Grace H. Jeon, MD, DAB CR6862 (2026)

DECISION

February 8, 2024, is the effective date of reactivation of the Medicare enrollment and billing privileges of Petitioner, Grace H. Jeon, MD, and her reassignment of the right to file claims with and receive payment from Medicare to Anaheim Surgical Associates.

I.  Procedural History and Undisputed Facts

The material facts are undisputed.  Any reasonable inferences are drawn in favor of Petitioner.

On January 18, 2024, Noridian Healthcare Solutions, a Medicare administrative contractor (MAC), notified Petitioner that her Medicare billing privileges were deactivated effective January 20, 2024, pursuant to 42 C.F.R. § 424.540(a)(4).1 Centers

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for Medicare & Medicaid Services (CMS) Exhibit (Ex.) 6.  The MAC advised Petitioner of the regulatory right to submit a rebuttal to the deactivation.  CMS Ex. 6 at 1-2.  There is no evidence before me showing that Petitioner challenged the deactivation determination by filing a rebuttal.

On February 8, 2024, the MAC received Petitioner’s enrollment applications to reactivate her billing privileges and to reassign her right to file claims with and receive payment from Medicare to Anaheim Surgical Associates.  CMS Exs. 7, 8, 10.

On February 27, 2024, the MAC informed Petitioner of its initial determination to reactivate Petitioner’s Medicare billing privileges and approving the reassignment to Anaheim Surgical Associates effective February 8, 2024.  CMS Ex. 4.

On March 6, 2024, Petitioner requested a reconsidered determination.  Petitioner requested that her reassignment to Anaheim Surgical Associates be changed to May 10, 2023.  CMS Ex. 3.  Petitioner provided some background information, which I accept as true for purposes of summary judgment.  Petitioner began providing services at Anaheim Surgical Associates on July 1, 2019.  Petitioner had reassigned her right to file claims with and receive payment for Medicare claims to Anaheim Surgical Associates effective July 1, 2019.  Anaheim Surgical Associates was required to reenroll in Medicare and the new enrollment and billing privileges were effective May 10, 2023.  When Anaheim Surgical Associates reenrolled in May 2023, it had not listed Petitioner and her reassignment in its application.  Petitioner states she and Anaheim Surgical Associates were unaware of the omission and that Petitioner’s reassignment was terminated for that reason.  I also accept as true Petitioner’s representation that she continuously provided care and services at Anaheim Surgical Associates from July 1, 2019, at least until she was informed of the deactivation.  CMS Ex. 3.  I note that CMS Ex. 10 also shows that Petitioner had a reassignment to Anaheim Surgical Associates in effect from July 1, 2019 to May 1, 2023.  CMS Ex. 10 at 7.  CMS Ex. 5 shows that Anaheim Surgical Associates Medicare billing privileges were deactivated effective May 1, 2023, for failure to update

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Medicare enrollment information related to the death of a partner/authorized official, and director/officer.  CMS Ex. 5 at 1.

On July 15, 2024, a MAC hearing officer upheld the reactivation effective date of February 8, 2024, the date the MAC received Petitioner’s Medicare enrollment application to reactivate her billing privileges that the MAC processed to approval.  The hearing officer explained that Petitioner was deactivated because she had no active employment association, reassignment, or practice location on file with CMS for an extended period in violation of Medicare enrollment requirements, after the deactivation and reactivation of Anaheim Surgical Associates’ billing privileges without the inclusion of Petitioner’s reassignment.  The hearing officer concluded that she was bound by 42 C.F.R. § 424.540(d)(2) which requires that the effective date of reactivation of Medicare billing privileges is the date the MAC received the Medicare enrollment application to reactivate that it could process to approval.  CMS Ex. 1 at 1-4.

Petitioner filed a request for hearing before an administrative law judge (ALJ) on July 23, 2024.  On July 25, 2024, the case was assigned to Judge Jacinta L. Alves for hearing and decision and her Standing Order was issued.

On August 29, 2024, CMS filed a motion for summary judgment and prehearing brief, with CMS Exs. 1 through 10.  Petitioner failed to respond to the CMS motion for summary judgment, and on October 4, 2024, Judge Alves ordered Petitioner to show cause why the case should not be dismissed.  On October 9, 2024, Petitioner responded by filing a copy of the reconsideration request dated March 6, 2024, that she previously filed with the MAC.  I accept Petitioner’s filing as evidence that Petitioner did not abandon her request for hearing and as her response to the CMS motion for summary judgment.

On December 23, 2025, this case was reassigned to me in anticipation of Judge Alves’ retirement, and the parties were advised by letter.

II.  Issues, Conclusions of Law, and Analysis

1. Issues

Whether I have jurisdiction to review the reconsidered determination by CMS or a MAC of the effective date of reactivation of Medicare billing privileges, which are the right to file claims with and to receive payment from Medicare; and

The effective date of reactivation of Petitioner’s billing privileges.

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2. Conclusions of Law and Analysis

My conclusions of law are set forth in bold text followed by my analysis applying the law to the undisputed facts.

1.  Summary judgment is appropriate.

Petitioner is entitled to a hearing on the record before an ALJ under the Social Security Act (Act).  Act §§ 205(b), 1866(h)(1), (j); Crestview Parke Care Ctr. v. Thompson, 373 F.3d 743, 748-51 (6th Cir. 2004).  However, when summary judgment is appropriate, no hearing is required.  The Departmental Appeals Board (Board) has long accepted that summary judgment is an acceptable procedural device in cases adjudicated pursuant to 42 C.F.R. pt. 498.  See, e.g., Crestview Parke, 373 F.3d at 748-51; Ill. Knights Templar Home, DAB No. 2274 at 3-4 (2009); Garden City Med. Clinic, DAB No. 1763 (2001); Everett Rehab. & Med. Ctr., DAB No. 1628 at 3 (1997).  The Board has accepted that Fed. R. Civ. P. 56 and related cases provide useful guidance for determining whether summary judgment is appropriate.  The parties were notified by Judge Alves Standing Order ¶ 8 that summary judgment is an available procedural device and that the law as it has developed related to Fed. R. Civ. P. 56 will be applied.

Summary judgment is appropriate when there is no genuine dispute as to any issue of material fact for adjudication and/or the moving party is entitled to judgment as a matter of law.  See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986); Mission Hosp. Reg’l Med. Ctr., DAB No. 2459 at 5 (2012) (and cases cited therein); Experts Are Us, Inc., DAB No. 2452 at 5 (2012) (and cases cited therein); Senior Rehab. & Skilled Nursing Ctr., DAB No. 2300 at 3 (2010) (and cases cited therein).  A test for whether an issue of fact is genuinely in dispute is whether “the evidence [as to that issue] is such that a reasonable jury could return a verdict for the nonmoving party.”  Liberty Lobby, 477 U.S. at 248.  In evaluating whether there is a genuine issue as to a material fact, an ALJ must view the facts and the inferences to be drawn from the facts in the light most favorable to the nonmoving party, which I have done.  See Pollock v. Am. Tel. & Tel. Long Lines, 794 F.2d 860, 864 (3rd Cir. 1986).

The undisputed facts set forth above are the facts necessary to resolve this case.  There is no genuine dispute of material fact related to the effective date of the reactivation of Petitioner’s billing privileges or the effective date of the reassignment to Anaheim Surgical Associates.  CMS is entitled to judgment as a matter of law and summary judgment is appropriate.

2.  Petitioner has no right to ALJ review of the determination of the MAC to deactivate her billing privileges.  42 C.F.R. § 424.546(f).

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3.  There is authority for ALJ review in this case, but it is limited to the effective date of reactivation of Petitioner’s Medicare enrollment and billing privileges, i.e., the date of reactivation of Petitioner’s right to submit claims to and receive payment from Medicare for care and services delivered to Medicare-eligible beneficiaries, and the effective date of the reassignment of billing privileges to Anaheim Surgical Associates

4.  February 8, 2024, is the effective date of reactivation of Petitioner’s billing privileges as that was the date the MAC received the Medicare enrollment application that it could process to approval.  42 C.F.R. § 424.540(d)(2).

5.  February 8, 2024, is the effective date of Petitioner’s reassignment of her billing privileges to Anaheim Surgical Associates.  42 C.F.R. §§ 424.520(d)(1), 424.522(a).

Two events are of concern to Petitioner in this case.

1.  Petitioner’s reassignment to Anaheim Surgical Associates ended when its Medicare enrollment and billing privileges were deactivated and then Anaheim Surgical Associates filed a reactivation enrollment application that was approved but did not list Petitioner’s reassignment.

2.  Petitioner’s Medicare enrollment and billing privileges were deactivated January 20, 2024, because it was discovered by the MAC that Petitioner had no reassignment or practice location for an extended period.

CMS Exs. 1, 3, 5, 6.  Although not specifically stated by Petitioner, the two events resulted in Petitioner being unable to bill for and receive payment from Medicare for services she provided to Medicare beneficiaries for some period.

The first event, Anaheim Surgical Associates’ deactivation and subsequent reactivation, is not before me because I have no request for hearing by Anaheim Surgical Associates before me.  Furthermore, there is no evidence and Petitioner does not assert any right to request review on behalf of Anaheim Surgical Associates.

The second event – not the deactivation but the reactivation of Petitioner’s Medicare billing privileges – is before me for decision.

The Secretary of the U.S. Department of Health & Human Services (the Secretary) promulgated regulations at 42 C.F.R. pt. 424 that establish a process for enrolling

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providers and suppliers in Medicare.  Pursuant to the regulations, CMS or the MAC may deactivate the billing privileges of an enrolled provider or supplier for any of the eight reasons listed in 42 C.F.R. § 424.540(a).  Pursuant to 42 C.F.R. § 424.540(a)(4), Medicare billing privileges may be deactivated if a provider or supplier fails to comply with Medicare enrollment requirements.  In this case, the MAC’s January 18, 2024 notice of deactivation cited 42 C.F.R. § 424.540(a)(4).  CMS Ex. 6.

Deactivation of billing privileges has no effect on a provider’s or supplier’s “participation agreement or any conditions of participation.”  42 C.F.R. § 424.540(c).  But a provider or supplier may receive no payment from Medicare for items or services provided to a Medicare-eligible beneficiary during the period of deactivation.  42 C.F.R. § 424.540(e).

The MAC’s January 18, 2024 determination to deactivate Petitioner’s Medicare enrollment and billing privileges is not subject to appeal or my review.  42 C.F.R. §§ 424.545(b), 424.546(f).  Petitioner does not dispute she received the MAC’s January 18, 2024 notice of the deactivation.  The MAC informed Petitioner she could file a rebuttal to the deactivation pursuant to 42 C.F.R. § 424.546.  CMS Ex. 6.  There is no evidence that Petitioner filed a rebuttal.  The regulations are clear that filing a rebuttal was Petitioner’s only recourse when her Medicare billing privileges were deactivated.  Failure to file the rebuttal within 15 calendar days from the date of the notice constitutes a waiver of the right to submit a rebuttal.  42 C.F.R. § 424.546(c).  Action or inaction by the MAC or CMS on a rebuttal is also not appealable or subject to review.  42 C.F.R. § 424.546(f).  Petitioner alleges she and Anaheim Surgical Associates were not notified that her reassignment to Anaheim Surgical Associates was terminated.  CMS Ex. 3.  But, she does not allege any error by the MAC in the deactivation of her billing privileges.  However, any errors made by the MAC in making that determination are not subject to my review and are immaterial to this decision because I have no authority to act related to the determination to deactivate Petitioner’s Medicare billing privileges.

The Secretary has not specifically stated that a provider or supplier has a right to ALJ review of CMS or MAC determinations related to the effective date of the reactivation of billing privileges.  42 C.F.R. §§ 424.545, 498.3(b), 498.5.  However, 42 C.F.R. § 498.3(b)(15) provides that “[t]he effective date of a Medicare provider agreement or supplier approval” is an initial determination subject to review by an ALJ.  The Board has given an expansive interpretation to 42 C.F.R. § 498.3(b)(15) and found a right to ALJ review of the effective date of enrollment in Medicare as well as the effective date of the reactivation of billing privileges.  See, e.g., Victor Alvarez, M.D., DAB No. 2325 at 3-12 (2010) (determination of effective date of enrollment in Medicare is an initial determination subject to ALJ review and Board appeal); Urology Grp. of NJ, LLC, DAB No. 2860 at 6 (2018) (no right to review of a CMS or MAC determination to deactivate billing privileges but right to review of the determination of the effective date of reactivation).

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Applying the reasoning of the Board in Alvarez and Urology, I conclude that a supplier has the right to ALJ review of the CMS or MAC determination of the effective date of reactivation of billing privileges.  Furthermore, the only determination of CMS or the MAC that is subject to my review in a provider or supplier enrollment case is the reconsidered determination.  42 C.F.R. § 498.5(l)(1)-(2); Neb Grp. of Ariz. LLC, DAB No. 2573 at 7 (2014).

Billing privileges may be reactivated in accordance with 42 C.F.R. § 424.540(b).  The provider or supplier must recertify the accuracy of its enrollment information, submit any missing information, and certify it complies with all applicable Medicare enrollment requirements.  42 C.F.R. § 424.540(b)(1).  CMS may for any reason require a deactivated provider or supplier to submit a complete Medicare enrollment application (CMS-855) to reactivate billing privileges.  42 C.F.R. § 424.540(b)(2).  The regulation clearly gives CMS and the MAC discretion to accept a certification and partial application with missing information provided or require that Petitioner submit a complete Medicare enrollment application.

The effective date of the reactivation of billing privileges is fixed by 42 C.F.R. § 424.540(d)(2).  The regulation requires that the effective date of reactivation of billing privileges is the date the MAC or CMS received the Medicare enrollment application that was processed to approval.  Therefore, by operation of 42 C.F.R. § 424.540(d)(2), the effective date of the reactivation of Petitioner’s Medicare enrollment and billing privileges must be February 8, 2024, the date the MAC received the enrollment application the MAC processed to approval.  CMS Exs. 4, 8.  The regulations grant no discretion to the MAC, CMS, or me to select a different reactivation effective date.  There was no error in the determination of the reactivation effective date.

The MAC’s February 27, 2024 notice of initial determination also provided that the reassignment effective date was February 8, 2024.  Pursuant to 42 C.F.R. § 424.522(a) (2023), which was in effect at the time of the initial determination,

A reassignment of benefits under [42 C.F.R.] § 424.80 is effective beginning 30 days before the Form CMS–855R is submitted if all applicable requirements during that period were otherwise met.

Therefore, the effective date of Petitioner’s reassignment could have been effective January 9, 2024, 30 days prior to the filing of the February 8, 2024 application.  But Petitioner did not meet all applicable requirements at that time because her billing privileges were deactivated.  When Petitioner’s billing privileges were reactivated effective February 8, 2024, her reassignment was also effective.

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Petitioner’s arguments can be construed to be that the government should be estopped from treating February 8, 2024, as Petitioner’s reactivation effective date.  But as a matter of law, estoppel against the federal government, if available at all, is presumably unavailable absent “affirmative misconduct,” such as fraud.  See, e.g., Pac. Islander Council of Leaders, DAB No. 2091 at 12 (2007); Off. of Pers. Mgmt. v. Richmond, 496 U.S. 414, 421 (1990).  I find no evidence in the record before me that any MAC or CMS representative acted fraudulently or engaged in any affirmative misconduct that Petitioners acted in detrimental reliance upon.  I conclude that estoppel is not an issue.

Petitioners’ arguments may be viewed as a request for equitable relief.  I have no authority to grant equitable relief.  US Ultrasound, DAB No. 2302 at 8 (2010).  I am bound to follow the Act and regulations, and I have no authority to declare statutes or regulations invalid or ultra vires.  1866ICPayday.com, L.L.C., DAB No. 2289 at 14 (2009) (noting that “[a]n ALJ is bound by applicable laws and regulations and may not invalidate either a law or regulation on any ground.”).

III.  Conclusion

For the foregoing reasons, I conclude that the effective date of reactivation of Petitioner’s Medicare enrollment and billing privileges and the effective date of reassignment of Petitioner’s billing privileges to Anaheim Surgical Associates is February 8, 2024.