Integrated Health Solutions, LLC, DAB CR6724 (2025)

DECISION

Petitioner, Integrated Health Solutions, LLC, challenges the Centers for Medicare & Medicaid Services’ (CMS’s) determination of its effective date of reactivation as a biller to the Medicare program following a period of deactivation due to its failure to revalidate.  As explained below, I find CMS properly determined October 1, 2024 as the reactivation effective date of Petitioner’s Medicare enrollment, as that is the date the Medicare administrative contractor received Petitioner’s reactivation application that was processed to approval.

I.     Background

Petitioner is a clinic/group practice that has been enrolled as a Medicare supplier since December 20, 2017.  CMS Ex. 2 at 4-5.  On February 29, 2024, CMS contractor National Government Services, Inc. (NGS) advised Petitioner that it was obligated to revalidate its Medicare enrollment by May 31, 2024.  CMS Ex. 2 at 15.  The letter informed Petitioner that it could submit its revalidation application either online through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or by mail.

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Id.  The letter, which was mailed to Petitioner, further warned Petitioner that “[i]f we don’t receive your response by then, we may stop your Medicare billing privileges.”  Id.

On June 7, 2024, NGS sent another letter to Petitioner advising that it was “placing a stay on [Petitioner’s] Medicare enrollment effective June 7, 2024 because you have not responded to our revalidation request . . .”  Id. at 17.  NGS further stated that Petitioner’s “claims for services and items you furnish during this [stay] period will be rejected.”  Id.  Petitioner was notified that its “[f]ailure to submit a revalidation application within 30 days of this notice may result in a deactivation of your Medicare enrollment.”  Id.  NGS informed Petitioner of its right to file a rebuttal if Petitioner believed the stay determination was incorrect.  Id. at 18.

On July 16, 2024, NGS deactivated Petitioner’s Medicare billing privileges effective June 1, 2024.  Id. at 19.  As the basis for the deactivation, NGS stated that Petitioner failed to submit a timely revalidation application.  Id. (citing 42 C.F.R. § 424.540(a)(3)).  NGS again advised Petitioner of its right to file a rebuttal if Petitioner believed the deactivation determination was incorrect.  Id.

On October 1, 2024, NGS received a reactivation application from Petitioner.  Id. at 4. NGS subsequently approved Petitioner’s reactivation application with an effective date of October 1, 2024.  Id. at 12.  NGS advised Petitioner that there would be a gap in billing privileges from June 1, 2024 to September 30, 2024.  Id.

Petitioner thereafter filed a request for reconsideration of the deactivation and the gap in billing privileges.  Id. at 2-3.  Petitioner specifically averred that it had received the revalidation request from NGS but, due to confusion with the PECOS system, experienced difficulties and delays in applying.  Id.  On January 15, 2025, NGS issued a reconsidered determination and found no error in reactivating Petitioner’s Medicare billing privileges as of October 1, 2024, with a billing gap from June 1, 2024 to September 30, 2024.  CMS Ex. 1.

On March 12, 2025, Petitioner timely requested a hearing to dispute the reconsidered determination.  DAB E-File Doc. Nos. 1-1a.  On March 18, 2025, the undersigned Administrative Law Judge (ALJ) was designated to hear and decide this case.  Id. at Doc. No. 2.  That same day, the Civil Remedies Division (CRD) acknowledged the hearing request and issued my Standing Pre-hearing Order (Standing Order).  Id. at Doc. No. 2a.  Among other things, the Standing Order instructed the parties to file prehearing exchanges by specified dates.  Id.

On April 22, 2025, CMS filed a motion for summary judgment and pre-hearing brief and three proposed exhibits (CMS Exs. 1-3).  Id. at Doc. Nos. 4-4d.  On May 27, 2025, Petitioner timely filed a pre-hearing brief and response to CMS’s motion for summary judgement.  Id. at Doc. No. 5.

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II.     Admission of Exhibits and Decision on the Record

Petitioner did not object to CMS Exs. 1 through 3.  In the absence of objections, I admit CMS Exs. 1 through 3 into the record.  Petitioner has not submitted any proposed exhibits.

If the parties wanted an in-person hearing, the parties had to submit written direct testimony from the witnesses and the opposing party had to request to cross-examine one or more of those witnesses.  Standing Order ¶¶ 11-13; CRDP §§ 16(b), 19(b).

Because neither party offered written direct testimony, I do not need to hold a hearing and may issue a decision based on the written record.  Vandalia Park, DAB No. 1940 (2004).  Therefore, I deny CMS’s motion for summary judgment as moot.  In rendering this decision on the record, I address the matters raised by Petitioner in its hearing request.

III.     Issue

Whether CMS had a legitimate basis to establish October 1, 2024, as the effective date of Petitioner’s reactivated Medicare billing privileges.  

IV.     Jurisdiction

I have jurisdiction to decide this case.  42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2).  

V.     Findings of Fact, Conclusions of Law, and Analysis1

A. Applicable Law

1. Enrollment

Petitioner participates in the Medicare program as a “supplier” of services.  Social Security Act (Act) § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services it furnishes to program beneficiaries, a prospective supplier must enroll in the program.  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.  When CMS determines 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.  42 C.F.R. § 424.505.

The effective date for its 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).  The “date of filing” is the date that the Medicare contractor “receives” a signed enrollment application that the Medicare contractor is able to process to approval.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).  If a supplier satisfies certain requirements, CMS may allow a supplier to bill retrospectively for up to 30 days prior to the effective date.  42 C.F.R. § 424.521(a)(1).

A Medicare beneficiary may assign the right to receive Medicare Part B benefits for covered medical services to an enrolled supplier who delivers those services.  Act § 1842(b)(3)(B)(ii) (42 U.S.C. § 1395u(b)(3)(B)(ii)); 42 C.F.R. § 424.55.  In certain circumstances, a supplier who has received an assignment of benefits may reassign those benefits to an employer, or to an individual or entity with which the supplier has a contractual arrangement.  Act § 1842(b)(6) (42 U.S.C. § 1395u(b)(6)); 42 C.F.R. § 424.80(b)(1)‑(2).  To reassign Medicare benefits, a supplier must submit and obtain CMS’s approval of a reassignment application.  Gaurav Lakhanpal, MD, DAB No. 2951 at 1-2 (2019) (citing 71 Fed. Reg. 20,754, 20,756 (Apr. 21, 2006)).  CMS applies the effective date rules at 42 C.F.R. §§ 424.520(d) and 424.521(a)(1) to reassignments of Medicare benefits.  See Medicare Program Integrity Manual (MPIM) (CMS Pub. 100-08) §§ 15.5.20(E)(3), 15.17.

2. Revalidation

To maintain billing privileges, a supplier must resubmit and recertify the accuracy of its enrollment information at least every five years, a process referred to as “revalidation.”  42 C.F.R. § 424.515.  Beyond these periodic revalidations, CMS may, at other times and for its own reasons, ask a supplier to recertify the accuracy of its enrollment information.  42 C.F.R. § 424.515(d).  Within 60 days of receiving CMS’s notice to recertify, the supplier must submit an appropriate enrollment application with complete and accurate information and supporting documentation.  42 C.F.R. § 424.515(a)(2).

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3. Deactivation

The regulation authorizing deactivation explains that “[d]eactivation [of Medicare billing privileges] is intended to protect the provider or supplier from the misuse of its billing number and to protect the Medicare Trust Funds from unnecessary overpayments.”  86 Fed. Reg. 62,240, 62,359 (Nov. 9, 2021).  CMS is authorized to deactivate an enrolled supplier’s Medicare billing privileges if the enrollee does not “furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information.”  42 C.F.R. § 424.540(a)(3).  If CMS deactivates a supplier’s Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b); see also 42 C.F.R. § 424.540(e).

4. Reactivation

The reactivation of an enrolled supplier’s billing privileges is governed by 42 C.F.R. § 424.540(b).  The process for reactivation is contingent on the reason for deactivation.  If CMS deactivates a supplier’s billing privileges due to a reason other than nonsubmission of a claim, the supplier must apply for CMS to reactivate its Medicare billing privileges by completing and submitting the appropriate enrollment application(s) or recertifying its enrollment information, if deemed appropriate.  42 C.F.R. § 424.540(a)(3), (b)(1).  The effective date of a reactivation of billing privileges, following a period of deactivation, is the date on which the Medicare contractor received the supplier’s submission that was processed to approval.  42 C.F.R. § 424.540(d)(2).

B. Analysis

1. NGS received Petitioner’s reactivation enrollment application on October 1, 2024 that was processed to approval, which is the effective date of its Medicare reactivated enrollment.

As discussed above, the effective date of a reactivation of Medicare billing privileges is the date on which the Medicare contractor received the supplier’s submission that was subsequently processed to approval.  Id.

In this case, NGS received a reactivation enrollment application from Petitioner on October 1, 2024, and this application was processed to approval.  CMS Exs. 1, 2 at 4-13. NGS appropriately found the effective date of Medicare billing privileges for Petitioner to be October 1, 2024, the date of receipt of the Medicare application that was subsequently approved by the contractor with a gap in billing privileges from June 1, 2024 through September 30, 2024.  CMS Exs. 1, 2 at 12.  Moreover, there is no evidence

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in the record before me of an application submitted earlier than the one Petitioner submitted on October 1, 2024, that NGS received and subsequently approved.2   Therefore, pursuant to 42 C.F.R. § 424.540(d)(2), the date NGS received Petitioner’s subsequently-approved reactivation enrollment application – October 1, 2024 – is the correct effective date of enrollment.  Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022).

2. I have no authority to review the deactivation of Petitioner’s billing privileges and cannot afford it equitable relief.

In its brief, Petitioner generally contends that NGS erred in deactivating its Medicare billing privileges, which resulted in a gap of billing privileges from June 1, 2024 to September 30, 2024.  P. Br. at 4-6.  Petitioner specifically details the timeline of events and its attempts to revalidate its application through the PECOS system.  Id. at 3-4.  Petitioner avers that when it initially attempted to revalidate on PECOS, the supplier, Integrated Health Solutions, LLC, was not listed in the system.  Id.  Petitioner also states that it called NGS and confirmed that Petitioner was not listed in PECOS because it had previously enrolled by paper application.  Id. at 4.  Petitioner states that its “active and repeated efforts to comply with revalidation requests — efforts that were systematically frustrated by CMS’ system configuration and legacy enrollment method, not willfully neglected” shows its good faith efforts to timely reactivate.  Id. at 5.  Petitioner’s request also includes a financial hardship argument.  Id. at 6.

While I acknowledge Petitioner’s argument, I have no authority to review NGS’s deactivation of Petitioner’s Medicare billing privileges.  CMS Ex. 2 at 19; Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6 (2019); Wishon Radiological Med. Grp.,

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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.  Deactivation decisions in fact have an altogether separate review process that requires a provider or supplier dissatisfied with deactivation to file a rebuttal with CMS’s administrative contractor.  42 C.F.R. §§ 424.545(b), 424.546.  It is not clear from the record whether Petitioner sought relief from NGS through this rebuttal process.  However, my jurisdiction in this case is limited to reviewing the effective date of the approval of Petitioner’s reactivation enrollment application.  42 C.F.R. § 498.3(b)(15).

Nor may I direct the contractor to allow retrospective reimbursement during the gap in billing privileges from June 1, 2024, through September 30, 2024.  A supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. §§ 424.540(e), 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.

Lastly, I have no authority to review CMS’s revalidation process or otherwise grant Petitioner any form of equitable relief.  See, e.g., US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”); Pepper Hill Nursing & Rehab. Ctr., LLC, DAB No. 2395 at 11 (2011) (holding that the ALJ and Board were not authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements); UpturnCare Co., DAB No. 2632 at 19 (2015) (providing the Board may not overturn the denial of provider enrollment in Medicare on equitable grounds).  While I am sympathetic to the fact that Petitioner’s practice has suffered a significant loss of income while rendering services to the Medicare program, I have no authority under the law to revise the effective date of reactivation determined by CMS.

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VII.     Conclusion

Because NGS received the reactivation application that was processed to approval on October 1, 2024, that same date 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).