C.J. Yoon, M.D., PC, CR6045 (2022)

DECISION

C.J. Yoon, M.D., is a physician, practicing in Indiana, who participates in the Medicare program through his sole owner practice group, C.J. Yoon, M.D., PC, the petitioner in this case.  After its Medicare billing privileges were deactivated, Petitioner applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, effective November 14, 2019, with a retrospective billing date of October 14, 2019.  As a result, Petitioner’s Medicare coverage lapsed from December 31, 2018, through October 14, 2019.  Petitioner now challenges the November 14 effective date and asks that the lapse in coverage be eliminated.

Because Petitioner C.J. Yoon, M.D., PC filed its subsequently-approved enrollment application on November 14, 2019, November 14 is the earliest possible effective date for its 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).

I have no authority to review the deactivation nor any rejected application.  Sokoloff, DAB No. 2972 at 6; Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); Ark. Health Grp., DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).

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Background

In a notice dated December 6, 2019, the Medicare contractor, Wisconsin Physician Service Insurance Corporation, advised Petitioner that it approved the supplier’s revalidated Medicare enrollment application, with a gap in billing privileges from December 14, 2018, through October 15, 2019.  CMS Ex. 11.  Petitioner requested reconsideration.  CMS Ex. 1.  In a reconsidered determination, dated March 9, 2020, the contractor affirmed (without specifying) the November 14 effective date but changed the onset of the billing gap from December 14 to December 31, 2018.  CMS Ex. 2.

Petitioner appealed.

CMS moves for summary judgment.  However, CMS proposes no witnesses.  Petitioner lists one witness and submits her written declaration, but CMS has not asked to cross-examine her.  (P. Ex. 1).  Because the sole witness’s direct testimony is already in the record, and no witnesses will be cross-examined, an in-person hearing would serve no purpose.  This matter may therefore be decided based on the written record.  See Acknowledgment and Pre-hearing Order at 3, 6 (¶¶ 4(c)(iv), 10) (April 20, 2020).1

CMS submits its motion and brief (CMS Br.) with 11 exhibits (CMS Exs. 1-11).  Petitioner submits its brief (P. Br.) and 9 exhibits (P. Exs. 1-9).  In the absence of any objections, I admit into evidence CMS Exs. 1-11 and P. Exs. 1-9.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

Petitioner filed its subsequently-approved enrollment application on November 14, 2019, and its reactivated Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).2

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Enrollment.  Petitioner C.J. Yoon, M.D., PC, 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 U.S.C. §§ 1834m(j), 1834n(a); 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. § 424.502.3  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 organization, 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 organization 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).

Revalidation and Deactivation.  To maintain its billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of its 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 its 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 its enrollment information, CMS may deactivate its billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3); 424.555(b).  To reactivate its 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

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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 July 27, 2018, the contractor directed Petitioner to revalidate its Medicare enrollment no later than October 31, 2018, updating or confirming the information in its record.  The letter warned that, if Petitioner failed to respond to the notice, the contractor could stop its Medicare billing privileges, and the supplier would not be paid for services rendered during the period of deactivation.  CMS Ex. 3.  In a second letter, dated September 26, 2018, the contractor gave Petitioner until December 31, 2018, to revalidate its enrollment.  CMS Ex. 4.

Responding to the notices, NWI Medical Management Group, Inc., submitted enrollment applications on behalf of Petitioner:  Form CMS-855I (for physicians), submitted on October 19, 2018, and Form CMS 855B (for group practices), which the contractor received on October 19, 2018, and November 5, 2018.  CMS Exs. 5, 6.4

The contractor determined that the applications were insufficient and, by letters dated November 14 and 26, 2018, sent Petitioner lists of requested revisions and requests for additional information.  CMS Exs. 7, 8.  The letters warned that the contractor would reject the applications if Petitioner did not furnish the complete information within 30 days.  CMS Ex. 7 at 1; CMS Ex. 8 at 1.

The contractor received no response.

In a letter dated December 15, 2018, the contractor advised Petitioner that its Medicare billing privileges were stopped, effective December 14, 2018, because the supplier had not revalidated its enrollment record or didn’t respond to requests for more information.  CMS Ex. 9.

On November 14, 2019, Petitioner submitted another enrollment application (Form CMS-855I), which the contractor subsequently approved.  CMS Exs. 10, 11.  Thus, pursuant to

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section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – November 14, 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.

Petitioner challenges the deactivation and complains that it did not receive the development requests or the deactivation notice, which were sent to its billing agent.  The billing agent stopped operating on November 9, 2018.  Petitioner also points to the September 26, 2018 letter, which gave the supplier a December 31, 2018 deadline to revalidate its application.  CMS Ex. 4.  Petitioner maintains that it could have met the December 31 deadline, but, with the November 2018 development letters, the contractor effectively moved the goalposts.  Notwithstanding the merits of his arguments, I simply have no authority to review the deactivation nor the rejected applications.  Chaplin Liu, M.D., DAB No. 2976 at 7; Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7; James Shepard, M.D., DAB No. 2793 at 8.

Conclusion

Because Petitioner C. J. Yoon, M.D., PC, filed its subsequently-approved reenrollment application on November 14, 2019, CMS properly granted its Medicare reenrollment effective that date.  CMS also had the authority to allow the supplier to bill up to 30 days prior to that effective date.