Steadfast Hospice, LLC, ALJ Ruling 2026-16 (HHS CRD April 2, 2026)

RULING DISMISSING REQUEST FOR HEARING

Petitioner, Steadfast Hospice, LLC, filed a request for an administrative law judge (ALJ) hearing.  For the reasons stated below, Petitioner's request for hearing (RFH) is dismissed.

On April 30, 2025, National Government Services (NGS), an administrative contractor for the Centers for Medicare and Medicaid Services (CMS), issued an initial determination revoking Petitioner's Medicare enrollment and billing privileges, effective May 30, 2025, pursuant to 42 C.F.R. § 424.535(a)(8)(ii).  RFH at 4.  On May 23, 2025, NGS reopened and revised its initial determination, informing Petitioner that its Medicare enrollment and billing privileges were revoked effective June 22, 2025, pursuant to 42 C.F.R. §§ 424.535(a)(8)(ii) and 424.535(a)(19).  Id. at 11.  Petitioner was advised of its right to request reconsideration if it disagreed with the initial determination.  Id. at 12.  On or about June 9, 2025, Petitioner submitted a reconsideration request.  Id. at 18.  On January 29, 2026, Petitioner filed a request for a hearing, which included a request to escalate.  As of the date Petitioner filed its request for a hearing, no reconsidered determination had been issued.  Id. at 1.

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On March 9, 2026, CMS filed a Motion to Dismiss (CMS Motion) pursuant to 42 C.F.R. § 498.70(b) because Petitioner does not yet have a right to a hearing.  CMS states that because a reconsidered determination has not been issued, there is no appealable decision and, therefore, no right to a hearing.  CMS Motion at 1-2.  Petitioner has not filed a response, and the deadline for doing so has passed.  Standing Order ¶ 6.  Accordingly, CMS's Motion is ripe for adjudication.

CMS is correct that Petitioner does not yet have a right to a hearing before an ALJ.  CMS's revocation of a provider's Medicare enrollment is an "initial determination" that the provider may appeal by requesting CMS's reconsideration of the adverse determination.  42 C.F.R. §§ 498.3(a), (b)(17)(i); 498.5(l)(1).  Petitioner filed a reconsideration request, but CMS has yet to issue its reconsidered determination.  RFH at 1, 18.  Although Petitioner acknowledges that the applicable Part 498 regulations do not prescribe a timeframe for issuing a reconsidered determination, Petitioner notes that, under 42 C.F.R. § 405.970, a reconsideration contractor must issue a decision within 60 days.  RFH at 1 n.1.  However, the claims appeals process is distinct from the provider and supplier enrollment process.

The Social Security Act authorizes the Secretary of Health and Human Services to establish regulations for enrolling providers and suppliers in the Medicare program.  42 U.S.C. § 1395cc(j)(1)(A).  The regulations provide that "[a] provider or supplier may appeal the initial determination . . . to revoke current billing privileges by following the procedures specified in part 498 of this chapter."  42 C.F.R. § 405.803.  Notably, and as Petitioner concedes, the regulations governing the enrollment appeals process do not impose any deadline by which CMS must issue a reconsidered determination following a timely request for reconsideration.  42 C.F.R. § 498.24.

Moreover, while the Part 405 regulations permit escalation1 beginning at the reconsideration level to ensure timely resolution of claims appeals, Part 498 requires exhaustion of administrative review and contains no mechanism allowing a provider to bypass reconsideration and proceed directly to ALJ review.  Compare 42 C.F.R. § 405.970(c)-(e) with 42 C.F.R. § 498.5(l).  The regulations require that a provider dissatisfied with an initial determination related to the revocation of Medicare billing privileges request reconsideration, and, if "dissatisfied with a reconsidered

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determination," seek a hearing before an ALJ.  42 C.F.R. § 498.5(l)(1), (2) (Emphasis added).

The Board has long held that "the regulations plainly require that CMS or one of its contractors issue a 'reconsidered determination' before the affected party is entitled to request a hearing before an ALJ."  Rollington Ferguson, M.D., DAB No. 2949 at 3 (2019) (quoting Cap. Dist. Behav. Health Psychs., PLLC, DAB No. 2866 at 4 (2018) (quoting Hiva Vakil, M.D., DAB No. 2460 at 5 (2012))).  Because CMS has yet to issue a reconsidered determination, Petitioner does not yet have a right to request a hearing; therefore, I dismiss Petitioner's request for hearing.  42 C.F.R. § 498.70(b).

A dismissal of a request for a hearing is binding unless vacated by an administrative law judge or the Departmental Appeals Board.  42 C.F.R. § 498.71(b).  Petitioner may request that I vacate this dismissal.  Petitioner must file such a request within 60 days of receiving this order and show why there is good cause for me to vacate the dismissal.  See 42 C.F.R. § 498.72.