Jersey Forensic Consulting, LLC, DAB CR6735 (2025)

DECISION

Petitioner, Jersey Forensic Consulting, LLC, is a group medical practice, located in Princeton, New Jersey.  After the Medicare contractor deactivated its 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 January 14, 2025.  As a result, Petitioner’s Medicare billing privileges lapsed from August 14, 2024, through January 13, 2025.

Citing “errors outside of my control,” the owner of Jersey Forensic asks that the lapse in billing privileges be rescinded.

Because Petitioner filed its subsequently-approved reactivation application on January 14, 2025, January 14 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2).

Background

The Medicare contractor, Novitas Solutions, Inc., approved Petitioner’s reactivation enrollment application effective January 14, 2025, with a gap in billing privileges from

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August 14, 2024, through January 13, 2025.  CMS Ex. 11.  Petitioner requested reconsideration, asserting that her biller and authorized representative should have timely resolved the issue but did not and had not updated the practice’s information on file with the Medicare contractor.  CMS Ex. 12 at 2.  In a reconsidered determination, dated April 9, 2025, a Provider Enrollment Hearing Specialist affirmed the January 14, 2025 reactivation date.  CMS Ex. 13 at 4.

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, 5, 6 (¶¶ 4(c)(iv), 8, 10) (April 16, 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 13 exhibits (CMS Exs. 1-13).  Although directed to do so, Petitioner did not file a brief or any other documents in response to CMS’s submissions.  Order at 3 (¶ 4).  In deciding this appeal, I consider the arguments made in Petitioner’s Request for Reconsideration (CMS Ex. 12) and hearing request.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).

In the absence of any objections, I admit into evidence CMS Exs. 1-13.  See Order at 5 (¶ 7).

Discussion

1. On January 14, 2025, 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).1

Enrollment.  Petitioner 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.

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

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Management and Budget.  42 C.F.R. § 424.502.2  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 practice 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).

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. § 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 July 31, 2023, the contractor directed Petitioner to revalidate its Medicare enrollment records no later than October 31, 2023, and cautioned that if the practice failed to respond, the contractor could stop its Medicare billing privileges.  CMS Ex. 2.  Petitioner did not respond.

In a letter dated April 24, 2024, sent by email, the contractor advised Petitioner that it was holding payment on the practice’s Medicare claims because the practice hadn’t revalidated its Medicare enrollment record.  The letter directed Petitioner to revalidate in

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order to resume payments and warned that Petitioner’s failure to respond to the notice would result in possible deactivation of the practice’s Medicare enrollment.  The contractor would not pay for services rendered during the period of deactivation.  CMS Ex. 3.  Again, Petitioner did not respond.

In a letter dated August 14, 2024, the contractor advised Petitioner that, pursuant to 42 C.F.R. § 424.540(a)(3), its Medicare billing privileges were deactivated, effective August 14, 2024, because it hadn’t timely revalidated its enrollment record.  The contractor would not pay any Medicare claims after that date.  CMS Ex. 4.

On November 19, 2024, Petitioner’s owner, Vivian Shnaidman, submitted, via PECOS, an initial enrollment application for herself, but not for the practice.  CMS Ex. 5.  The contractor responded by letter, dated November 27, 2024.  The letter informed the Owner Shnaidman that the contractor was closing the enrollment application and returning it.  The letter explained that the application (CMS-855B) was “unsolicited,” which means that the contractor received it more than seven months prior to its due date.  CMS Ex. 6.

On January 6, 2025, Owner Shnaidman submitted another initial enrollment application for herself.  CMS Ex. 7.  On January 10, 2025, the contractor again closed the request and returned the application, explaining that it was unsolicited.  CMS Ex. 8.

On January 14, 2025, Petitioner (the medical practice) finally submitted, via PECOS, its own reactivation application, which, after receiving additional information, the contractor processed to approval.  CMS Exs. 9, 10, 11.  January 14, 2025 is therefore the effective date for reactivating Petitioner’s billing privileges.   See 42 C.F.R. § 424.540(d)(2).

Owner Shnaidman explains that she was unaware of the deactivation until September 2024, when she stopped receiving Medicare payments.  She describes the interactions she had with her “biller and authorized representative,” who assured her that she was resolving the issue and that Petitioner would be able to bill for services.  CMS Ex. 12 at 2.  Petitioner also concedes that she “was aware” that the practice’s current address was not on file with Medicare and had asked her biller to update the information.  CMS Ex. 12 at 2.  In her hearing request, she explains that, because “of errors outside of [her] control,” she treated Medicare patients for many months without any reimbursement.  Hearing Request.

But 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

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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 n1 (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., 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.

Conclusion 

Because Petitioner filed its subsequently-approved reactivation application on January 14, 2025, January 14, 2025 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).