Dermatology at Midtowne PC, DAB CR6836 (2026)

DECISION

This decision affirms the determination of Wisconsin Physicians Service Insurance Corporation (WPS), a contractor for the Centers for Medicare & Medicaid Services (CMS), that April 25, 2024 is the reactivation effective date of Medicare enrollment and billing privileges for Dermatology at Midtowne PC (hereinafter referred to as Petitioner).

I. Background and Procedural History

On December 20, 2024, Petitioner timely requested a hearing before an administrative law judge (ALJ) to contest an unfavorable reconsideration determination regarding the reactivation effective date of its Medicare enrollment and billing privileges.  P. Request for Hearing.

On December 26, 2024, I issued an acknowledgment letter, my standing pre-hearing order (Standing Order), and the Civil Remedies Division Procedures (CRDP).

On January 30, 2025, 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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On March 6, 2025, Petitioner filed a combined brief and opposition to CMS’s Motion for Summary Judgment (P. Br.), a witness list, and six exhibits (P. Exs. 14-19).

II. Admission of Exhibits and Decision on the Record

Though Petitioner provided a list of proposed witnesses, CMS did not request cross-examination of those witnesses.  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. 1-13 are admitted into evidence.

On March 20, 2025, CMS filed objections to P. Exs. 14, 15, and 17 arguing that Petitioner has not shown good cause for the submission of new evidence.1  The regulations provide that when new documentary 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 argues that there is good cause for the submission of new evidence because counsel was not retained until after the reconsideration process took place.  Departmental Appeals Board (DAB) E-File Dkt. No. 1d.

The regulations do not define “good cause.”  The Board has not provided a precise definition of “good cause” as used in 42 C.F.R. pt. 498, but explains that whether good cause exist turns on a case-by-case evaluation of whether the facts “fit within any reasonable definition of good cause.”  William Garner, MD, DAB CR5447 at 3 (2019) (and cases cited herein).  In some cases, good cause has been construed to mean “an event beyond a party’s control” that has prevented the party from offering the evidence at reconsideration.  City Crown Home Health Agency, Inc., DAB CR3130 at 4 (2014).  Good cause has also been found to exist in cases where a Petitioner could not have reasonably anticipated the need to submit that evidence.  Garner, DAB CR5447 at 3-4.  However, the fact that Petitioner was not represented by counsel at the reconsideration stage is not sufficient to establish good cause for failure to submit evidence at the reconsideration stage that was otherwise available.  See A To Z DME, LLC, DAB No. 2303 at 7 (2010).

P. Ex. 14 is the affidavit of Dr. Dipa Patel, Petitioner’s owner.  Petitioner argues that, now that it has hired counsel, “it is prudent for [Petitioner] to determine if there are additional records that would be relevant to [its] request.  DAB E-File Dkt. No. 1d.  I do

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not find that this is sufficient to show good cause for why Dr. Patel’s affidavit was not provided at the reconsideration stage.

P. Ex. 15 consists of two emails dated April 2, 2024 and April 23, 2024 regarding billing credentialing.  These emails existed at the time Petitioner requested reconsideration, and I do not find good cause as to why Petitioner was unable to submit the exhibit during reconsideration.

P. Ex. 17 consists of two emails dated September 11, 2024.  Because these emails did not exist at the time Petitioner requested reconsideration, I find good cause for why Petitioner was unable to submit them at that time.  CMS further argues that Petitioner has failed to show why P. Ex. 17 is relevant to the issue of this case.  Under the regulations, I may receive any evidence that is relevant and material.  42 C.F.R. § 498.60(b)(1).  Relevant evidence is any evidence that has a tendency to make a fact more or less probable than without the evidence.  Fed. R. Evid. 401.  As P. Ex. 17 consists of communications with the Medicare contractor regarding Petitioner’s reconsideration, I find that it is relevant to this matter.

CMS’s objections to P. Exs. 14 and 15 are sustained.  CMS’s objection to P. Ex. 17 is overruled. P. Exs. 16-19 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

Whether WPS, acting on behalf of CMS, properly established April 25, 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 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.

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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, a medical practice/clinic enrolled as a supplier in the Medicare program, is owned by Dr. Dipa Patel, who also serves as a physician in the practice.  See P. Br.  By notice letter dated June 23, 2023, WPS, on behalf of CMS, requested that Petitioner revalidate its Medicare enrollment record by September 30, 2023.  CMS Ex. 1.  The notice letter warned that failure to respond may result in the deactivation of Medicare billing privileges and a gap in reimbursement. Id.  The notice was addressed to Dr. Patel and sent to Petitioner’s address at 555 Midtowne Nest 301, Grand Rapids, Michigan 49503.  Id.

On November 3, 2023, WPS 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. 2.  The notice warned that a failure to respond may result in deactivation of Petitioner’s Medicare enrollment and may cause a gap in reimbursement.  Id.  The second notice letter was also addressed to Dr. Patel and sent to the same address as the initial notice.  Id.

On January 11, 2024, WPS issued a notice informing Petitioner that its billing privileges were deactivated effective January 10, 2024, due to failure to timely revalidate its enrollment record.  CMS Ex. 3.  The notice stated that claims would not be paid after the deactivation date.  Id.  The notice was addressed to Petitioner and sent to the same address as the June 23, 2023 and November 3, 2023 notice letters.  Id.

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WPS received Petitioner’s Medicare enrollment application on January 29, 2024.  CMS Ex. 4.  On February 13, 2024, WPS issued a letter requesting that Petitioner provide supporting documentation to complete processing of the enrollment application.  CMS Ex. 5.  The letter warned that the enrollment application would be rejected if the requested information was not received within 30 calendar days pursuant to 42 C.F.R. § 424.525.  Id.

On March 14, 2024, WPS issued notice that Petitioner’s Medicare enrollment application was rejected due to missing or incomplete documentation.  CMS Ex. 6.

Petitioner submitted another Medicare enrollment application on April 25, 2024.  CMS Ex. 7 at 12.  On May 1, 2024, WPS issued a notice requesting additional information and corrections to the application.  CMS Ex. 8.  Petitioner resubmitted the application on May 13, 2024.  CMS Ex. 9.

By letter dated May 15, 2024, WPS informed Petitioner that its reactivation enrollment application was approved with an effective date of April 25, 2024.  CMS Ex. 10.  The letter also stated there would be a gap in billing privileges from January 11, 2024 through April 24, 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.

On June 13, 2024, Petitioner requested reconsideration of the reactivation date decision, requesting that the gap in billing privileges be reinstated.  CMS Ex. 11.  WPS issued an unfavorable reconsideration determination on October 21, 2024.  CMS Ex. 13.

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 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 good faith efforts to comply with the revalidation requirements, including repeated communications with WPS.  See P. Br.  Petitioner claims that it did not receive the initial notices regarding reactivation sent by WPS.  P. Br. at 2.  However, Petitioner goes on to admit that around the same time it hired a new office manager with no previous healthcare experience and “it is possible she received notices from WPS and failed to inform MidTowne and Dr. Patel of the same.”  P. Br.

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at 3.  Petitioner also notes that Dr. Patel was not informed of the November 3, 2023 letter until March 15, 2024.  Id.  Petitioner has not provided proof, nor argued, that any of the notices issued by WPS were mailed to the wrong address.  Petitioner merely speculates whether the notice letters were received or mishandled by an employee.  This does not show that WPS erred in sending the notice letters or failed to provide notice, nor does it provide a legal basis for relief.

Much of Petitioner’s argument focuses on the delays in submitting its second reactivation application.  P. Br. at 2, 5, 10, and 14.  Petitioner again alleges to not have received the February 13, 2024 information letter in which WPS requested additional information to process Petitioner’s reactivation application.  P. Br. at 4.  Petitioner describes a series of unfortunate events that occurred in February 2024, including the departure of Petitioner’s office manager, Dr. Patel handling administrative duties for the office, and a data breach.  Id.  Apparently, these events serve as excuses as to why Petitioner cannot confirm receipt of the February 13, 2024 letter from WPS.  Id.  Though unfortunate, these excuses do not provide a legal basis for me to determine that the reactivation effective date is incorrect.  To the extent that Petitioner is requesting equitable relief, 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)).

Petitioner made several calls to WPS for assistance in updating its address and other information in the Provider Enrollment Chain and Ownership System (PECOS) system. P. Br. at 5, 6.  Petitioner claims that WPS failed to mention the importance of submitting the second reactivation application while simultaneously addressing inaccuracies in the PECOS system.  Petitioner declares, without statutory or regulatory authority, that due to WPS’ mis-advice, problems with the PECOS filing system, and failure to provide notice, CMS should have provided an effective date of January 11, 2024, or in the alternative March 26, 2024.  P. Br. at 2, 13.  Again, without legal authority, Petitioner argues that WPS should have provided more than two notices before deactivating its Medicare billing privileges.  P. Br. at 14.  However, Petitioner has not proven that WPS was under any legal obligation to provide advice on the effect of waiting, nor was there any legal obligation to provide additional notices.  Regarding any alleged “mis-advise”, the Supreme Court has held that a Medicare program participant has a “duty to familiarize itself with the legal requirements for cost reimbursement,” and erroneous advice from a governmental agent is, “in itself, insufficient to raise an estoppel” argument.2  Heckler v. Cmty. Health Servs. of Crawford Cnty., Inc., 467 U.S. 51, 64 (1984).  Additionally, the Board has ruled that difficulty with navigating PECOS does not present a legal ground

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for the Board or an ALJ to set an earlier effective date.  Chaplin Liu, M.D., DAB. No. 2976 at 9-10 (2019).

By requesting a reactivation date of January 11, 2024, Petitioner essentially argues that deactivation of Medicare billing privileges should not have been imposed.  Neither the deactivation of billing privileges nor the rejection of enrollment applications are “initial determinations” subject to ALJ review under 42 C.F.R. Part 498.  See 42 C.F.R. § 424.525(d); 42 C.F.R. § 498.3(b).  If Petitioner was dissatisfied with the deactivation determination, its remedy was to file a rebuttal with NGS.  See CMS Ex. 3.  Petitioner declined to do so.  Additionally, Petitioner admits to not timely submitting its revalidation application.  P. Ex. 16.  The only reviewable issue in this case is the effective date of Petitioner’s reactivated Medicare billing privileges.  Additionally, as a supplier, Petitioner is responsible for the materials, including enrollment applications, that it submits to CMS and its contractors.  This includes ensuring that applications contain complete and accurate information as required by the regulations.  42 C.F.R. §§ 424.515, 424.510.  Petitioner cannot avoid responsibility by blaming a new employee with no healthcare experience, who was unfamiliar with the billing process, nor by blaming WPS.  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 mentions that it will incur substantial financial loss if unable to bill for services provided during the deactivation.  P. Br. at 2.  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).

In this case, Petitioner’s Medicare billing privileges were deactivated effective January 10, 2024, for failure to revalidate enrollment within the specified time period.  CMS Ex. 3.  It is undisputed that Petitioner filed an enrollment application that WPS was able to subsequently process to approval on April 25, 2024.  CMS Ex. 7.  Based on the evidence provided, I find that the hearing officer did not err in determining that Petitioner’s reactivation effective billing date is April 25, 2024.

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VIII. Conclusion

For the reasons stated above, I find that WPS, on behalf of CMS, correctly determined that Petitioner’s reactivation effective date for Medicare enrollment and billing privileges is April 25, 2024.  Therefore, CMS’s determination is AFFIRMED.