Orthopedic Institute of Michigan, PLLC, DAB CR6881 (2026)

DECISION

The Centers for Medicare & Medicaid Services (CMS), acting through its Medicare administrative contractor, Wisconsin Physicians Service Insurance Corporation (WPS), denied Orthopedic Institute of Michigan, PLLC’s (Petitioner) Medicare enrollment application pursuant to 42 C.F.R. § 424.530(a)(1).  Petitioner challenges the denial.  For the reasons set forth below, I have determined that CMS had a legal basis to deny Petitioner’s Medicare enrollment application. 

I. Background and Procedural History

On February 25, 2025, Petitioner, a Medicare Part B supplier, submitted an application to reactivate a deactivated Medicare billing number.  CMS Ex. 1.  CMS, through WPS, issued a notice denying the application on April 29, 2025.  CMS Ex. 2. 

Petitioner submitted a timely request for reconsideration on May 29, 2025.  CMS Ex. 3.  

On August 31, 2025, WPS issued a reconsidered determination upholding the denial of Petitioner’s Medicare enrollment.  CMS Ex. 4 at 1.  

Petitioner requested a hearing before an Administrative Law Judge (ALJ) on November 7, 2025. 

Page 2

On November 12, 2025, the Civil Remedies Division (CRD) issued an Acknowledgement Letter, my Standing Order, and the CRD Procedures. 

On January 9, 2026, CMS filed a combined Motion for Summary Judgment and a prehearing brief (CMS Br.) along with four exhibits (CMS Exs. 1-4). 

On February 20, 2026, Petitioner filed a Response to Summary Judgment (P. Br.) along with nine exhibits (P. Exs. 1-9). 

CMS filed objections to P. Exs. 1 and 7 on March 11, 2026. 

II. Issue1 

The issue is whether CMS had a legal basis to deny Petitioner’s February 25, 2025 Medicare enrollment application pursuant to 42 C.F.R. § 424.530(a)(1).2 

III. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R. §§ 498.3(b)(17), 498.5(l)(2); see also Social Security Act (Act) § 1866(j)(8) (codified at 42 U.S.C. § 1395cc(j)(8)). 

Page 3

IV. Evidence and Decision on Written Record

Absent objection, CMS Exs. 1-4 are admitted in evidence.  CMS objected to P. Exs. 1 and 7.  However, CMS’s objections are overruled.  P. Exs. 1-9 are admitted into evidence.  

Neither party identified witnesses to testify in this matter.  As stated in the Standing Order, a hearing will only be held to allow parties to cross-examine witnesses.  Because no witnesses have been identified, CMS’s motion for summary judgment is moot and this matter will be decided on the written record.  See Standing Order ¶¶ 12, 13. 

V. Legal Authorities

The Act authorizes the Secretary of Health and Human Services (Secretary) to establish regulations for enrolling providers and suppliers in the Medicare program.  Act § 1866(j)(1)(A) (42 U.S.C. § 1395cc(j)(1)(A)).  Petitioner is a supplier of health care services for purposes of the Medicare program.  See Act § 1861(d) (42 U.S.C. § 1395x(d)); 42 C.F.R. § 400.202 (definition of supplier). 

In order to enroll in the Medicare program and receive billing privileges, suppliers must meet certain criteria.  42 C.F.R §§ 424.505, 424.510, 424.516.  The regulations define enrollment as “the process that Medicare uses to establish eligibility to submit claims for Medicare‑covered items and services . . . .”  42 C.F.R. § 424.502.  As applicable here, section 424.516(a)(2) provides that a supplier must be in “[c]ompliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the . . . supplier . . . will furnish and bill Medicare.”  Pursuant to 42 C.F.R. § 424.530(a)(1), CMS may deny a prospective supplier’s enrollment application if CMS determines that the supplier fails to comply with any enrollment requirement. 

A prospective provider or supplier that is denied enrollment may appeal CMS’s reconsidered determination in accordance with 42 C.F.R. Part 498, subpart A.  42 C.F.R. § 424.545(a).  The reconsidered determination to deny the enrollment of a provider or supplier under 42 C.F.R. § 424.530 is an “initial determination” that may be appealed through the administrative process to the ALJ and then to the Board.  42 C.F.R. § 498.3(b)(17); see also, e.g., Deann Worthington, NP, DAB No. 2661 at 2 (2015). 

VI. Findings of Fact

On November 14, 2024, WPS issued a letter informing Petitioner that all individual providers and suppliers designated at the high screening level must complete a fingerprint-based background check within 30 calendar days from the date of the letter.

Page 4

CMS Ex. 3 at 19.  The letter specifically requested fingerprints for Michael Brager.  CMS Ex. 3 at 20.  

Petitioner submitted a Medicare enrollment application on November 25, 2024.  On December 2, 2024, WPS informed Petitioner that the application was denied because the initial application was submitted prior to the expiration of a re-enrollment bar.  P. Ex. 4 at 14. 

On February 25, 2025, Petitioner submitted a Medicare enrollment application to reactivate a deactivated Medicare billing number.  CMS Ex. 1.  On that application, both Michael Brager and Elie Khoury are listed as being five percent or greater direct/indirect owner partners.  CMS Ex. 1 at 5, 7. 

On April 29, 2025, WPS issued a notice informing Petitioner that its Medicare enrollment application was denied because CMS had not received fingerprints for Michael Brager or Elie Khoury.  CMS Ex. 2. Petitioner requested reconsideration.  CMS Ex. 4 at 1.  On August 31, 2025, CMS issued a reconsidered determination upholding the denial of Petitioner’s Medicare enrollment pursuant to 42 C.F.R. § 424.530(a)(1) because the fingerprints were not received at the time of the disposition of the application. 

VII. Analysis and Conclusions of Law

CMS may deny a provider’s or supplier’s enrollment in the Medicare program for noncompliance with the enrollment requirements described in Title 42 of the Code of Federal Regulations.  42 C.F.R. § 424.530(a)(1).  Pursuant to 42 C.F.R. § 424.518(c)-(d), a fingerprint-based background check is required for all individuals with a five percent or greater ownership interest in a provider or supplier that falls under the high-risk category. 

Here, WPS identified Petitioner as a supplier that fell under the high-risk category and both Drs. Brager and Khoury were listed on the February 25, 2025 Medicare enrollment application as individuals with a five percent or greater ownership interest.  CMS Ex. 1 at 5, 7.  Petitioner’s February 25, 2025 enrollment application was denied because as of the date of the notice letter (April 29, 2025), WPS had not received the required fingerprints from Drs. Brager and Khoury.  CMS Ex. 2. 

In this case, Petitioner maintains that Dr. Khoury is not a five-percent or greater owner in Petitioner’s practice.  P. Br. at 1.  Petitioner argues that Dr. Khoury was a retired physician whose participation in the practice had ended and that his PECOS enrollment record was marked “deleted” with a documented end date of October 1, 2021.  Id.  The evidence to support Petitioner’s claim is an email dated August 7, 2024, from an unidentified party which states, “correct the requested termination date for Elie Khoury.  The providers (sic) last claim is dated 05/02/24.  If the requested date 01/01/21 is used, this will cause an overpayment.”  P. Ex. 2.  There is also a rejected/withdrawn Medicare

Page 5

application dated December 6, 2024, that shows Dr. Khoury as deleted as of January 1, 2021.  P. Ex. 4 at 8.  However, on November 18, 2024, Dr. Khoury submitted a Medicare enrollment application which was subsequently denied because the group enrollment was deactivated.  P. Ex. 4 at 19.  More importantly, Dr. Khoury remained listed as a five-percent or greater direct/indirect owner on the February 25, 2025 Medicare enrollment application that Petitioner submitted to WPS.  CMS Ex. 1 at 7.  Even if Petitioner previously requested Dr. Khoury to be deleted from a Medicare application that was ultimately rejected or withdrawn, it had a duty to ensure the accuracy of the new Medicare application before submitting it to CMS. 

Therefore, CMS did not err in determining that Petitioner failed to submit fingerprints for Dr. Khoury because he was listed as a five-percent or greater owner on the February 25, 2025 Medicare enrollment application submitted by Petitioner.  

Instead of  submitting new fingerprints for Dr. Brager, Petitioner continued to rely on the fingerprints previously submitted in response to an October 17, 2024 fingerprint request from WPS.  CMS Ex. 3 at 1.  However, there was an unexplained delay in processing those fingerprints.  On July 16, 2025, Sarah Brown, Petitioner’s representative, sent an email to a WPS representative indicating that the fingerprints were still being processed.  P. Ex. 8 at 3.  No evidence was provided to corroborate this information.  Therefore, as the hearing officer determined, the fingerprints were not received at the time of the disposition of the application.  CMS Ex. 4 at 3.  After the initial determination was issued, Petitioner mailed a copy of Dr. Brager’s fingerprints and a request for reconsideration.  P. Br. at 5; P. Ex. 7. 

Lastly, Petitioner argues that the proper remedy is to grant its billing privileges with an effective date of November 2024, due to WPS’s failure to process a timely fingerprint submission.  P. Br. at 8.  I am unable to grant that request.  According to Petitioner, it was subject to a re-enrollment bar beginning October 29, 2024, which remained in effect in November 2024 and served as the basis of the denial for Petitioner’s November 25, 2024 Medicare enrollment application.  P. Br. at 8; P. Ex. 4 at 14.  There is no legal basis to overturn the re-enrollment bar that was imposed, nor is that at issue in this case.  There is no legal basis to even discuss an effective date, as no Medicare enrollment application submitted by Petitioner has been processed to approval by the Medicare contractor.  

The evidence shows that Petitioner did not provide fingerprint background checks for Dr. Elie Khoury and Dr. Michael Brager, which resulted in the enrollment denial for Petitioner’s February 25, 2025 Medicare enrollment application.

Page 6

VIII. Conclusion

Based on the evidence set forth, CMS established a legal basis for the denial of Petitioner’s February 25, 2025 Medicare enrollment application.  Therefore, the denial of Petitioner’s Medicare enrollment application under 42 C.F.R. § 424.530(a)(1), based on failing to meet the supplier standards found in 42 C.F.R. § 424.518(c)(2), (d), is affirmed.