Janet Whitney, D.O., DAB CR6716 (2025)

DECISION

The effective date of the reassignment of Medicare benefits of Petitioner, Janet Whitney, D.O., is January 31, 2024.

I.     Background and Procedural History

Petitioner is a practitioner.  See CMS Exhibit (Ex.) 7 at 1.  On December 19, 2023, Noridian Healthcare Solutions (Noridian), a Medicare administrative contractor, received Petitioner’s Form CMS-855R to terminate her reassignment to Bradley B. Bailey, M.D. and Roger B. Schechter, M.D., Inc. (Bailey).  Id.  Petitioner signed the request to terminate.  Id.  Noridian sent a notification of completion of the termination on January 3, 2024.  CMS Ex. 6.  On March 1, 2024, Noridian received a Medicare reassignment application from Petitioner to reassign her Medicare billing privileges to Bailey.  CMS Ex. 5.  On March 15, 2024, Noridian approved Petitioner’s reassignment of benefits, effective March 1, 2024, with retrospective billing privileges authorized beginning February 1, 2024.1  CMS Ex. 4.

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On March 22, 2024, Petitioner submitted a request for reconsideration.  CMS Ex. 3.  Petitioner argued that the December 19, 2023, termination of her reassignment to Bailey was filed in error by a previous credentialing company.  CMS Ex. 1.  Petitioner requested an effective date of January 4, 2024.  Id.

Noridian issued a reconsidered determination on June 20, 2024, in which it explained that Petitioner’s reassignment of benefits application was received on March 1, 2024, and that the earliest possible billing date was February 1, 2024.2  CMS Ex. 1.  Noridian stated that the effective date was issued correctly in accordance with CMS guidelines and that the January 4, 2024, requested date cannot be granted.  Id. at 3.

Petitioner submitted a request for an administrative law judge (ALJ) hearing that was received on August 16, 2024.  Thereafter, the Civil Remedies Division issued a standing pre-hearing order (Pre-Hearing Order) that directed the parties to file their respective pre-hearing exchanges.  CMS filed a pre-hearing brief and motion for summary judgment, along with eight proposed exhibits (CMS Exs. 1-8).  Petitioner filed documents including copies of the reconsidered determination and medical records along with an explanation letter after an Order to Show Cause was issued.  Neither party objected to the other’s exhibits or filings, and, therefore, they are admitted into evidence.

Similarly, neither party has submitted written direct testimony, as addressed in sections 10 through 12 of the Pre-Hearing Order.  A hearing for the purpose of cross-examination is therefore unnecessary.  I consider the record in this case to be closed, and the matter is ready for a decision on the merits.3

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This case was transferred to me on May 7, 2025.

II.     Issue

Whether the effective date of Petitioner’s reassigned Medicare benefits is January 31, 2024.

III.     Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R § 498.3(b)(15); Victor Alvarez, M.D., DAB No. 2325 at 8-12 (2010); see also 42 U.S.C. § 1395cc(j)(8).

IV.     Findings of Fact, Conclusions of Law, and Analysis4

Pursuant to 42 C.F.R. § 424.522(a), the effective date of Petitioner’s March 1, 2024 reassignment of benefits is January 31, 2024, which is 30 days before the date of receipt of the Medicare reassignment enrollment application that Noridian was able to process to approval, pursuant to 42 C.F.R. § 424.522(a).

Petitioner is a “supplier” for purposes of the Medicare program.  See CMS Ex. 7 at 1; see also 42 U.S.C. § 1395x(d); 42 C.F.R. §§ 400.202 (definition of supplier), 498.2.  A “supplier” furnishes items or services under Medicare and the term applies to physicians or other practitioners who are not included within the definition of the phrase “provider of services.”  42 U.S.C. § 1395x(d).  A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The regulations at 42 C.F.R. Part 424, subpart P, establish the requirements for a supplier to enroll in the Medicare program.  42 C.F.R. §§ 424.510-424.516; see also 42 U.S.C. § 1395cc(j)(1)(A) (authorizing the Secretary of the U.S. Department of Health and Human Services to establish regulations addressing the enrollment of providers and suppliers in the Medicare program).  A supplier who seeks billing privileges under Medicare “must submit enrollment information on the applicable enrollment application.”  42 C.F.R. § 424.510(a)(1).  “Once the provider or supplier successfully completes the enrollment process . . . , CMS enrolls the provider or supplier into the Medicare program.”  Id.; see also 42 C.F.R. § 424.510(d) (listing enrollment requirements).  When the contractor approves an enrollment application, it sets the effective date for approval of billing privileges.  See Alexander C. Gatzimos, MD, JD, LLC d/b/a Michiana Adult Medical Specialists, DAB No. 2730 at 2 (2016).  “The effective date of a physician’s or physician organization’s enrollment in Medicare is ‘the later of the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare

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contractor or the date [the supplier] first began furnishing services at a new practice location.’”  Alexander C. Gatzimos, DAB No. 2730 at 2-3; see Gaurav Lakhanpal, MD, DAB No. 2951 at 6 (2019) (“the effective date of . . . reassignment of billing privileges is . . . the date that [the contractor] received [the] reassignment application that was subsequently approved.”).

The Departmental Appeals Board (DAB) has explained that “[t]he governing law on how CMS (and its Medicare contractors) determine the effective date for [suppliers] applying for Medicare billing privileges is set by regulation.”  Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017).  Petitioner argues the filing of the termination of the reassignment on December 19, 2023, was done in error by a prior credentialing company.  CMS Ex. 1; Petitioner Request for Hearing (Hrg. Req.).  Petitioner further explains that she asked the credentialing company to process the termination of the reassignment at the end of January because she was starting her own business, but the company misunderstood and filed the paperwork early.  Hrg. Req. at 1.

However, Petitioner signed the CMS Form 855R dated December 19, 2023, terminating the reassignment of her billing privileges.  Noridian processed the application and notified Petitioner the termination was complete on January 3, 2024.  On March 1, 2024, Petitioner filed a new CMS Form 855R reassigning her billing privileges to Bailey.  Therefore, the earliest possible effective date for Petitioner’s reassignment of benefits is March 1, 2024, pursuant to 42 C.F.R. § 424.522(a), with billing privileges authorized beginning 30 days earlier on January 31, 2024.  Accordingly, I conclude that, pursuant to 42 C.F.R. § 424.522(a), the effective date of Petitioner’s reassignment of benefits is January 31, 2024.  See, e.g., Gaurav Lakhanpal, DAB No. 2951 at 6 (2019).

To the extent that Petitioner’s request for an earlier billing date is based on principles of equitable relief, I cannot grant such relief.  US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither the ALJ nor the [DAB] is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”).  Petitioner points to no authority by which I may grant her relief from the applicable regulatory requirements, and I have no authority to declare statutes or regulations invalid or ultra vires.  1866ICPayday.com, L.L.C., DAB No. 2289 at 14 (2009) (“An ALJ is bound by applicable laws and regulations and may not invalidate either a law or regulation on any ground . . . .”).

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V.     Conclusion

For the foregoing reasons, I uphold the January 31, 2024, effective date of Petitioner’s reassigned Medicare benefits.