Brian Petersen, M.D., CR6481 (2024)

DECISION

The Centers for Medicare & Medicaid Services (CMS), through a Medicare contractor, determined that the effective date for the reassignment of Medicare benefits from Brian Petersen, M.D. (Dr. Petersen or Petitioner) to his employer, Integra Imaging, PS (Integra) is August 13, 2023.  Petitioner requested a hearing to obtain a different effective date, asserting that a previous termination of Petitioner’s reassignment to Integra was in error and that the effective date of reassignment should be the same date as the date of termination for the previous reassignment.

I affirm CMS’s determination that the effective date for Petitioner’s reassignment of Medicare billing privileges to Integra is August 13, 2023.  I do so because I only have jurisdiction to determine whether CMS set the correct effective date for the reassignment based on the governing regulations.  I cannot consider whether CMS correctly or incorrectly terminated Petitioner’s previous reassignment to Integra.  Therefore, because CMS received the application for reassignment of Petitioner’s Medicare benefits on September 12, 2023, CMS properly set the effective date for reassignment as 30 days before Petitioner submitted the application, which is August 13, 2023.

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I.  Background and Procedural History

On February 5, 2024, Petitioner requested a hearing before an administrative law judge to dispute CMS’s January 23, 2024 reconsidered determination, which stated that August 13, 2023, is the effective date for Petitioner’s reassignment of Medicare benefits to Integra.

On February 6, 2024, the Civil Remedies Division acknowledged receipt of the hearing request and issued my Standing Order.  In response, CMS filed a brief/motion for summary judgment (CMS Br.) and nine proposed exhibits.  Petitioner then filed a brief/opposition to summary judgment (P. Br.) and three proposed exhibits.  One of the proposed exhibits was written direct testimony from a witness.  P. Ex. 3.  Finally, CMS filed notice that it waived its right to submit a reply brief.

II.  Admission of Evidence

Neither party objected to any of the proposed exhibits.  See Standing Order ¶ 10.  Therefore, I admit them all into the record.

III.  Decision on the Written Record

I directed the parties to submit the written direct testimony of any witnesses they wanted to offer.  Standing Order ¶ 11; Civil Remedies Division Procedures (CRDP) § 16(b).  I informed the parties that, if a party submitted written direct testimony from one or more witnesses, then I would only hold an in-person hearing if the opposing party requested to cross-examine the witness or witnesses.  Standing Order ¶¶ 12-13; CRDP § 19(b).

CMS did not submit any written direct testimony and did not request to cross-examine the witness from whom Petitioner submitted written direct testimony.  Therefore, I do not hold an in-person hearing in this case, and I issue this decision based on the written record.  Standing Order ¶ 14; CRDP § 19(d); see also Vandalia Park, DAB No. 1940 (2004).

IV.  Issue

Whether August 13, 2023, is the correct effective date for Petitioner’s reassignment of Medicare benefits to Integra.

V.  Jurisdiction

I have jurisdiction to decide the issue in this case.  See 42 C.F.R. § 498.3(b)(15).

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VI.  Findings of Fact, Conclusions of Law, and Analysis

1. On September 12, 2023, a CMS contractor received Petitioner’s application to reassign Medicare benefits to Integra (CMS-855R), which the CMS contractor approved.  The CMS contractor set August 13, 2023, as the effective date for reassignment.

Petitioner is a physician who is employed by Integra.  P. Ex. 3 ¶ 5.  On September 12, 2023, Petitioner electronically filed a CMS-855R application seeking reassignment of Petitioner’s Medicare benefits (i.e., Medicare program reimbursements for services provided to Medicare beneficiaries) to Integra.  CMS Exs. 4-5.  In late September and early October 2023, the CMS contractor requested additional information from Petitioner, which Petitioner provided.  CMS Exs. 6-7.

In an October 6, 2023 notice of initial determination, the CMS contractor approved Petitioner’s reassignment of Medicare benefits and informed Petitioner that the effective date for reassignment was August 13, 2023.  CMS Ex. 8.  Petitioner requested reconsideration of the initial determination; however, the CMS contractor affirmed August 13, 2023, as the effective date for reassignment.  CMS Ex. 9; P. Ex. 1; Electronic Filing System (E-File) Doc. No. 1a.

2. Under 42 C.F.R. § 424.522(a), Petitioner’s reassignment of Medicare benefits to Integra is effective August 13, 2023.

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) (defining a provider).  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).

For Medicare Part B claims, beneficiaries may assign their Medicare benefits to an enrolled physician or non-physician supplier providing services to those beneficiaries.  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 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).  Most importantly for this case:

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A reassignment of benefits under § 424.80 is effective beginning 30 days before the Form CMS-855R is submitted if all applicable requirements during that period were otherwise met.

42 C.F.R. § 424.522(a) (emphasis added).

In the present case, the record is clear that Petitioner submitted and CMS received the CMS-855R application to reassign Medicare benefits to Integra on September 12, 2023.  CMS Ex. 4 at 1.  After receiving additional information from Petitioner, CMS approved that application.  CMS Exs. 6-8.  Therefore, the effective date for the reassignment is 30 days before September 12, 2023, which is August 13, 2023.

Although Petitioner does not dispute the analysis above, Petitioner seeks a reassignment effective date of January 1, 2022, because CMS allegedly terminated Petitioner’s reassignment on January 1, 2022, incorrectly.  P. Br. at 1-2, 4-5.  Petitioner asserts that:  an employee of Integra mistakenly filed notice with CMS that Petitioner wanted to terminate the reassignment to Integra; the employee left Integra shortly after submitting that notice to CMS; despite the erroneous notice, Integra continued to bill Medicare for Petitioner’s services because Petitioner was still employed by Integra; and CMS’s efforts to confirm the request for termination were never received by Integra because CMS emailed the now former employee at a defunct email address.  P. Ex. 1; P. Ex. 3 ¶¶ 6-9; see also CMS Exs. 1-3.

Petitioner’s argument really challenges the termination of Petitioner’s previous reassignment to Integra rather than challenges the effective date for the new reassignment.  However, I only have jurisdiction over the question as to whether an effective date was properly established in the applicable regulations.  42 C.F.R. § 498.3(b)(15); see also Sandeep Gupta, M.D., DAB No. 3088 at 6-11 (2023) (concluding that the effective date for reassignment is appealable in the same manner as the effective date for Medicare enrollment).¹

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VII.  Conclusion

The effective date of Petitioner’s reassignment of Medicare benefits is August 13, 2023.

Endnotes

¹  A similar situation arises when a supplier’s Medicare billing privileges have been deactivated.  While there is a right to administrative law judge review of the effective date of reactivation, there is no right to administrative law judge review of the deactivation that gave rise to the need to reactivate.  Tosan Fregene, M.D. and Oncology Clinics, Inc., DAB No. 3018 at 7 (2020).