The Therapy Center, LLP, DAB CR6952 (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, The Therapy Center, LLP, is January 16, 2026. 

I.  Procedural History

On April 29, 2026, Petitioner requested a hearing to dispute the reactivation effective date for its Medicare billing privileges.  On May 5, 2026, the Civil Remedies Division acknowledged receipt of Petitioner’s hearing request, provided the parties with a prehearing submission schedule, and issued my Standing Order and the Civil Remedies Division Procedures (CRDP).  On June 8, 2026, CMS filed a brief/motion for summary judgment and fourteen proposed exhibits.  Petitioner did not file an exchange. 

II.  Admission of Evidence

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

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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 CRDP § 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 CRDP § 19(b).  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); CRDP § 19(d). 

IV.  Issue

Whether January 16, 2026, 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 since 2006.  CMS Ex. 14 at 1.
2. In an August 29, 2025 notice, a CMS contractor advised Petitioner that it must revalidate the information in Petitioner’s Medicare enrollment record every five years.  The notice warned Petitioner that a failure to revalidate its enrollment information by November 30, 2025, may result in deactivation of its Medicare billing privileges.  The notice further explained that Medicare would not pay Petitioner for services rendered during the period of deactivation and that this will “cause a gap in your reimbursement.”  CMS Ex. 1; CMS Ex. 2.

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3. The CMS contractor addressed the August 29, 2025 notice to Brian Gerety, who is listed in Petitioner’s Medicare enrollment record as an owner, managing employee, director, partner, and authorized official of Petitioner’s group practice.  CMS Ex. 1 at 1; CMS Ex. 2 at 1; CMS Ex. 14 at 12-13.
4. In a December 3, 2025 notice, the CMS contractor informed Petitioner that it was placing a stay on Petitioner’s Medicare enrollment record as of December 3, 2025, because Petitioner did not respond to the August 29, 2025 revalidation notice.  The notice advised that, during the stay, Medicare claims for items and services provided to beneficiaries would be rejected.  The notice stated that Petitioner could file a rebuttal to appeal the stay.  The notice further stated that the CMS contractor would deactivate Petitioner’s Medicare enrollment unless Petitioner submitted a revalidation application within 30 days.  The notice warned that Petitioner would not be paid for services rendered during the period of deactivation which “will cause a gap in your reimbursement.”  CMS Ex. 3 at 1-2; CMS Ex. 4 at 1-2.
5. In a January 9, 2026 notice, the CMS contractor advised Petitioner that it was deactivating Petitioner’s Medicare billing privileges effective December 1, 2025, because Petitioner did not timely revalidate its enrollment record.  The notice stated that Petitioner could file a rebuttal to appeal the deactivation.  The notice also stated that Petitioner could reactivate its Medicare enrollment by filing an enrollment application to revalidate its Medicare enrollment record.  The notice made it clear that “[w]e will not pay any claims after [December 1, 2025].”  CMS Ex. 5 at 1-2; CMS Ex. 6 at 1-2.
6. On January 16, 2026, CMS received an enrollment application to reactivate Petitioner’s Medicare enrollment.  CMS Exs. 7-8.
7. In a January 30, 2026 notice of initial determination, the CMS contractor approved Petitioner’s application and reactivated Petitioner’s Medicare billing privileges effective January 16, 2026.  The determination also stated Petitioner “will have a gap in billing privileges from December 01, 2025 through January 15, 2026 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. 9 at 1.
8. On February 20, 2026, Petitioner requested reconsideration of the reactivation effective date.  CMS Ex. 11. 

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9. On April 17, 2026, the CMS contractor issued an unfavorable reconsideration determination affirming the January 16, 2026 reactivation effective date “as well as a gap in coverage between the date of deactivation December 01, 2025 and the day prior to the date of reactivation January 15, 2026.”  CMS Ex. 13 at 3. 

VII.    Conclusions of Law and Analysis

1. The effective date for reactivation of Petitioner’s Medicare billing privileges is January 16, 2026. 

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 in the Medicare program.  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.  The term “Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.”  42 C.F.R. § 424.502.  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 is noncompliant with enrollment requirements and the supplier can remedy that noncompliance by submission of an application, such as a revalidation application, then CMS may stay the supplier’s enrollment for up to 60 days.  42 C.F.R. § 424.541(a)(1), (3)(ii).  A stay of enrollment ends when the supplier has resumed compliance with all Medicare enrollment requirements or the stay expires.  42 C.F.R. § 424.541(a)(5).  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).  CMS may deactivate the Medicare billing privileges of a supplier that is noncompliant with enrollment requirements even if a stay is still in effect.  42 C.F.R. § 424.521(b)(8). 

To reactivate billing privileges, the supplier must recertify that its enrollment 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

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contractor received the . . . supplier’s reactivation submission that was processed to approval by the Medicare contractor.”  42 C.F.R. § 424.540(d)(2).

In the present case, the CMS contractor deactivated Petitioner’s billing privileges because Petitioner did not timely revalidate its Medicare enrollment information.  CMS Exs. 5-6.    CMS received Petitioner’s revalidation/reactivation enrollment application on January 16, 2026, and CMS was able to process that application to approval.  CMS Exs. 7-9.  Therefore, CMS correctly set January 16, 2026, as the date of reactivation.  42 C.F.R. § 424.540(d)(2). 

2. I do not have the authority to modify the January 16, 2026 effective date for reactivation based on Petitioner’s arguments.

Petitioner requests an earlier reactivation effective date so that there is no gap in its Medicare billing privileges.  Petitioner provides the following reasons for this request:

• Petitioner was not notified by mail or email that revalidation was due (CMS Ex. 11 at 2).
• The revalidation request was only received by one of Petitioner’s providers after the revalidation was already due (CMS Ex. 11 at 2).
• Petitioner was confused by the revalidation notice because it was addressed to one of its providers and only learned that Petitioner’s group practice needed to revalidate after contacting the CMS contractor (H’rg Req. at 1).
• Petitioner tried to log onto the Provider Enrollment, Chain, and Ownership System (PECOS) several times to electronically file the reactivation application, but could not do so based on “unexpected maintenance or errors.”  When Petitioner tried to call and speak to a person about this, Petitioner was placed on hold for long periods of time and would get disconnected (CMS Ex. 11 at 2).
• Petitioner’s staff member who handled enrollment matters unexpectedly passed away, delaying Petitioner’s ability to revalidate efficiently (H’rg Req. at 1).
• Petitioner experienced serious financial hardship, which required Petitioner to reduce its administrative staff, limiting Petitioner’s ability to manage complex administrative processes (H’rg Req. at 2).
• Petitioner’s “original application was prepared and mailed in a timely manner; however, it was not received and had to be resubmitted.” (H’rg Req. at 1). 

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• Petitioner has received many claims denials related to the period of deactivation despite speaking to a representative from Medicare who said the denials were errors and the claims would be reprocessed (CMS Ex. 11 at 2).
• The loss of reimbursement for the deactivation period “places [Petitioner’s] practice in a precarious position.”  Petitioner’s practice employs many individuals who have worked for Petitioner for many years (H’rg Req. at 2). 

My jurisdiction is limited to determining if the date of reactivation established by CMS was factually and legally correct.  See 42 C.F.R. § 498.3(b)(15). 

Petitioner’s arguments that it failed to timely receive the revalidation notice and that it was incorrectly directed to an individual at Petitioner’s group practice are related to the efficacy of the deactivation.  I have no jurisdiction to review a deactivation that CMS imposed.  42 C.F.R. § 424.546(f).  Rather, as stated in the January 9, 2026 deactivation notice, Petitioner had the right to file a rebuttal with CMS to appeal the deactivation.  CMS Ex. 5 at 1-2; CMS Ex. 6 at 1-2; 42 C.F.R. §§ 424.545(b), 424.546.  The right to file a rebuttal is the exclusive administrative appeal right for a deactivation.  See Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8 (2022). 

Petitioner alleges that CMS or CMS contractor staff stated that Petitioner’s claims involving the period of deactivation would be reprocessed and paid.  However, I am unable to provide an earlier effective date based on anything CMS or contractor staff may have said.  See Fam. Health Servs. of Darke Cnty., Inc., DAB No. 2269 at 18-20 (2009). 

Petitioner alleges financial hardship due to deactivation; however, financial hardship is not a legal basis to change the effective date of reactivation 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). 

To the extent that Petitioner’s allegations concerning failed efforts to use PECOS and mail to file the revalidation application relate to obtaining an earlier reactivation effective date, Petitioner did not provide any proof related to those allegations. 

Finally, Petitioner appears to seek equitable relief; however, I do not have the authority to provide equitable relief.  US Ultrasound, DAB No. 2302 at 8 (2010).   

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VIII.  Conclusion

I affirm CMS’s determination that the effective date for the reactivation of Petitioner’s Medicare billing privileges is January 16, 2026.