Laura Brock, PT, DAB CR5522 (2020)

DECISION

I sustain the determination of a Medicare contractor, as affirmed on reconsideration, to grant Petitioner, Laura Brock, PT, an effective date of May 3, 2019, for reassignment of her Medicare benefits to a third party, Motion PT. 

I. Background

The Centers for Medicare & Medicaid Services (CMS) moved for summary judgment or, in the alternative, for a decision based on the parties’ written exchanges.  With its motion, CMS filed 21 proposed exhibits that it identified as CMS Ex. 1-CMS Ex. 21.  Petitioner filed a brief opposing the motion but filed no exhibits of her own.  Petitioner filed no objection to my receiving CMS’s exhibits into the record.

I receive CMS’s exhibits into the record and decide this case based on the parties’ exchanges.  It is unnecessary that I decide whether the criteria for summary judgment are met here inasmuch as neither party offered the written direct testimony of a witness. Consequently, there is no need to convene an in-person hearing.

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II. Issues, Findings of Fact and Conclusions of Law

A. Issue

The issue is whether a Medicare contractor, acting on behalf of CMS, appropriately granted Petitioner an effective date of May 3, 2019, for reassignment of benefits.

B. Findings of Fact and Conclusions of Law

I take notice that “reassignment of benefits” is a term of art used by the Medicare program to describe a situation in which a supplier of services assigns to a third party the authority to claim benefits for items or services that he or she has rendered.  The term is not defined explicitly by regulations.  However, regulations define the circumstances under which Medicare allows reassignment of benefits.  Generally, Medicare allows an individual supplier to reassign the right to claim benefits only where the reassignment is to a Medicare-participating entity under an employer-employee relationship or under a contractual arrangement.  42 C.F.R. § 424.80(a)-(b).

Regulations also govern the effective date of participation in Medicare.  Stated simply, the earliest effective date that a Medicare contractor or CMS will grant to an applicant for participation is the filing date of an application for participation (or, in this case, reassignment of benefits) that the contractor or CMS accepts and processes to completion.  42 C.F.R. § 424.520(d).  If a contractor or CMS finally rejects an application, the sole choice left to the applicant, if he or she wants to participate, is to file a new application.  There is no right of appeal from a rejection of an application to participate.  42 C.F.R. § 424.525(d).

Petitioner sought to reassign the right to file claims to an entity, Motion PT.  That entity first became enrolled in the Medicare program effective May 3, 2019 with authority to claim retroactively to April 3, 2019, for services provided to beneficiaries.  CMS Exs. 20-21.1

Petitioner first filed an application on March 18, 2019, requesting that her authority to claim reimbursement be reassigned to Motion PT, effective February 1, 2019.  CMS Ex. 1.  On May 2, 2019, the contractor rejected this application on the ground that Petitioner failed to provide evidence to the contractor that she was enrolled as a Medicare supplier.  CMS Ex. 5.  On April 3, 2019, Petitioner filed a second enrollment application with the contractor and a separate application that her authority to claim reimbursement be reassigned to Motion PT.  CMS Exs. 3-4.  The contractor rejected these applications on May 13, 2019, because the contractor had not, at that point, received Motion PT’s enrollment application.  CMS Ex. 7.

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Petitioner filed another reassignment application on May 3, 2019.  CMS Ex. 6.  The contractor erroneously returned this application to Petitioner.  Petitioner filed additional enrollment and reassignment applications on May 13, 2019.  CMS Exs. 8-9.  The contractor processed these applications and, recognizing that it had erroneously returned the May 3 application, granted Petitioner participation and reassignment of benefits, effective May 3, 2019, with the right to claim retrospectively to April 3, 2019, for services rendered to Medicare beneficiaries.  CMS Ex. 15.  Petitioner unsuccessfully requested reconsideration of this determination and then filed a request for a hearing.

As a matter of law, the earliest effective date that the contractor could assign to Petitioner was May 3, 2019, for two reasons.  First, it was not until May 3, 2019, that Petitioner filed an application that the contractor accepted and processed.  Previous applications by Petitioner, which the contractor rejected, serve as no basis for Petitioner to claim participating status and Petitioner has no right to appeal the rejections. 

Second, the entity to which Petitioner sought to reassign her right to file benefits claims, Motion PT, was not enrolled in Medicare as a supplier prior to May 3, 2019.  Put simply, Motion PT did not exist as a Medicare-participating entity prior to that date and, consequently, Petitioner could not lawfully assign the right to file benefits claims to it prior to May 3, 2019.

I do not find persuasive Petitioner’s arguments that she should have been assigned an earlier effective date.  First, Petitioner asserts that there is a dispute as to whether the contractor properly rejected the applications that Petitioner filed prior to May 3.  From this argument I infer that Petitioner seeks to appeal those rejections.  However, and as I have explained, Petitioner has no right to appeal the rejections.  In this case I may decide only whether the contractor properly assigned an effective date for reassignment of benefits premised on Petitioner’s May 3, 2019 application.  I find that it did, for the reasons that I have stated.

Second, Petitioner apparently contends that she is entitled to file reimbursement claims for her services independently from her reassignment of those claims to Motion PT.  However, Petitioner has not offered any evidence to establish that she was enrolled independently prior to May 3, 2019, nor has she offered proof that she filed claims based on her allegedly independent status.  Moreover, Petitioner’s assertions, if that’s what she is contending, are outside of the ambit of the case before me.  The only issue that I have authority to hear and decide is the effective date of Petitioner’s reassignment of benefits to Motion PT.

Finally, in her hearing request, Petitioner asserted that she and her employer suffered financial hardship because of her inability to claim reimbursement for services that she provided prior to April 3, 2019.  That is an equitable claim, essentially consisting of a

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challenge to the contractor’s review based on fairness grounds.  I have no authority to consider that argument.  Willie Goffney Jr., M.D., DAB No. 2763 at 8-9 (2017).

1. Motion PT has not challenged its effective participation date.
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