Lake Shore OB GYN of Decatur S C, DAB CR6850 (2026)

DECISION

I affirm the determination of the Centers for Medicare & Medicaid Services (CMS) that the effective date for the reactivation of the Medicare billing privileges for Petitioner, Lake Shore OB GYN of Decatur SC, is February 10, 2025.  

I.  Procedural History

On August 21, 2025, Petitioner requested a hearing to dispute the reactivation effective date for its Medicare billing privileges.  On August 25, 2025, the Civil Remedies Division (CRD) acknowledged receipt of Petitioner’s hearing request, provided the parties with a prehearing submission schedule, and issued my Standing Order.  On September 29, 2025, CMS filed a brief/motion for summary judgment (CMS Br.) and 11 proposed exhibits.  On October 1, 2025, CRD issued a notice that Petitioner’s prehearing exchange deadline was extended due to the lack of appropriated funds for the Department of Health and Human Services.  Based on the notice, Petitioner’s prehearing exchange was due on December 16, 2025.  Petitioner did not file an exchange. 

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II.  Admission of Evidence

Absent objection, I admit all of CMS’s proposed exhibits into the record.  See Standing Order ¶ 10; CRD Procedures § 14(e). 

III.  Decision on the Written Record

I directed the parties to submit written direct testimony for any witnesses they wanted to offer.  Standing Order ¶ 11; see also CRD Procedures § 16(b).  I also informed the parties as follows: 

If the parties either do not file any written direct testimony or the parties do not request to cross-examine any of the witnesses from whom written direct testimony has been submitted, I will consider such actions by the parties to serve as a constructive request for a decision on the written record because there will be no reason to hold an in-person hearing.  

Standing Order ¶ 7(g)(iii); see also CRD Procedures § 19(d).  I further advised:  “Unless a hearing is required for cross-examination of a witness or witnesses, the record will be closed and the case will be ready for a decision after all the submission deadlines have passed.”  Standing Order ¶ 14. 

Neither party submitted written direct testimony from any witnesses and all submission deadlines have passed.  Therefore, I decide this case on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 11-12 (2022); CRD Procedures § 19(d). 

IV.  Issue

Whether February 10, 2025, is the correct effective date for the reactivation of Petitioner’s Medicare billing privileges. 

V.  Jurisdiction

I have jurisdiction to decide the issue in this case.  42 C.F.R. § 498.3(b)(15). 

VI.  Findings of Fact

1.  Petitioner was enrolled in the Medicare program as a clinic/group practice.  See CMS Ex. 1 at 1; CMS Ex. 8 at 1. 

2.  A CMS contractor sent a notice, on March 29, 2024, advising Petitioner that every five years it must revalidate the information in Petitioner’s Medicare enrollment

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record.  The notice warned Petitioner that a failure to revalidate its enrollment information by June 30, 2024, may result in deactivation of its Medicare billing privileges.  The notice further explained that Petitioner would not be paid for services rendered during the period of deactivation and that this will “cause a gap in your reimbursement.”  CMS Ex. 2 at 1. 

3.  The CMS contractor sent a notice, on July 2, 2024, informing Petitioner of its failure to timely revalidate its Medicare enrollment record and that the contractor was placing a stay on Petitioner’s Medicare enrollment.  The notice again stated that a failure to revalidate would result in deactivation of its Medicare enrollment and that deactivation meant that Petitioner could not be paid for services rendered during the period of deactivation.  Finally, the notice stated that Petitioner could file a rebuttal if Petitioner thought that the determination to stay its enrollment was incorrect.  CMS Ex. 4 at 1-2.

4.  The postal service returned the July 2, 2024 notice to the CMS contractor as “UNCLAIMED UNABLE TO FORWARD.”  CMS Ex. 5 at 3. 

5.  In an August 12, 2024 notice, the CMS contractor informed Petitioner that its Medicare billing privileges were being deactivated as of July 1, 2024, “because [Petitioner has] not timely revalidated [Petitioner’s] enrollment record with us, or [Petitioner’s] revalidation application has been rejected because you did not timely respond to our requests for more information.  We will not pay any claims after this date.”  CMS Ex. 6 at 1.  The notice advised Petitioner that it could file a rebuttal if Petitioner believed the deactivation was incorrect.  CMS Ex. 6 at 1-2.  Finally, the notice stated that Petitioner could revalidate its Medicare enrollment record through filing an enrollment application.  CMS Ex. 6 at 2. 

6.  The postal service returned the August 12, 2024 notice to the CMS contractor as “NOT DELIVERABLE AS ADDRESSED UNABLE TO FORWARD.”  CMS Ex. 3 at 4; CMS Ex. 7 at 4. 

7.  On February 10, 2025, CMS received Petitioner’s Medicare enrollment application that Petitioner electronically filed to revalidate its Medicare enrollment information.  CMS Ex. 8 at 1. 

8.  In a March 26, 2025 notice, the CMS contractor approved Petitioner’s reactivation enrollment application and advised Petitioner “will have a gap in billing privileges from July 2, 2024 through February 9, 2025 for failing to fully revalidate during a previous revalidation cycle.  [Petitioner] will not be reimbursed for services provided to Medicare beneficiaries during this time period since [Petitioner was] not in compliance with Medicare requirements.”  CMS Ex. 10 at 1-2. 

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9.  On or about April 2, 2025, Petitioner requested reconsideration of the effective date for reactivation.  CMS Ex. 11. 

10.  On July 21, 2025, the CMS contractor issued an unfavorable reconsideration determination.  The CMS contractor upheld the reactivation effective date of February 10, 2025, with “a gap in coverage between July 02, 2024 and February 09, 2025.”  Electronic Filing System (E-File) Doc. No. 1a at 4-5. 

VI.  Conclusion of Law

1.  The effective date of reactivation for Petitioner’s Medicare billing privileges is February 10, 2025, because CMS received Petitioner’s revalidation enrollment application on February 10, 2025, and a CMS contractor was able to process that application to approval.  42 C.F.R. § 424.540(d)(2). 

VII.  Analysis

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A “supplier” includes “a physician or other practitioner, 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).  A supplier must enroll in the Medicare program to receive payment for covered items or services.  42 U.S.C. §§ 1395n(a), 1395u(h)(1); 42 C.F.R. § 424.505.  To enroll, the supplier must submit an enrollment application and provide all required information.  42 C.F.R. § 424.510(a). 

To maintain enrollment, a supplier must recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  To do this, a supplier “must submit to CMS the applicable enrollment application with complete and accurate information and applicable supporting documentation within 60 calendar days of [CMS’s] notification to resubmit and certify to the accuracy of its enrollment information.”  42 C.F.R. § 424.515(a)(2).  If a supplier fails to submit information required by CMS within 90 days of receiving notice from CMS to revalidate, then CMS may deactivate the supplier’s Medicare billing privileges.  42 C.F.R. § 424.540(a)(3).  

To reactivate billing privileges, the supplier must recertify that its reenrollment information currently on file with CMS is correct and furnish any missing information.  42 C.F.R. § 424.540(b)(1).  When a supplier seeks reactivation, “[t]he effective date of a reactivation of billing privileges under this section is the date on which the Medicare contractor received the . . . supplier’s reactivation submission that was processed to approval by the Medicare contractor.”  42 C.F.R. § 424.540(d)(2). 

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Petitioner requests a shorter gap in Medicare billing privileges.  Petitioner explains that the failure to timely revalidate was based on miscommunication between Medicare and Petitioner.  Further, Petitioner had extensive staff turnover, which resulted in the practice’s physicians handling administrative matters.  Petitioner first received notice of the deactivation when its Medicare claims were no longer being processed.  Petitioner was also delayed by trying to electronically file the revalidation enrollment application.  Finally, deactivation is a significant financial hardship.  CMS Ex. 11; Hr’g Req.  

CMS asserts that Petitioner’s arguments do not concern the effective date of reactivation but rather the determination to deactivate Petitioner’s Medicare billing privileges.  CMS states that I have no jurisdiction to review CMS’s determination to deactivate Petitioner’s Medicare billing privileges and that I only have jurisdiction to determine whether CMS properly set the reactivation effective date.  CMS Br. at 4-5. 

CMS is correct.  I am unable to modify the effective date for reactivation based on Petitioner’s assertions that it did not receive adequate communication from CMS concerning revalidation or due to financial hardship.1   My jurisdiction is limited to determining whether CMS assigned Petitioner the correct date of reactivation.  See 42 C.F.R. § 498.3(b)(15) (effective date for supplier approval is an appealable initial determination).  As CMS points out, I do not have jurisdiction to review CMS’s decision to deactivate Petitioner’s Medicare billing privileges.  See 42 C.F.R. §§ 424.545(b), 424.546(f) (CMS has the sole authority to consider any rebuttal to the deactivation filed by a supplier); Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8 (2022). 

Although Petitioner alleges difficulty in electronically filing the revalidation enrollment application, the effective date of reactivation cannot be earlier than the date CMS receives the application.  42 C.F.R. § 424.540(d)(2).  In addition, Petitioner had the option to mail a paper application to CMS.  CMS Ex. 2 at 1.  Further, financial hardship is not a legal basis to change the effective date because the regulations prohibit CMS from paying Petitioner for any health care items or services provided during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b); 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see also Goffney v. Becerra, 995 F.3d 737, 743 (9th Cir. 2021).  

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VIII.  Conclusion

The effective date for the reactivation of Petitioner’s Medicare billing privileges is February 10, 2025.