John G. Scaramella MD SC, DAB CR6958 (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, John G. Scaramella MD SC, is October 13, 2025.

I.  Procedural History

On April 24, 2026, Petitioner requested a hearing to dispute the reactivation effective date for its Medicare billing privileges.  On April 30, 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 4, 2026, CMS filed a brief/motion for summary judgment and six 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 October 13, 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 has been enrolled in the Medicare program as a clinic/group practice since 1999.  See CMS Ex. 4 at 1.
2. In an April 30, 2025 notice, a CMS contractor, acting for CMS, 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 July 31, 2025, 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. 1 at 1.

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3. In a September 10, 2025 notice, the CMS contractor informed Petitioner that its Medicare billing privileges were being deactivated as of August 1, 2025, “because [Petitioner has] not timely revalidated [Petitioner’s] enrollment record with us, or [Petitioner’s] revalidation application has been rejected because [Petitioner] did not timely respond to our requests for more information.  We will not pay any claims after this date.”  CMS Ex. 2 at 1.  The notice advised Petitioner that it could file a rebuttal if Petitioner believed the deactivation was incorrect.  CMS Ex. 2 at 1-2.  Finally, the notice stated that Petitioner could revalidate its Medicare enrollment record through filing an enrollment application.  CMS Ex. 2 at 2.
4. On October 13, 2025, CMS received a revalidation enrollment application from Petitioner.  CMS Ex. 3.
5. In a December 4, 2025 notice of initial determination, the CMS contractor approved Petitioner’s enrollment application and reactivated Petitioner’s Medicare billing privileges.  The notice stated that Petitioner “will have a gap in billing privileges from August 01, 2025 through October 12, 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. 4 at 1-2.
6. On December 22, 2025, Petitioner requested reconsideration of the effective date for reactivation.  CMS Ex. 5.
7. On February 26, 2026, the CMS contractor issued an unfavorable reconsideration determination that affirmed October 13, 2025, as the reactivation effective date.  CMS Ex. 6.  The reconsidered determination also stated that there would be gap in Medicare coverage between August 01, 2025, and October 12, 2025.  CMS Ex. 6 at 4.

VII.    Conclusions of Law and Analysis

1. The effective date for reactivation of Petitioner’s Medicare billing privileges is October 13, 2025, because that is the date CMS received Petitioner’s application to reactivate billing privileges and CMS was able to approve that application.

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

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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 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).  The supplier has the right to file a rebuttal with CMS to appeal the deactivation.  42 C.F.R. §§ 424.545(b), 424.546

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

Petitioner asserts that it failed to timely revalidate its Medicare enrollment record because the CMS contractor sent the revalidation notice directly to Petitioner’s offices rather than to Petitioner’s billing service.  This was problematic because the revalidation notice appears to have been misdelivered or left in a common area within the building where Petitioner has its offices, resulting in receipt of the notice after the revalidation deadline had passed.  Petitioner is a small practice and employs a billing service to manage all credentialling, revalidation, and correspondence.  Petitioner requests an earlier reactivation date based on the delayed receipt of the notice and on Petitioner’s long history of participation in the Medicare program.  Petitioner also notes that the loss of income based on the period of deactivation will be detrimental to the practice because Petitioner primarily treats Medicare beneficiaries.  H’rg Req.; CMS Ex. 5.

I am sympathetic to Petitioner’s situation.  However, 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).  In the present case, CMS received Petitioner’s revalidation/reactivation enrollment application on October 13, 2025, and CMS was able to process that application to approval.  CMS Ex. 3 at 1; CMS Ex. 4 at 1.  These are the only facts material to the issue I can decide.  Therefore, CMS correctly set October 13, 2025, as the date of reactivation. 42 C.F.R. § 424.540(d)(2).

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Unfortunately, Petitioner’s arguments address the legitimacy of the deactivation (i.e., delayed receipt of the revalidation notice resulted in deactivation).  I have no jurisdiction to review whether a deactivation should have been imposed.  42 C.F.R. § 424.546(f).  Rather, as stated in the September 10, 2025 deactivation notice, Petitioner had the right to file a rebuttal with CMS to appeal the deactivation.  CMS Ex. 2 at 1-2; see also 42 C.F.R. § 424.545(b), 424.546(a).  The right to file a rebuttal is the exclusive administrative appeal for deactivations, and only CMS may decide that appeal.  See Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8 (2022).

Finally, 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).

VIII.  Conclusion

I affirm CMS’s determination that the effective date for the reactivation of Petitioner’s Medicare billing privileges is October 13, 2025.