Jan Earl Warner, PhD, HSPP, DAB CR5528 (2020)

DECISION

Petitioner’s Medicare enrollment and billing privileges were deactivated on March 6, 2018, as a result of his failure to timely comply with a request that he revalidate his individual Medicare enrollment record. For the reasons discussed below, I conclude that the effective date of Petitioner’s reactivated Medicare enrollment and billing privileges is December 27, 2018, with retrospective billing privileges authorized beginning November 27, 2018.

I. Background and Procedural History

On October 10, 2017, Wisconsin Physicians Service Insurance Corporation (WPS), a Medicare administrative contractor, informed Petitioner, a psychologist, that he was required to revalidate his individual Medicare enrollment record, to include his reassignments of benefits, no later than December 31, 20171 . Centers for Medicare &

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Medicaid Services (CMS) Exhibit (Ex.) 1 at 1, 3; see CMS Ex. 9 at 2 (enrollment application reporting that Petitioner is a psychologist).  WPS instructed Petitioner to “update or confirm all the information in [his] record.”  CMS Ex. 1 at 1, 3.  WPS cautioned Petitioner that if it did not receive his response by December 31, 2017, it “may stop [his] Medicare billing privileges.”  CMS Ex. 1 at 1, 3.  WPS also warned that Petitioner “will not be paid for services rendered during the period of deactivation” and deactivation “will cause a gap in [his] reimbursement.”  CMS Ex. 1 at 1, 3.  After Petitioner did not revalidate his enrollment prior to the December 31, 2017 deadline, WPS sent Petitioner a letter on January 5, 2018, in which it informed him that he “ha[d] not revalidated by the requested due date of December 31, 2017.”  CMS Ex. 2 at 1.  On March 7, 2018, WPS sent a letter informing Petitioner that, because he had not revalidated his enrollment, his billing privileges had been deactivated effective March 6, 2018.  CMS Ex. 3 at 1.

WPS received a Form CMS-855I application for purposes of revalidation and reactivation on or about May 7, 2018.2   CMS Ex. 4.  In that application, Petitioner listed Ms. Carmen S. Sonego as the contact person for the application.  CMS Ex. 4 at 4.  Petitioner provided contact information for Ms. Sonego that included a mailing address and two email addresses.  CMS Ex. 4 at 4.  

In a May 11, 2018 email message sent to both of Ms. Sonego’s email addresses, WPS directed Petitioner to submit a Form CMS-855R enrollment application to reassign benefits.  CMS Ex. 5 at 1; see CMS Ex. 1 at 1 (revalidation request specifically requiring Petitioner to revalidate any reassignments of benefits).  In an apparent response to this request, Petitioner submitted a Form CMS-855R reassignment of benefits application that was received on May 29, 2018.  CMS Ex. 6.  Petitioner again listed Ms. Sonego as the contact person for the Form CMS-855R application, and he identified her as both the “Administrator” and the “spouse of [the] organization president.”  CMS Ex. 6 at 3.

On June 5, 2018, WPS mailed a letter to Petitioner informing him that section 6B of his application “is not signed/dated by a current Authorized Official.”  CMS Ex. 7 at 1.  WPS explained that “[t]his information must be mailed with an original signature, with a copy of this letter.”  CMS Ex. 7 at 1.  WPS cautioned that it “may reject [Petitioner’s] application if [he does] not furnish complete information within 30 days from the postmarked date of this letter pursuant to 42 [C.F.R. §]424.525.”  CMS Ex. 7 at 1.  After Petitioner did not respond within 30 days of this request, WPS informed Petitioner, in a

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letter, dated July 5, 2018, that his May 2018 enrollment application had been rejected.3  CMS Ex. 8 at 1.  The letter explained that Petitioner was “required to submit complete applications and all supporting documents within 30 calendar days from the postmark date of the contractor request for missing/incomplete information.”  CMS Ex. 8 at 1.

On December 27, 2018, WPS received a Form CMS-855I enrollment application.  CMS Ex. 9 at 1.  Thereafter, WPS sent development requests to Ms. Sonego by email in which it requested that Petitioner submit a Form CMS-855R reassignment of benefits application and other documentation (CMS Exs. 10, 12), and Petitioner complied with those requests.  CMS Exs. 11, 13.  On February 6, 2019, WPS informed Petitioner that it had approved his enrollment application, but that there would be a gap in his reactivated billing privileges.  CMS Ex. 13.  WPS explained that while Petitioner’s “PTAN(s) and effective date(s) remain the same, [he] will have a gap in billing privileges from March 6, 2018 through December 26, 2018 for failing to timely submit [his] revalidation application.”  CMS Ex. 13 at 1.

Petitioner submitted a reconsideration request, dated February 26, 2019, which largely consisted of “detailed documentation from [his] Practice Manager Carmen Sonego MSN.”  CMS Ex. 14 at 1-2, 8.  Ms. Sonego, in a “table of notes,” explained that she was handling enrollment matters for the following three individuals/entities during that timeframe:  Petitioner; Dr. Sonego (a physician in the same practice);4  and David F. Sonego, M.D. and Associates (the practice, itself).5  CMS Ex. 4.  The “table of notes” included a timeline of Ms. Sonego’s revalidation and enrollment-related tasks and communications, but did not reference or include any supporting documentation.  CMS Ex. 4 at 2-4.  As relevant here, Ms. Sonego alleged that she incidentally learned of the revalidation request in February 2018 when she communicated with WPS by telephone about another matter.  CMS Ex. 14 at 4.  Further, and with respect to the May 2018 enrollment application, Ms. Sonego did not report that she (or Petitioner, himself) responded to the June 5, 2018 development request.  CMS Ex. 4.  Ms. Sonego also reported that, following the rejection of Petitioner’s application in July 2018, she did not submit another enrollment application until December 17, 2018.  CMS Ex. 14 at 3 (reporting that she “signed and mailed to WPS” a Form CMS-855I enrollment application on December 17, 2018, but had “no notes by me as to why this was done.”).

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WPS issued a reconsidered determination on April 24, 2019, wherein it maintained the same effective date of Petitioner’s reactivated billing privileges. CMS Ex. 16 at 1. However, WPS authorized Petitioner 30 days of retrospective billing privileges, beginning November 27, 2018. CMS Ex. 16 at 2. WPS otherwise upheld the gap in Petitioner’s billing privileges based on Petitioner’s failure to timely submit complete and accurate enrollment information in response to the revalidation request. CMS Ex. 16 at 1-2.

Petitioner submitted a request for an administrative law judge (ALJ) hearing (P. RFH) that was received on June 28, 2019. The Civil Remedies Division issued my standing pre-hearing order (Pre-Hearing Order) on July 5, 2019, which directed the parties to file their respective pre-hearing exchanges. CMS filed a memorandum of law and motion in support of summary judgment and pre-hearing brief, along with 17 proposed exhibits (CMS Exs. 1-17). Petitioner filed a cross-motion for summary judgment and pre-hearing brief, along with five proposed exhibits (P. Exs. 1-5). In the absence of any objections, I admit all submitted exhibits into the evidentiary record.

A hearing for the purpose of cross-examination is unnecessary because neither party has identified any proposed witnesses who would testify at an oral hearing. Pre-Hearing Order, §§ 12-14. Further, both parties requested judgment on the written record. CMS Br. at 1; P. Br. at 4. I consider the record in this case to be closed, and the matter is ready for a decision on the merits.6

II. Issue

Whether CMS had a legitimate basis to assign Petitioner a December 27, 2018 effective date for his reactivated billing privileges, with retrospective billing authorized beginning November 27, 2018.

III. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R § 498.3(b)(15); Victor Alvarez, M.D., DAB No. 2325 at 8-12 (2010); see also 42 U.S.C. § 1395cc(j)(8).

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IV. Findings of Fact, Conclusions of Law, and Analysis7

1. On October 10, 2017, WPS requested that Petitioner revalidate his individual Medicare enrollment record no later than December 31, 2017.

2. Petitioner did not respond to the revalidation request, and WPS deactivated Petitioner’s billing privileges effective March 6, 2018.

3. WPS received an enrollment application on or about May 7, 2018, and requested additional development of the application on May 11 and June 5, 2018.

As a psychologist, Petitioner is a “supplier” for purposes of the Medicare program.  See CMS Ex. 9 at 1; see also 42 U.S.C. § 1395x(d); 42 C.F.R. §§ 400.202 (definition of supplier); 498.2.  A “supplier” furnishes items or services under Medicare, and the term applies to physicians or other practitioners who are not included within the definition of the phrase “provider of services.”  42 U.S.C. § 1395x(d).  A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The regulations at 42 C.F.R. Part 424, subpart P, establish the requirements for a supplier to enroll in the Medicare program.  42 C.F.R. §§ 424.510-424.516; see also

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42 U.S.C. § 1395cc(j)(1)(A) (authorizing the Secretary of the U.S. Department of Health and Human Services to establish regulations addressing the enrollment of providers and suppliers in the Medicare program).  A supplier who seeks billing privileges under Medicare “must submit enrollment information on the applicable enrollment application.”  42 C.F.R. § 424.510(a)(1).  “Once the provider or supplier successfully completes the enrollment process . . . CMS enrolls the provider or supplier into the Medicare program.”  Id.; see also 42 C.F.R. § 424.510(d) (listing enrollment requirements).  Thereafter, “[t]o maintain Medicare billing privileges, a . . . supplier . . . must resubmit and recertify the accuracy of its enrollment information every 5 years.”  42 C.F.R. § 424.515.  Further, a supplier “may be required to revalidate [its] enrollment outside the routine 5-year revalidation cycle.”  42 C.F.R. § 424.515(e).

CMS is authorized to deactivate an enrolled supplier’s Medicare billing privileges if the enrollee does not provide complete and accurate information within 90 days “of receipt of notification.”  42 C.F.R. § 424.540(a)(3).  If CMS deactivates a supplier’s Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b); Urology Grp. of NJ, LLC, DAB No. 2860 at 10 (2018) (“The regulations, taken together, clearly establish that a deactivated provider or supplier was not intended to be entitled to Medicare reimbursement for services rendered during the period of deactivation.”).  Further, and quite significantly, the Departmental Appeals Board (DAB) has unambiguously stated that “[i]t is certainly true that [the petitioner] may not receive payment for claims for services during any period when his billing privileges were deactivated.”  Willie Goffney, Jr., M.D., DAB No. 2763 at 6 (2017), aff’d, Goffney v. Azar, 2:17-CV-8032 (C.D. Cal. Sept. 25, 2019); see Urology Grp., DAB No. 2860 at 11 (“Taking these unique effects of revocation into consideration, it is reasonable to conclude that CMS intended for revocations and deactivations to share the feature of precluding a provider or supplier from collecting reimbursement for services rendered during the period of inactive Medicare billing privileges, while simultaneously intending for revocations to have more severe consequences on a provider’s or supplier’s ability to participate.”); Frederick Brodeur, M.D., DAB No. 2857 at 16 (2018) (“Allowing a deactivated supplier to bill for services furnished during a period of deactivation would conflict with section 424.555(b) of the regulations . . . .”).  The regulation authorizing deactivation explains that “[d]eactivation of Medicare billing privileges is considered an action to protect the provider or supplier from misuse of its billing number and to protect the Medicare Trust Funds from unnecessary overpayments.”  42 C.F.R. § 424.540(c).

On October 10, 2017, WPS mailed a letter to Petitioner directing him to revalidate his Medicare enrollment record no later than December 31, 2017, and WPS warned that Petitioner’s failure to revalidate could result in deactivation of his Medicare billing privileges, with a resulting gap in reimbursement.  CMS Ex. 1 at 1, 3.  WPS thereafter deactivated Petitioner’s billing privileges on March 6, 2018, after Petitioner did not revalidate his individual enrollment record.  CMS Ex. 3 at 1.  Although Petitioner claims

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that he did not receive a revalidation request (P. Br. at 2), the evidence indicates that the revalidation requests were sent to his correct address.  Compare CMS Ex. 1 at 1, 3 with CMS Exs. 4 at 2-4; 9 at 2-4 (listing same address on the revalidation request and the enrollment applications).  And even though Petitioner claims that he first learned of the pending revalidation request between February 19 and 23, 2018 (CMS Ex. 14 at 4 and P. RFH at 4), he did not attempt to revalidate his enrollment until May 7, 2018.  CMS Ex. 4. 

In addition to purportedly not receiving the revalidation request and notice of deactivation, Petitioner also claims that he was not informed that his billing privileges had been deactivated on March 6, 2018.  P. Br. at 2; see CMS Ex. 14 at 4; P. RFH at 4.  Petitioner similarly claims that he did not receive a May 29, 2018 development letter (P. Br. at 2), but I note that WPS did not issue a development request on May 29, 2018.8   Petitioner also alleges he did not receive the June 5, 2018 development letter (P. Br. at 2), yet the evidence indicates that WPS mailed the letter to the address Petitioner listed on his enrollment record.  CMS Exs. 4 at 2-4; 9 at 2-4.  And consistent with Petitioner’s apparent inability to receive mail and email communications from WPS, Petitioner alleges he did not receive the July 5, 2018 notice that his May 7, 2018 enrollment application had been rejected.  P. Br. at 2.  Petitioner has not supported his claims that, on multiple occasions, he did not receive correspondence from WPS, by submitting evidence that WPS utilized an incorrect mailing or email address.  Nor has Petitioner submitted sworn written direct testimony supporting his allegations.9  See Pre-Hearing Order §§ 12-14.

The pertinent regulation with respect to the effective date of reactivation is 42 C.F.R. § 424.520(d).  Urology Grp., DAB No. 2860 at 7 (“The governing authority to determine the effective date for reactivation of Petitioner’s Medicare billing privileges is 42 C.F.R. § 424.520(d).” (emphasis omitted)).  Section 424.520(d) states that “[t]he effective date for billing privileges for physicians . . . is the later of – (1) [t]he date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or (2) [t]he date that the supplier first began furnishing services at a new practice location.”  The DAB has explained that the “date of filing” is the date “that an application, however sent to a contractor, is actually received.”  Alexander C. Gatzimos, MD, JD, LLC, DAB No. 2730 at 5 (2016) (emphasis omitted).  WPS deactivated

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1. WPS mailed this letter to an address in Mishawaka, Indiana, which is the same address Petitioner reported in subsequent enrollment applications. CMS Exs. 4 at 2-4, 10; 9 at 2-4.
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2. WPS received a signed certification statement and provider agreement by mail on May 7, 2018. CMS Ex. 4 at 6-10 (each page marked with a stamp indicating receipt on the 127th day (May 7) of 2018).
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3. WPS inaccurately references a Form CMS-855B application (rather than a Form CMS-855I application). However, based on Petitioner’s unsupported allegation that he did not receive this correspondence, such an error would be irrelevant. Petitioner Brief (Br.) at 2.
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4. Ms. Sonego discussed Dr. Sonego’s gap in billing privileges from July 5 through September 30, 2018, which is not a matter that I can review. CMS Ex. 14 at 3.
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5. Ms. Sonego reported that the practice had been notified on April 23, 2018, that its payments were being withheld due to “incomplete [r]evalidation.” CMS Ex. 14 at 3.
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6. Because the parties have not identified any witnesses and a hearing is unnecessary, I need not address whether summary judgment is appropriate.
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7. Findings of fact and conclusions of law are in italics and bold font.
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8. The evidence indicates that WPS sent Petitioner a development request via email on May 11, 2018. CMS Ex. 5 at 1. Petitioner responded to that request on May 29, 2018, when he submitted a Form CMS-855R enrollment application to reassign benefits. CMS Ex. 6.
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9. It appears that Petitioner was not alone in his difficulties with receiving communications from WPS; Petitioner reported that a physician in his practice, and the practice itself, were separately subject to deactivation and/or a gap in Medicare billing privileges. CMS Ex. 14 at 3; P. RFH at 3.
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