Naveed Vehra, DAB CR6699 (2025)

DECISION

Petitioner, Naveed Vehra, is a neurologist with a solo practice – Naveed Vehra, MD, PLLC – in Glendale, Arizona.  After the Medicare contractor deactivated his Medicare billing privileges, Petitioner Vehra submitted a new application, seeking to reactivate his enrollment.  Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the contractor approved the application, with an effective billing date of April 23, 2024.  As a result, Petitioner’s Medicare coverage lapsed from September 21, 2023, through April 22, 2024. 

Petitioner acknowledges that the staff member responsible for his revalidation, did not timely and completely respond to the contractor’s requests for corrections and additional information.  However, citing his significant revenue loss and resulting stress on himself, his employees, and his practice, he asks that the lapse in billing privileges be rescinded. 

Because Petitioner filed his subsequently-approved reactivation application on April 23, 2024, April 23 is the earliest possible effective date for his Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2).

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Background

The Medicare contractor, Noridian Healthcare Solutions, approved Petitioner’s reactivation enrollment application effective April 23, 2024, with a gap in billing privileges from September 21, 2023, through April 22, 2024.  P. Ex. 2 (E-file # 1b).  Petitioner requested reconsideration, asserting that his practice had not timely filed its revalidation application because of “unavoidable error and circumstances,” problems accessing the Noridian and PECOS sites, and “poor management and judgment.”  P. Ex. 3 (E-file # 1c).  In a reconsidered determination, dated January 13, 2025, a contractor hearing officer affirmed the April 23, 2024 reactivation date.  E-file # 1.  

Petitioner appeals, and the matter is now before me.  E-file # 1a.1

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Standing Order at 5, 10 (¶¶ 8(d)(iv), 14) (March 6, 2025).  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 nine exhibits (CMS Exs. 1-9).  Although directed to do so, Petitioner did not file a brief or any other documents in response to CMS’s submissions.  Standing Order at 5 (¶ 8(b)).  I consider the arguments and exhibits submitted with Petitioner’s hearing request.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).  With his written argument, Petitioner submits three exhibits (P. Exs. 1-3).  

In the absence of any objections, I admit into evidence CMS Exs. 1-9 and P. Exs. 1-3.  See Standing Order at 9 (¶ 11).  

Discussion

1. On April 23, 2024, Petitioner filed his subsequently-approved Medicare reactivation application, and the effective date of his reactivation can be no earlier than that date.  42 C.F.R. § 424.540(d)(2).2

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Enrollment.  Petitioner Vehra, through his practice group, Naveed Vehra, MD, PLLC, participates in the Medicare program as a “supplier” of services.  See Social Security Act (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 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). 

Because this case involves reactivation, additional regulations apply. 

Reactivation.  The regulations governing reactivation 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.

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§ 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).

Petitioner’s deactivation and reactivation.  Here, in a letter dated April 25, 2023, the contractor directed Petitioner to revalidate his Medicare enrollment records no later than July 31, 2023, and cautioned that if he failed to respond, the contractor could stop his Medicare billing privileges.  CMS Ex. 1. 

Petitioner submitted a revalidation application (CMS-855I), which the contractor received on July 25, 2023.  CMS Ex. 2.  

In a letter dated August 21, 2023, the contractor advised Petitioner that it had received the application and directed him to make revisions and supply additional supporting documentation by September 20, 2023.  The letter warned that the contractor might reject the application if Petitioner did not furnish complete information within 30 calendar days of the letter date.  CMS Ex. 3. 

Petitioner submitted another revalidation application (CMS-855I), which the contractor received on September 6, 2023.  CMS Ex. 4.  

In a letter dated September 21, 2023, the contractor advised Petitioner that his Medicare billing privileges were stopped, effective September 21, 2023, because he had not submitted all of the required information.  CMS Ex. 5.  

On November 9, 2023, Petitioner submitted another reactivation application.  CMS Ex. 6.  In an e-mail, dated November 24, 2023, the contractor again advised Petitioner that his application was incomplete and directed him to submit his electronic signature before December 4, 2023.  The email warned that failing to furnish the complete information requested “will result in your Medicare application being rejected.”  CMS Ex. 7. 

Petitioner did not respond, and, in a letter dated December 27, 2023, the contractor rejected the application, citing 42 C.F.R. § 424.525.  CMS Ex. 8. 

On April 23, 2024, the Medicare contractor received Petitioner’s reactivation submission that it processed to approval.  CMS Ex. 9; P. Ex. 2 (E-file # 1b).  April 23 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner explains that he entrusted the revalidation application to an employee who did not submit the requested documentation and then hid her mistakes from him so that he

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could not correct them.  Pointing out the revenue loss and accompanying stress, he asks me to reinstate his billing privileges, effective September 21, 2023.  Hr’g Req. 

But 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). 

Further, I have no authority to review a deactivation or rejected application.  Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8; 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. d/b/a Baptist Health Family Clinic Lakewood, DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017). 

Nor may I grant an earlier effective date based on equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 9 (2019).

Conclusion

Because Petitioner Vehra filed his subsequently-approved reactivation application on April 23, 2024, April 23 is the earliest possible effective date.  See 42 C.F.R. § 424.540(d)(2).  Retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).