Nephrology Associates, Inc., DAB CR6842 (2026)

DECISION

Petitioner, Nephrology Associates, Inc., is a group medical practice, located in Rhode Island, that participates in the Medicare program as a supplier of services.  After the Medicare Contractor deactivated the practice’s 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 Medicare contractor approved the application, with a reactivation effective date of March 25, 2025.  As a result, Petitioner’s billing privileges lapsed from December 9, 2024, through March 24, 2025. 

Petitioner challenges the contractor’s action and asks for a reactivation date of December 10, 2024. 

Because Petitioner filed its subsequently-approved reactivation application on March 25, 2025, March 25 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2). 

I have no authority to review the contractor’s rejection of an earlier application nor to order retrospective reimbursement for services provided during the period of deactivation.

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Background

Because Petitioner did not report a major change in its Medicare enrollment (the death of a managing employee), the Medicare contractor, National Government Services, Inc., deactivated its billing privileges.  Petitioner subsequently submitted a reactivation enrollment application, which the contractor approved, effective March 25, 2025.  CMS Ex. 8.  In response, Petitioner requested reconsideration.  CMS Ex. 9.  In a reconsidered determination, dated August 21, 2025, a contractor enrollment specialist affirmed the March 25, 2025 effective date.  CMS Ex. 10. 

Petitioner appealed.

CMS moves for summary judgment, which Petitioner opposes. 

Decision on the written record.  My initial order instructs the parties to list any proposed witnesses and to submit their written direct testimony.  Acknowledgment and Prehearing Order at 4, 5 (¶¶ 4(c)(iv), 8); see CRD Procedures ¶ 16(b).  The order also directs the parties to indicate which, if any, of the opposing side’s witnesses the party wishes to cross-examine and explains that an in-person hearing is needed only if a party wishes to cross-examine the opposing side’s witnesses.  Order at 5, 6 (¶¶ 9, 10).  Neither party lists any witnesses.  Because there are no witnesses to be examined or cross-examined, an in-person hearing would serve no purpose, and I may decide this case based on the written record.  See CRD Procedures ¶ 19(b).  

I therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  See Order at 6 (¶ 11).1 

Exhibits.  CMS submits its motion and brief (CMS Br.) with 10 exhibits (CMS Exs. 1-10).  In the absence of any objections, I admit into evidence CMS Exs. 1-10. 

Petitioner submits its argument in response (P. Br.) with no exhibits.2 

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Discussion

1. On March 25, 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).3 

Enrollment.  Petitioner participates in the Medicare program as a “supplier” of services.  See Social Security Act § 1861(d); 42 C.F.R. §§ 400.202, 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a supplier must enroll in the program.  Act §§ 1835(a), 1842(h)(1); 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 Management and Budget.  42 C.F.R. § 424.502.4   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 physician and non-physician practitioner organizations 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 re-enrollment after a deactivation, additional regulations apply. 

Deactivation and reactivation.  “Deactivate” means that a supplier’s billing privileges are stopped but can be restored when it submits updated information.  42 C.F.R. § 424.502 (defining “deactivate”).  When a supplier’s billing privileges are deactivated, no payment is made for otherwise Medicare-covered services furnished to beneficiaries.  42 C.F.R. § 424.555(b).  If the supplier furnishes those services while deactivated, the expenses incurred are the supplier’s responsibility.  42 C.F.R. § 424.555(c). 

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To maintain its billing privileges, a supplier must, among other requirements, report changes to the information it supplied on its current enrollment application.  42 C.F.R. § 424.540(a)(2).  Changes that must be reported within 90 days include “a change of any managing employee.”  Id. 

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).

CMS may reject a supplier’s enrollment application if the “supplier fails to furnish complete information on the . . . enrollment application within 30 days from the date the contractor requested the missing information.”  42 C.F.R. § 424.525(a)(1).  Tosan Fregene, M.D. and Oncology Clinics, Inc., DAB No. 3018 at 2 (2020). 

Here, Joseph Chazen was listed on Petitioner’s February 7, 2022 Medicare enrollment application as a “managing employee, director/officer and authorized official.”  However, Joseph Chazen died on July 26, 2024.  CMS Ex. 2 at 1. 

In a letter dated September 9, 2024, the Medicare contractor advised Petitioner that, because Joseph Chazen had died, Petitioner had 90 calendar days from the postmarked date of the letter to provide a change of information that would allow the contractor “to verify [Petitioner’s] full compliance with regulations.”  CMS Ex. 1.  The letter warned that if Petitioner failed to comply with the 90-day deadline, CMS would deactivate its enrollment pursuant to 42 C.F.R. § 424.540(a)(3).  Id.  

Petitioner did not submit the requested information, and, in a letter, dated December 10, 2024, the contractor advised Petitioner that its Medicare billing privileges were being deactivated, effective December 9, 2024, pursuant to 42 C.F.R. § 424.540(a)(3).  CMS Ex. 2. 

On December 12, 2024, Petitioner submitted a new enrollment application (CMS form 855S).  CMS Ex. 3.  However, the contractor learned that the Rhode Island Department of State had revoked the practice’s registration (effective October 12, 2022).  CMS Ex. 5.  In an email dated December 17, 2024, the contractor advised Petitioner that registration with the state is a “requirement that must be fulfilled in order to enroll in Medicare” and directed Petitioner to reactivate with the Department of State and submit evidence that it had completed its registration.  CMS Ex. 4. 

In a letter dated January 21, 2025, the contractor advised Petitioner that it rejected the December 12, 2024 application because Petitioner did not respond to its December 17,

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2024 request, and evidence of the practice’s active registration with the Rhode Island Department of State was missing.  CMS Ex. 6. 

On March 25, 2025, the Medicare contractor received Petitioner’s Medicare application (Form CMS-855S), which it processed to approval.  CMS Exs. 7, 8.  March 25, 2025 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner does not dispute these facts but challenges the notion that “the rejection [of its December 12, 2024 application] extinguished the legal significance of a timely reactivation submission for purposes of determining the effective date under 42 C.F.R. §§ 424.520(d) and 424.540(d)(2).”  P. Br. at 3.  The regulations say otherwise.  CMS may reject a supplier’s enrollment application if the “supplier fails to furnish complete information on the . . . enrollment application within 30 calendar days from the date of the Medicare contractor’s request for the missing information.”  42 C.F.R. § 424.525(a)(1).  After CMS rejects the enrollment application, the supplier must complete and submit a new enrollment application with all supporting documentation.  42 C.F.R. § 424.525(c).  CMS determines the effective date based on the application it approved, not the one it rejected.  42 C.F.R. § 424.520(d); Tosan Fregene, DAB No. 3018 at 2. 

I have no authority to review the contractor’s determination to reject an application.  42 C.F.R. § 424.525(d); Tosan Fregene, DAB No. 3018 at 7; see 42 C.F.R. § 498.3(b) (defining “initial determinations” that are subject to review by an administrative law judge and the Departmental Appeals Board). 

Nor may I grant Petitioner an earlier effective date based on any equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6, 9 (2019); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); Ark. Health Grp. d/b/a Baptist Health Family Clinic Lakewood, DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8-9 (2017).  

Finally, I may not direct the contractor to allow retrospective reimbursement.  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.  

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86 Fed. Reg. 62,240, 62,459-60 (Nov. 9, 2021); see Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022). 

Conclusion

Because Petitioner filed its subsequently-approved reactivation application on March 25, 2025, March 25 is the earliest possible effective date for its reactivation.  See 42 C.F.R. § 424.540(d)(2).  

I may not review the contractor’s rejection of an earlier application, and retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).