to review. Therefore, I neither affirm nor reverse that determination.
I. Background and Procedural History
Petitioner is a Certified Registered Nurse Anesthetist (CRNA), who was enrolled in the Medicare program as a supplier. On May 20, 2021, Petitioner electronically filed an application seeking reassignment of Medicare benefits from Petitioner to Atlantic. CMS Ex. 1. In a May 26, 2021 initial determination, a CMS contractor approved Petitioner’s reassignment of Medicare benefits and informed Petitioner that the effective date for
reassignment was January 19, 2021. CMS Ex. 2. Petitioner filed a request for reconsideration with documents supporting the request. Petitioner asserted that the effective date should be January 4, 2021. CMS Ex. 3. In a July 23, 2021 reconsidered determination, the CMS contractor upheld the initial determination. CMS Ex. 4.
Petitioner requested a hearing before an administrative law judge to dispute the reconsidered determination. The Civil Remedies Division acknowledged receipt of the hearing request and issued my Standing Prehearing Order. In response, CMS filed a brief/motion for summary judgment (CMS Br.) and five proposed exhibits. Petitioner did not file a prehearing exchange; however, Petitioner requested a decision based on the documents that she previously submitted in the case. DAB E-File Document #7.
II. Admission of Evidence and Decision on the Written Record
I render this decision based on the written record because Petitioner requested that I do so. 42 C.F.R. § 498.66.
Petitioner did not object to CMS’s proposed exhibits; therefore, I admit CMS Exs. 1-5 into the record. 42 C.F.R. § 498.66(d)(1).
Whether the effective date for Petitioner’s reassignment of Medicare benefits to Atlantic is correct.
I have jurisdiction to decide the issue in this case. See 42 C.F.R. § 498.3(b)(15).
V. Findings of Fact, Conclusions of Law, and Analysis
My findings of fact and conclusions of law are set forth in italics and bold font.
The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers. 42 U.S.C. §§ 1302, 1395cc(j). A “supplier” is “a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services” under the Medicare provisions of the Act. 42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u). A CRNA is a practitioner recognized under the Act. 42 U.S.C. § 1395x(bb); 42 C.F.R.§ 410.69.
A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services. 42 C.F.R. § 424.505. A supplier seeking billing privileges under the
Medicare program must “submit enrollment information on the applicable enrollment application. Once the . . . supplier successfully completes the enrollment process . . . CMS enrolls the . . . supplier into the Medicare program.” 42 C.F.R. § 424.510(a)(1). CMS then establishes an effective date for billing privileges under the requirements stated in 42 C.F.R. § 424.520(d) and may permit a retrospective billing period under 42 C.F.R. § 424.521(a).
For Medicare Part B claims, a beneficiary may assign his or her benefits to an enrolled physician or non-physician supplier providing services to that beneficiary. 42 U.S.C. § 1395u(b)(3)(B)(ii). In certain circumstances, a supplier who has received an assignment of benefits may reassign those benefits to an employer, or to an individual or entity with which the supplier has a contractual arrangement. 42 U.S.C. § 1395u(b)(6); 42 C.F.R. § 424.80(b)(1)-(2).
1. On May 20, 2021, the CMS contractor received Petitioner’s application to reassign Medicare benefits to Atlantic (CMS-855R), which the CMS contractor approved.
Petitioner electronically submitted an application to reassign Medicare benefits to Atlantic. Petitioner indicated that the reason for her submission was: “A Medicare Part B practitioner is currently enrolled in Medicare and is reassigning his/her benefits to a Part B supplier, Part B practitioner or Part A provider currently enrolled in Medicare.” CMS Ex. 1 at 1. Petitioner requested that CMS make the reassignment effective as of January 4, 2021. CMS Ex. 1 at 2.
The CMS contractor ultimately approved this application and provided Petitioner with a January 19, 2021 effective date for the reassignment. CMS Ex. 2.
2. Petitioner’s reassignment of Medicare benefits to Atlantic is effective May 20, 2021.
Petitioner asserts that the effective date for reassignment of Medicare benefits ought to be January 4, 2021, because “this is the date [Petitioner] received privileges at the hospital and began seeing patients.” Hearing Req. at 1; CMS Ex. 3 at 4. Petitioner submitted a letter jointly from Sentara Leigh Hospital and Sentara Norfolk General Hospital to support this argument. CMS Ex. 3 at 5.
CMS argues that the date of receipt of Petitioner’s application for reassignment is the effective date for the reassignment because the CMS contractor approved that application. CMS Br. at 5.
The effective date for Medicare billing privileges for physicians, non‑physician practitioners, and physician or non‑physician practitioner organizations is the later of the
“date of filing” or the date the supplier first began furnishing services at a new practice location. 42 C.F.R. § 424.520(d). The “date of filing” is the date that the Medicare contractor “receives” an enrollment application that the Medicare contractor is able to process to approval. Donald Dolce, M.D.,DAB No. 2685 at 8 (2016). This regulation applies to applications for the reassignment of Medicare benefits. Gaurav Lakhanpal, MD, DAB No. 2951 at 6-8 (2019).
In the present case, it is undisputed that the CMS contractor received Petitioner’s reassignment application on May 20, 2021. CMS Ex. 1 at 2. This is later than the date that Petitioner first began furnishing services at the new practice locations indicated by Petitioner. Therefore, May 20, 2021 is the effective date of reassignment.
The CMS contractor, in both the initial and reconsidered determinations, incorrectly informed Petitioner that the effective date for the reassignment is January 19, 2021. CMS Ex. 2 at 1; CMS Ex. 4 at 3. This is incorrect because, while the CMS contractor may provide a retrospective period for the reassignment, that is not the effective date of the reassignment. Compare 42 C.F.R. § 424.520(d) with 42 C.F.R. § 424.521(a). The CMS contractor was also incorrect in its determinations because the retrospective period may not exceed 90 days preceding the effective date; therefore, the CMS contractor violated the regulations when it did not correct the 120-day retrospective period in the reconsidered determination. CMS Ex. 5 ¶¶ 8-9; 42 C.F.R. § 424.521(a). However, I only have authority to review the effective date in this case and not the retrospective period assigned by the CMS contractor.
The effective date of Petitioner’s reassignment of Medicare benefits is May 20, 2021.
Scott Anderson Administrative Law Judge