Addison-Central Pathology, PLLC, DAB CR6807 (2025)

DECISION

This decision affirms the determination of National Government Services (NGS), a contractor for the Centers for Medicare & Medicaid Services (CMS), that May 15, 2024 is the reactivation effective date of Medicare enrollment and billing privileges for Addison-Central Pathology, PLLC (hereinafter referred to as Petitioner). 

I. Background and Procedural History

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

On October 23, 2024, I issued an acknowledgment letter, my standing pre-hearing order (Standing Order), and the Civil Remedies Division Procedures (CRDP). 

On November 26, 2024, CMS filed a Motion for Summary Judgment and a pre-hearing brief (CMS Br.), along with 19 exhibits (CMS Exs. 1-19).  CMS did not offer witnesses or provide any sworn declarations. 

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Petitioner filed an opposition to CMS’s Motion for Summary Judgment (P. Br.) and one exhibit (P. Ex. 1) on December 20, 2024. 

On December 23, 2024, CMS filed an objection to P. Ex. 1. 

II. Admission of Exhibits and Decision on the Record

Neither party offered witnesses, and both parties have requested a decision on the written record.  P. RFH at 1 n.2; Departmental Appeals Board E-filing Docket No. 5 at 1; CMS Br. at 1 n.1, 14.  Therefore this case will be decided on the written record, without considering whether the standards for summary judgment are satisfied.  Standing Order ¶ 6(f); CRDP § 19(b). 

In the absence of objections, CMS Exs. 1-19 are admitted into evidence. 

On December 23, 2204, CMS filed an objection to P. Ex. 1 arguing that Petitioner has not shown good cause for the submission of new evidence.  The regulations provide that when new evidence is submitted for the first time at the ALJ level, I must determine whether good cause exists for submitting that evidence.  42 C.F.R. § 498.56(e)(1).  If I do not find good cause for submitting the evidence for the first time at the ALJ level, I must exclude the evidence from the proceeding and may not consider it in reaching a decision.  42 C.F.R. § 498.56(e)(2)(ii).  Here, Petitioner has not argued that there is good cause for the submission of P. Ex. 1.  Nor has Petitioner explained why the evidence, a contract first executed in 2009 and most recently amended in 2018, was not previously submitted at the reconsideration level.  Therefore, I find that good cause does not exist and CMS’s objection to P. Ex. 1 is sustained.  

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

Whether NGS, acting on behalf of CMS, properly established May 15, 2024, as the reactivation effective date for Petitioner’s enrollment in the Medicare program.  

V. Legal Authorities

The Social Security Act (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 

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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 in order 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.  If 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. 

Once enrolled, CMS may deactivate a provider or supplier’s Medicare billing privileges for any of the reasons listed at 42 C.F.R. § 424.540(a).  If CMS deactivates a supplier’s Medicare billing privileges, then the supplier may file a rebuttal to the deactivation.  42 C.F.R. §§ 424.545(b), 424.546(a)(1).  When CMS issues a determination based on a rebuttal, that determination is not an appealable initial determination.  42 C.F.R. § 424.546(f). 

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). 

VI. Findings of Fact

Petitioner is a clinic/group practice enrolled as a supplier in the Medicare program.  CMS Ex. 17.  In October 2021, Petitioner underwent a reorganization and changed its name from Addison Central Pathology SC to Addison Central PLLC.  P. Br. at 2.  

By notice letter dated May 31, 2023, CMS requested that Petitioner revalidate its Medicare enrollment record by August 31, 2023.  CMS Ex. 16.  The notice warned that failure to respond may result in the deactivation of Medicare billing privileges and a gap in reimbursement.  Id.  

On September 11, 2023, NGS issued a notice informing Petitioner that all Medicare payments were placed on hold due to Petitioner’s failure to revalidate its enrollment record.  CMS Ex. 15.  The notice warned that a failure to respond may result in deactivation of Petitioner’s Medicare enrollment.  Id. 

On September 19, 2023, NGS received a Medicare enrollment application from Petitioner which was ultimately rejected due to an incomplete signature.  CMS Ex. 13. 

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On November 14, 2023, NGS received another Medicare enrollment application from Petitioner.  CMS Ex. 10.  That application was ultimately rejected due to missing or incomplete information, specifically an IRS tax document, a CMS 588 EFT application, and a voided check or bank letter.  Id. 

NGS issued a revised determination on November 15, 2023, notifying Petitioner that its Medicare billing privileges were deactivated effective November 8, 2023, for failure to timely revalidate its enrollment record or for failure to timely respond to requests for additional information.  CMS Ex. 12.  Petitioner was informed that no claims would be paid after November 8, 2023.  Id.  Petitioner was also advised it should file a rebuttal to the deactivation if it disagreed with the determination.  Id. 

NGS received a Medicare enrollment application from Petitioner on January 30, 2024.  On February 26, 2024, NGS closed the request and returned the application.  CMS Ex. 8.  

Petitioner submitted an application for Medicare enrollment on March 20, 2024.  On April 1, 2024, NGS requested additional information from Petitioner, but that information was not received.  CMS Ex. 6.  By notice letter dated May 7, 2024, NGS informed Petitioner that its March 20, 2024 Medicare enrollment application was rejected due to missing or incomplete items, specifically a voided check or bank letter.  Id. 

On May 15, 2024, Petitioner resubmitted a web-based Medicare enrollment application.  CMS Ex. 5 at 11.  NGS issued an initial determination dated July 5, 2024, informing Petitioner that its reactivation enrollment application was approved with an effective date of May 15, 2024.  CMS Ex. 4.  Petitioner was also informed that there would be a gap in billing privileges from November 11, 2023 through May 14, 2024, due to failure to fully revalidate during a previous revalidation cycle, and that Petitioner would not be reimbursed for services provided to Medicare beneficiaries during those dates.  Id. at 2. 

On July 26, 2024, Petitioner requested reconsideration of the reactivation date decision, requesting a reactivation effective date of November 8, 2023.  CMS Ex. 3.  

On August 7, 2024, NGS acknowledged receipt of Petitioner’s reconsideration request.  CMS Ex. 2.  CMS issued an unfavorable reconsideration determination on August 23, 2024.  CMS Ex. 1. 

VII. Analysis

CMS may deactivate Medicare billing privileges if a provider or supplier 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).  Once Medicare billing privileges are 

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deactivated, the effective date of the reactivation of billing privileges is the date on which the Medicare contractor received the provider’s or supplier’s reactivation submission that was processed to approval by the Medicare contractor.  42 C.F.R. § 424.540(d)(2). 

Petitioner argues that it made necessary efforts to comply with the revalidation requirements, but its third-party contractor made repeated errors that caused delays in the reactivation process.  See P. Br.  Petitioner contracted with AdvantEdge to provide billing and credentialing services.  P. RFH.  Petitioner argues that despite repeatedly making AdvantEdge aware of its name change and reorganization, the contractor continuously confused its name on Medicare revalidation submissions which caused several delays.  Id.  Petitioner argues that its Medicare enrollment should not have been deactivated for the mistakes made by AdvantEdge.  P. Br. at 3. 

Neither the deactivation of billing privileges nor the rejection of an enrollment applications are “initial determinations” subject to ALJ review under 42 C.F.R. Part 498.  See 42 C.F.R. § 424.525(d).  If Petitioner was dissatisfied with the deactivation determination, its remedy was to file a rebuttal with NGS.  See CMS Ex. 12.  Petitioner declined to do so.  As a supplier, Petitioner is responsible for the materials, including enrollment applications, that it submits to CMS and its contractors.  This includes ensuring that the applications contain complete and accurate information as required by the regulations.  42 C.F.R. §§ 424.515, 424.510.  Petitioner cannot avoid responsibility by simply blaming a third-party contractor that it employed to address billing and credentialing matters and that it authorized to submit filings on its behalf.  Nor does an alleged breach of contract give an ALJ the authority to overturn NGS’s determination to reject unsuccessful enrollment applications because the processing “did not go as the applicant expected or preferred.”  Iowa Cancer Specialists, PC, DAB No. 3109 at 7 (2023) (quoting Lindsay Zamis, M.D., a Pro. Corp., DAB No. 2802 at 9-10 (2017)). 

Lastly, Petitioner argues that it will suffer financial hardship if it is unable to bill for services provided during the deactivation.  P. RFH.  While I understand Petitioner’s concerns about the financial impacts of the billing gap during the deactivation, the applicable regulation does not provide for a retrospective or retroactive billing period, nor do I have the authority to add a period of retrospective or retroactive billing.  See 42 C.F.R. § 498.3(b)(15).  In addition, the regulations prohibit CMS from paying a supplier for items or services furnished to Medicare beneficiaries during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b).  Finally, I have no authority to reverse CMS’s determination on equitable grounds.  Iowa Cancer Specialists, PC, DAB No. 3109 at 8 (citing Edward J.S. Picardi, M.D., DAB No. 3045 at 17 (2021); Anil Hanuman, D.O., DAB No. 3080 at 10 (2022)). 

In this case, Petitioner’s Medicare billing privileges were deactivated effective November 8, 2023 for failure to revalidate enrollment within the specified time period.  CMS Ex. 1 at 3-4.  While Petitioner filed several applications to reactivate its Medicare billing privileges, it is undisputed that Petitioner’s billing 

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privileges were deactivated effective November 8, 2023 and it filed an enrollment application NGS was able to subsequently process to approval on May 15, 2024.  CMS Exs. 4, 5.  Based on the evidence provided, I find that the hearing officer did not err in determining that Petitioner’s reactivation effective billing date is May 15, 2024. 

VIII. Conclusion

For the reasons stated above, I find that NGS, on behalf of CMS, correctly determined that Petitioner’s reactivation effective date for Medicare enrollment and billing privileges is May 15, 2024.  Therefore, CMS’s determination is AFFIRMED.