Zvezdomir P. Zamfirov, M.D., and All Star Pain Management and Regenerative Medicine, LLC, DAB CR6599 (2025)

DECISION

Petitioners, All Star Pain Management and Regenerative Medicine, LLC, are group medical practices, located in Annapolis, Maryland.  Petitioner Zvezdomir Zamfirov, M.D., is a physician who owns the practices and assigns his Medicare benefits to them.  After the Medicare contractor deactivated Petitioners’ Medicare billing privileges, effective May 15, 2024, Petitioners submitted new applications, seeking to reactivate their enrollments.

Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the Medicare contractor approved the applications, with an effective billing date of May 22, 2024.  As a result, Petitioners’ Medicare coverage lapsed from May 15 through May 21, 2024.  Here, Petitioner maintains that the deactivation was caused by a clerical mistake and asks for an earlier effective date.

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On May 22, 2024, the Medicare contractor received Petitioners’ reactivation submission that it processed to approval.  May 22, 2024 is therefore the effective date for reactivating its billing privileges.  See 42 C.F.R. § 424.540(d)(2).

I have no authority to review the deactivation nor to order retrospective reimbursement for services provided during the period of deactivation.

Background

In notice letters dated May 30, 2024, the Medicare contractor, Novitas Solutions, advised Petitioners that the contractor approved their reactivation enrollment and reassignment applications with a gap in billing privileges from May 15, 2024, through May 21, 2024.  CMS Exs. 6, 7, 8, 9.

Petitioners requested reconsideration.  CMS Exs. 10, 11.  In a reconsidered determination, dated August 1, 2024, a contractor hearing specialist affirmed the initial determination, with the seven-day gap in billing privileges.  CMS Ex. 16.

Petitioner appeals, and the matter is now before me.

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) (August 27, 2024).  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 19 exhibits (CMS Exs. 1-19).  In the absence of any objections, I admit into evidence CMS Exhibits 1-19.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Although directed to do so, Petitioners declined to file a brief or any other documents.  Acknowledgment and Pre-hearing Order at 3 (¶ 4(b)).  In the absence of a brief, I consider the arguments set forth in their reconsideration submissions.  CMS Exs. 10, 11; see Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).1

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Discussion

On May 22, 2024, Petitioners filed their subsequently-approved Medicare reactivation applications, and the effective date of their reactivations can be no earlier than that date.  42 C.F.R. § 424.540(d)(2).2

Enrollment.  Petitioners participate in the Medicare program as “suppliers” of services.  See 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.  Act §§ 1834(j), 1835(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 submitting a new enrollment application, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “[t]he date that the . . . supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d)(1) (emphasis added).  Because this case involves re-enrollment after a deactivation, additional regulations apply.

Re-enrollment following deactivation.  The regulations governing re-enrollment after a deactivation differ in some ways from the enrollment regulations.  See 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021).

To maintain its billing privileges, a supplier must resubmit and recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  CMS may also perform off-cycle revalidations at any time.  42 C.F.R. § 425.515(d).  Within 60 days of receiving CMS’s notice, the supplier must submit the applicable enrollment application and supporting documentation.  42 C.F.R. § 424.515(a)(2).  CMS may deactivate a

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supplier’s billing privileges if the supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receiving CMS’s request that it do so.  42 C.F.R. § 424.540(a)(3).

To reactivate its billing privileges, the supplier must recertify that its enrollment information currently on file with Medicare is correct, furnish any missing information, as appropriate, and comply with all applicable enrollment requirements.  42 C.F.R. § 424.540(b)(1).  CMS may also require that a deactivated supplier submit a complete enrollment application.  42 C.F.R. § 424.540(b)(2).  The effective date of reactivation of billing privileges is the date on which the Medicare contractor received the supplier’s submissions that were processed to approval.  42 C.F.R. § 424.540(d)(2).

Here, in letters dated December 29, 2023, the contractor directed the group practices to revalidate their Medicare enrollment records no later than March 31, 2024, and cautioned that their failing to respond would result in their Medicare billing privileges being deactivated.  CMS Ex. 3.  Petitioners submitted a group-practice enrollment application on March 26, 2024.  CMS Ex. 4.  However, the contractor determined that the application was not complete and, in an email dated April 8, 2024, it directed Petitioners to submit a copy of the supplier’s DEA (Drug Enforcement Administration) registration, with the issue date, and sections of the enrollment application.  The email warned that the enrollment applications could be rejected if the suppliers did not furnish complete information within 30 calendar days.  CMS Ex. 5.  On April 15, 2024, the suppliers uploaded a copy of Petitioner Zamfirov’s DEA registration.  CMS Ex. 17.  They did not, however, submit the additional information requested.

In notice letters, dated May 15, the contractor advised Petitioners that their Medicare billing privileges were being deactivated effective May 15, 2024, pursuant to 42 C.F.R. § 424.540(a)(3), because the suppliers had not fully and accurately responded to the contractor’s April 8, 2024 request for additional information and documentation.  CMS Exs. 1, 2.

On May 22, 2024, the Medicare contractor received Petitioners’ reactivation submission that it then processed to approval.  CMS Exs. 6, 7.  May 22, 2024, is therefore the effective date for reactivating its billing privileges.  See 42 C.F.R. § 424.540(d)(2).

Petitioners have argued that their billing privileges were deactivated because of a simple, clerical error (the application lacked a voided check containing the practice’s complete name).  CMS Ex. 16 at 3.  However, I have no authority to review a deactivation.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6 (2019); 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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Nor may I direct the contractor to allow retrospective reimbursement.  A supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. § 424.540(e); 42 C.F.R. § 424.555(b).  This represents a departure; CMS previously permitted retrospective billing after reactivation.  In promulgating the new regulation, the Secretary explained the change:

After careful reflection . . . the most sensible approach from a program integrity perspective is to prohibit such payments altogether.  In our view, a provider or supplier should not be effectively rewarded for its non-adherence to enrollment requirements (for example, failing to respond to a revalidation request or failing to timely report enrollment information changes) by receiving payment for services or items furnished while out of compliance.

86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022).

Conclusion

Because Petitioners filed their subsequently-approved reactivation applications on May 22, 2024, May 22 is the earliest possible effective date.  See 42 C.F.R. § 424.540(d)(2).

I may not review the deactivation.

Retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).