LTR, LLC, DAB CR6610 (2025)

DECISION

Petitioner, LTR, LLC, is a physical and occupational therapy group practice, located in Ankeny, Iowa.  After the Medicare contractor deactivated the practice’s Medicare billing privileges, Petitioner submitted a new application, seeking to reactivate its enrollment.  Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the contractor approved the application, with an effective billing date of May 1, 2024.  As a result, Petitioners’ Medicare coverage lapsed from April 10 through 30, 2024. 

Petitioner has challenged the deactivation, claiming that it did not receive, from the Medicare contractor, notice that it was required to revalidate its Medicare enrollment. 

Because Petitioner filed its subsequently-approved reactivation application on May 1, 2024, May 1 is the earliest possible effective date for its Medicare reactivation.  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.

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Background

The Medicare contractor, Wisconsin Physicians Service, has approved Petitioner’s reactivation enrollment application with an effective date of May 1, 2024.  CMS Ex. 6 at 3.  Petitioner requested reconsideration, challenging the deactivation, but saying nothing about the effective date for its reactivation.  CMS Ex. 4.  In a reconsidered determination, dated September 4, 2024, a contractor representative affirmed the May 1, 2024 effective date.  CMS Ex. 5 at 3. 

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) (September 19, 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 six exhibits (CMS Exs. 1-6).  In the absence of any objections, I admit into evidence CMS Exhibits 1-6.  Acknowledgment and Pre-hearing Order at 5 (¶ 7).  Although directed to do so, Petitioner declined to file a brief or any other documents.  Acknowledgment at 3 (¶ 4(b)).  In the absence of a brief, I consider the arguments set forth in Petitioner’s reconsideration submissions.  See CMS Ex. 5 at 2 (listing the documents submitted at reconsideration); Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).1

Discussion

1. On May 1, 2024, Petitioner filed its subsequently-approved Medicare reactivation application, and the effective date of its reactivation can be no earlier than that date.  42 C.F.R. § 424.540(d)(2).2

Enrollment.  Petitioner LTR, LLC participates in the Medicare program as a “supplier” 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.

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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 “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (emphasis added).  However, 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 significant 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 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 a letter dated October 25, 2023, the contractor directed the group practice to revalidate its Medicare enrollment records no later than January 31, 2024, and cautioned that its failing to respond could result in its Medicare billing privileges being deactivated.  CMS Ex. 1.  Petitioner did not respond.

In a notice letter dated April 10, 2024, the contractor advised Petitioner that, because it had not timely revalidated its enrollment, the practice’s Medicare billing privileges were

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deactivated, effective April 9, 2024, pursuant to 42 C.F.R. § 424.540(a)(3).  CMS Ex. 3.  Section 424.540(a)(3) authorizes the contractor to deactivate a supplier’s Medicare billing privileges if the supplier does not comply with all enrollment requirements. 

On May 1, 2024, the Medicare contractor received Petitioner’s reactivation submission that it processed to approval.  CMS Ex. 6.  May 1, 2024 is therefore the effective date for reactivating its billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner complains that it did not receive the October 25, 2023 letter directing it to reactivate its Medicare enrollment.  CMS Ex. 4.  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).  

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, 62,420-21 (Nov. 9, 2021); see Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022).

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Conclusion

Because Petitioner filed its subsequently-approved reactivation application on May 1, 2024, May 1 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).