Meher Mallick, M.D., DAB CR6800 (2025)

DECISION

This decision affirms the determination of National Government Services (NGS), a contractor for the Centers for Medicare & Medicaid Services (CMS), that the effective date for the reassignment of Dr. Meher Mallick's (hereinafter referred to as Petitioner) Medicare enrollment and billing privileges is June 8, 2024, with a retroactive billing date of May 9, 2024.

I.  Background and Procedural History

On November 21, 2024, Petitioner, pro se, timely requested a hearing before an administrative law judge (ALJ) to contest an unfavorable reconsideration determination regarding the effective date of his Medicare enrollment.  (P. RFH).

On November 25, 2024, I issued an acknowledgment letter and standing pre-hearing order (Standing Order), and the Civil Remedies Division Procedures (CRDP).

On December 26, 2024, CMS filed a Motion for Summary Judgment and a pre-hearing brief (CMS Br.), along with 13 exhibits (CMS Exs. 1-13).  CMS did not offer witnesses or provide any sworn declarations.

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Petitioner failed to file a pre-hearing exchange by February 3, 2025, the deadline established in the Standing Order.  An Order to Show Cause was issued on February 7, 2025, ordering Petitioner to show cause by February 17, 2025, as to why the case should not be dismissed.

On February 19, 2025, Petitioner filed a statement, presumably in response to the Order to Show Cause, requesting reconsideration of the effective date decision.

II.  Admission of Exhibits and Decision on the Record

Neither party offered witnesses, therefore this case will be decided on the written record, without considering whether the standards for summary judgment are satisfied.  CRDP § 19(b).

In the absence of objections, CMS Exs. 1-13 are admitted into evidence.

III.  Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2);  see also 42 U.S.C. § 1395cc(j)(8).

IV.  Issue

The issue to be decided is:

Whether June 8, 2024, is the correct effective date for the reassignment of Petitioner's Medicare benefits pursuant to the regulations.

V.  Findings of Fact

As a physician, Petitioner is enrolled as a supplier in the Medicare program.  CMS Ex. 1.  On May 1, 2024, Petitioner began working with a new practice, Midwest Nephrology and Hypertension Associates.  CMS Ex. 10 at 2.  Petitioner began seeing patients on the same date.  Id.

As a result of his new employment, Petitioner sought to have his Medicare enrollment benefits reassigned to Rashid A. Dalal, M.D., P.C., by submitting a Medicare Enrollment Application for the Reassignment of Benefits (CMS-855R application) on April 30, 2024.  CMS Ex. 1.  On May 14, 2024, NGS requested additional information because Petitioner's application was not signed by the appropriate person.  CMS Ex. 2. However, by notice letter dated June 18, 2024, NGS informed Petitioner that the reassignment application was rejected due to missing or incomplete information.  Id.

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Petitioner submitted another CMS-855R application which NGS received on July 8, 2024.  CMS Exs. 3, 4.  NGS approved that application on July 19, 2024. CMS Ex. 6.

By initial determination dated July 26, 2024, NGS informed Petitioner of the approval and provided a "reassignment effective date"1 of May 9, 2024.  CMS Ex. 7.

On August 22, 2024, Petitioner submitted a request for reconsideration requesting that his reassignment date be changed from May 9, 2024, to May 1, 2024, the date when he began to see patients.  CMS Exs. 8, 9.

NGS issued an unfavorable reconsideration decision on October 29, 2024.  CMS Ex. 12.

VI.  Legal Authorities

The Social Security Act (the Act) establishes the enrollment process for providers and suppliers participating in Medicare or Medicare related programs.  42 U.S.C. §§ 1302, 1395cc(j).  Under the Act, "suppliers" are physicians or other practitioners, a facility or other entity (other than a provider of services) that furnishes items or services under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u). Providers include hospitals, skilled nursing facilities, and home health agencies.  42 U.S.C. § 1395x(u).  Petitioner is a "supplier."  42 U.S.C. § 1395x(d); 42 C.F.R. § 400.202.

A provider or supplier must be enrolled in the Medicare program to receive payment for covered items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary.  42 C.F.R. § 424.505.  Once enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered.  42 C.F.R. § 424.505.

The regulations provide that the effective date of enrollment for a physician or nonphysician practitioner may only be the later of two dates:  the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or the date when the practitioner first began providing services at a new practice location.  42 C.F.R. § 424.520(d).  An enrolled physician or nonphysician practitioner may retrospectively bill Medicare for services provided to Medicare-eligible beneficiaries up to 30 days prior to the effective date of enrollment, if circumstances precluded enrollment before the services were provided.  42 C.F.R. § 424.521(a)(1).

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The determination of a supplier's effective date is an initial determination subject to ALJ review.  42 C.F.R. § 498.3(b)(15).  However, unlike the determination of a supplier's effective date, "[e]nrollment applications that are rejected are not afforded appeal rights."  42 C.F.R. § 424.525(d); see 42 C.F.R. § 498.3(b).

VII.  Analysis

Reassignment applications, such as the one at issue in this case, are subject to different effective date guidelines.  Pursuant to 42 C.F.R, § 424.522(a), the effective date of reassignment applications is 30 days before the application is submitted, if all application requirements have otherwise been met.  In addition, the regulations provide that certain providers and suppliers may retrospectively bill for services when the provider or supplier has met all program requirements (including State licensure requirements), and services were provided at the enrolled practice location for up to 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.  42 C.F.R. § 424.521(a).

It is undisputed that Petitioner joined a new practice and began seeing patients on May 1, 2024.  However, the controlling date for determining the reassignment of Medicare billing privileges is not the date when the doctor began treating patients, it is 30 days before the date when the approved CMS-855R application was received, which is July 8, 2024.  Additionally, Petitioner meets the requirements for 30 days of retrospective billing.  Therefore, CMS correctly determined that Petitioner's retrospective date for the reassignment of benefits is May 9, 2024, 60 days prior to July 8, 2024.

Petitioner argues that the office manager initially submitted his CMS-855R application in February 2024, but the post office lost the application.  P. RFH.  According to Petitioner, the application was resubmitted, but mailed to the wrong Medicare office, while the third application was ultimately denied.  Additionally, Petitioner's office manager mentions that there were several attempts to communicate with CMS regarding this issue.  Petitioner states that multiple efforts were made to ensure that his reassignment benefits were timely reassigned and requests that the effective date be changed to May 1, 2024. However, I do not have the legal authority to grant Petitioner's request.  Petitioner's arguments regarding communications with CMS and delays in the process amount to a request for equitable relief.  The regulations do not provide this tribunal with the authority to grant equitable relief; thus Petitioner's effective date cannot be changed based upon the reasons provided.  US Ultrasound, DAB No. 2302 at 8 (2010) ("[n]either 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.").  For the reasons explained above, I have concluded that the retrospective date of May 9, 2024, is correct.

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VIII.  Conclusion

For the reasons stated above, I find that NGS, on behalf of CMS, correctly determined that Petitioner's effective date for the reassignment of his Medicare enrollment and billing privileges is June 8, 2024, with a retroactive billing date of May 9, 2024. Therefore, CMS's reconsidered determination is AFFIRMED.