Melissa Tucker, NP, DAB CR6569 (2024)

DECISION

I affirm the determination of the Centers for Medicare & Medicaid Services (CMS) that the effective date for the reactivation of the Medicare billing privileges for Petitioner, Melissa Tucker, is March 12, 2024.  I also affirm the determination that the effective date for Petitioner’s reassignment of Medicare benefits to Pennsylvania Urgent Care Centers, PLLC (Pennsylvania Urgent Care) is February 11, 2024.

I.   Procedural History

On June 21, 2024, Petitioner filed a request for hearing before an administrative law judge (RFH) seeking an effective date of November 15, 2023, for the reactivation of billing privileges and the reassignment of her Medicare benefits to Pennsylvania Urgent Care.

On June 24, 2024, the Civil Remedies Division acknowledged receipt of the hearing request and issued my Standing Order.  On July 15, 2024, CMS filed a brief/motion for summary judgment (CMS Br.) and six proposed exhibits.  On July 26, 2024, Petitioner

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filed a notice that she was appointing three non-attorney representatives to appear on her behalf in this case.  However, Petitioner ultimately did not file a prehearing exchange.  

II.   Admission of Evidence

I admit all of CMS’s proposed exhibits without objection.  See Standing Order ¶ 10.  

III.  Decision on the Written Record

I directed the parties to submit the written direct testimony for any witnesses they wanted to offer.  Standing Order ¶ 11.  I also informed the parties as follows: 

If the parties either do not file any written direct testimony or the parties do not request to cross-examine any of the witnesses from whom written direct testimony has been submitted, I will consider such actions by the parties to serve as a constructive request for a decision on the written record because there will be no reason to hold an in-person hearing.  

Standing Order ¶ 7(g)(iii).  I further advised:  “Unless a hearing is required for cross-examination of a witness or witnesses, the record will be closed and the case will be ready for a decision after all the submission deadlines have passed.”  Standing Order ¶ 14. 

Neither party submitted written direct testimony from any witnesses and all submission deadlines have passed.  Therefore, I decide this case on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 11-12 (2022); Civil Remedies Division Procedures § 19(d). 

IV.  Issues

1. Whether March 12, 2024, is the correct effective date for the reactivation of Petitioner’s Medicare billing privileges.
2. Whether February 11, 2024, is the correct effective date for the reassignment of Medicare benefits to Pennsylvania Urgent Care. 

V.  Jurisdiction 

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

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VI.  Findings of Fact

1. On March 12, 2024, CMS received from Petitioner applications to reactivate her Medicare billing privileges as a nurse practitioner and to reassign her Medicare benefits to Pennsylvania Urgent Care.  CMS Exs. 1, 2.  
2. On March 22, 2024, a CMS contractor approved Petitioner’s applications with an effective date of February 12, 2024.  CMS Ex. 3.
3. On April 1, 2024, Petitioner requested reconsideration of the February 12, 2024 effective date for reactivation and reassignment, and Petitioner asked for an effective date of November 15, 2023.  CMS Ex. 4.
4. On June 5, 2024, the CMS contractor issued a reconsidered determination stating that Petitioner’s effective date for reactivation of Medicare billing privileges and the reassignment of Medicare benefits was March 12, 2024, and that Petitioner’s period of retrospective billing started on February 11, 2024.  CMS Ex. 5.
5. On June 5, 2024, the CMS contactor issued a correction to its March 22, 2024 initial determination and stated that the effective date for each of Petitioner’s Provider Transaction Access Numbers (PTAN) was February 12, 2024.  CMS Ex. 6.

VII.  Conclusions of Law and Analysis

1. The effective date for the reactivation of Petitioner’s Medicare billing privileges is March 12, 2024.

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” includes “a physician or other practitioner . . . that furnishes items or services” under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d).  A supplier must enroll in the Medicare program to receive payment for covered items or services.  42 U.S.C. §§ 1395n(a),1395u(h)(1); 42 C.F.R. § 424.505.  To enroll, the supplier must submit an enrollment application and provide all required information.  42 C.F.R. § 424.510(a). 

CMS may deactivate a supplier’s Medicare billing privileges for a variety of reasons and a supplier may request to reactivate those billing privileges.  42 C.F.R. § 424.540(a)-(b).   If a supplier seeks reactivation, “[t]he effective date of a reactivation of billing privileges under this section is the date on which the Medicare contractor received the . . . supplier’s

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reactivation submission that was processed to approval by the Medicare contractor.”  42 C.F.R. § 424.540(d)(2). 

In this case, CMS received Petitioner’s enrollment application to reactivate Medicare billing privileges on March 12, 2024.  CMS Ex. 1 at 1.  CMS approved that application.  CMS Ex. 3.  Therefore, the effective date of reactivation is March 12, 2024.1

Petitioner argued both on reconsideration and in this proceeding that the filing of an enrollment application was delayed through no fault of her own.  Petitioner stated that, in October 2023, she attempted to electronically file the reactivation and reassignment applications through the Provider, Enrollment, Chain, and Ownership System (PECOS); however, PECOS displayed an “Error Message” that Petitioner could not be verified in the National Plan and Provider Enumeration System (NPPES).  Petitioner attempted to remedy the situation but had difficulty doing so.  Eventually, Petitioner learned that there was a discrepancy in her date of birth on file with NPPES.  In February 2024, Petitioner requested to correct her birth date with NPPES, which was approved on March 6, 2024.  Based on the time that it took to resolve the NPPES issue, Petitioner requested an effective date for the reactivation of billing privileges to be November 15, 2023.  RFH at 1, 3-4; CMS Ex. 4 at 2.  

Petitioner’s argument revolves around her National Provider Identifier (NPI).  The Act required the Secretary to adopt standards for providing a unique health identifier for each individual, employer, health plan, or health care provider for use in the health care system.  42 U.S.C. § 1320d-2(b)(1).  The Secretary established the NPI.  45 C.F.R. § 162.406.  The Secretary also established the National Provider System (NPS), which assigns “a single, unique NPI” to health care providers.  45 C.F.R. § 162.408(a).  When a supplier files an enrollment application with the Medicare program, the supplier must report the supplier’s NPI.  42 C.F.R. § 424.506(b)(1)(i).  When a supplier files a Medicare claim, the supplier must include the supplier’s NPI or else a Medicare contractor will deny the claim.  42 C.F.R. § 424.506(c). 

Although it is unclear who was at fault for the incorrect date of birth information with NPPES, it does not matter for this adjudication.  My jurisdiction is limited to determining whether CMS assigned the correct date for reactivation under the law.  While this situation is unfortunate, I do not have jurisdiction to provide Petitioner with an earlier effective date for reactivation based on the problems she encountered with her NPI.

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2. The effective date for Petitioner’s reassignment of Medicare benefits to Pennsylvania Urgent Care is February 11, 2024.

The Act permits beneficiaries to assign their Medicare benefits to an enrolled physician or non-physician supplier.  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, 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).  When CMS approves the reassignment of Medicare benefits, the reassignment “is effective beginning 30 days before the [reassignment application] is submitted if all applicable requirements during that period were otherwise met.”  42 C.F.R. § 424.522(a). 

On March 12, 2024, CMS received Petitioner’s application to reassign Medicare benefits to Pennsylvania Urgent Care.  Therefore, the reassignment is effective February 11, 2024. 

VIII.  Conclusion

1. March 12, 2024, is the effective date for the reactivation of Petitioner’s Medicare billing privileges.
2. February 11, 2024, is the effective date of Petitioner’s reassignment of Medicare benefits to Pennsylvania Urgent Care.