Homayoun Sasson, MD, DAB CR6256 (2023)

DECISION

Petitioner, Homayoun Sasson, MD is a physician, practicing in Great Neck, New York,
who participates in the Medicare program as a supplier of services.  He assigns his benefits to his medical practice, H. Sasson, M.D., P.C.  He apparently (and, it seems, mistakenly) terminated his Medicare enrollment.  When he realized the consequences of that action, he reapplied, reassigning his benefits to his medical practice.  The Centers for Medicare & Medicaid Services (CMS) has granted his application, with an effective date of June 14, 2022, and a retrospective billing date of March 16, 2022.  Petitioner now asks for an earlier effective date. 

Because he filed his subsequently-approved Medicare application on June 14, 2022, I find that June 14 is the correct effective date for Petitioner’s enrollment.  I may not review CMS’s retrospective billing determination. 

Background

In a notice letter, dated July 15, 2022, the Medicare contractor, National Government Services, advised Petitioner Sasson that it approved his Medicare enrollment and reassignment application, with an effective date of June 14, 2022.  CMS Ex. 8.

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Petitioner requested reconsideration, asking for a billing date of January 2, 2022, the date he erroneously disenrolled.  Petitioner conceded that his office staff made an error with the disenrollment but complained that he did not understand the Medicare rules and that the contractor’s staff had not helped.  In fact, they had misled his staff.  Had the contractor provided accurate information, they would immediately have acted to reenroll Petitioner.  Petitioner also asserted that, during the period of his disenrollment, he continued to provide services, for which he would not be reimbursed unless his reassignment was made retroactive.  CMS Ex. 10.  

In a reconsidered determination, dated July 29, 2022, the contractor affirmed the initial determination.  CMS Ex. 11.  Petitioner appealed. 

While the appeal was pending, the contractor reopened and revised its reconsidered determination, as authorized by 42 C.F.R. §§ 498.30 and 498.32.  In the revised reconsideration, dated October 14, 2022, the contractor again determined that June 14, 2022 was the correct effective date but added a retrospective billing date of March 16, 2022.  See 42 C.F.R. § 424.521(a) (allowing suppliers to bill, retroactively, up to 90 days prior to the effective date). 

CMS has moved for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre-hearing Order at 4, 5 (¶¶ 4(c)(iv), 8) (September 12, 2022).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied. 

CMS submits its motion and brief (CMS Br.) with 13 exhibits (CMS Exs. 1-13).  Petitioner submits a response to CMS’s motion and brief (P. Response).  In the absence of any objections, I admit into evidence CMS Exs. 1-13.  See Acknowledgment and Pre-hearing Order at 5 (¶ 7). 

Discussion

On June 14, 2022, Petitioner filed his subsequently-approved application, and June 14, 2022 is therefore the effective date of his enrollment.  42 C.F.R. § 424.520(d).¹

Enrollment.  Petitioner Sasson participates in the Medicare program as a “supplier” of services.  Social Security Act § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a prospective supplier must enroll in the program.  Act § 1834(j)(1)(A); 42 C.F.R. § 424.505.  “Enrollment” is the process by which CMS and its contractors: 1) identify the prospective supplier; 2) validate the supplier’s eligibility to provide items or services to Medicare beneficiaries;

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3) identify and confirm a supplier’s owners and practice location; and 4) grant the supplier Medicare billing privileges. 42 C.F.R. § 424.502.  

To enroll, a prospective supplier must complete and submit an enrollment application.
42 C.F.R. §§ 424.510(d)(1), 424.515(a).  An enrollment application is either a CMS-approved paper application or an electronic process approved by the Office of Management and Budget.  42 C.F.R. § 424.502.²  When CMS determines that a prospective supplier meets the applicable enrollment requirements, it grants Medicare billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  For a physician, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (emphasis added). 

If a physician (or physician organization) meets all program requirements, CMS may allow him to bill retrospectively for up to 30 days prior to the effective date “if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.”  42 C.F.R. § 424.521(a)(1).  Under other circumstances, CMS may allow him to bill retrospectively for up to 90 days.  42 C.F.R. § 424.521(a)(2).  I have no authority to review CMS’s determinations regarding retrospective billing.  See 42 C.F.R. § 498.3(b). 

Petitioner’s enrollment.  Voluntary termination means that a provider or supplier submits a written confirmation to CMS of its decision to discontinue enrollment in the Medicare program.  42 C.F.R. § 424.502.  On December 13, 2021, Petitioner submitted an application (CMS-855I) to the Medicare contractor, asking to voluntarily terminate his enrollment, effective January 1, 2022.  CMS Ex. 2 at 7.  He signed the application and certified that he had read its contents and that the information it contained was “true, correct, and complete.”  CMS Ex. 2 at 26 (Certification Statement ¶ 1). 

In a notice dated January 6, 2022, the contractor advised Petitioner that it approved his request to terminate, effective January 2, 2022.  The notice advised Petitioner that Medicare would not reimburse him for any claims with dates of service on or after the effective date of his termination.  CMS Ex. 3. 

On June 14, 2022, Petitioner filed a new Medicare enrollment application (CMS-855I), which the contractor subsequently approved.  CMS Ex. 6 at 6-36.  Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment application – June 14, 2022 – is the correct effective date.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie

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Goffney, Jr., M.D., DAB No. 2763 at 7 (2017), aff’d, Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019). 

Pursuant to its authority under section 424.521(a)(2), CMS has allowed Petitioner to bill 90-days retrospectively, so his effective billing date is March 16, 2022.³

Even if I concluded that the contractor’s representatives were unresponsive or provided inaccurate information (and the evidence on that is thin), Petitioner is not entitled to an earlier effective date based on the misrepresentations of a contractor’s employee.  The regulations are explicit, and neither the contractor nor its employees have the authority to change them – by providing misinformation or otherwise.  See Heckler v. Cmty. Health Servs. of Crawford Cnty., Inc., 467 U.S. 51, 63 (1984) (holding that those who participate in the Medicare program are supposed to understand its rules); Schweiker v. Hansen, 450 U.S. 785, 790 (1981) (holding that a Social Security employee’s erroneous advice – upon which an applicant for mother’s insurance benefits relied, to her detriment – did not estop the Secretary of Health and Human Services from denying her retroactive benefits for the period for which she was eligible for benefits but had not filed the required written application); New Grove Manor, DAB No. 3090 at 15 (2023); Hartford HealthCare at Home, Inc., DAB No. 2787 at 8-9 (2017).

I have no authority to grant Petitioner an earlier effective date based on any equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 9 (2019).

Conclusion

Because Petitioner filed his subsequently-approved Medicare application on June 14, 2022, June 14 is the correct effective date of his enrollment.

Endnotes

¹ I make this one finding of fact/conclusion of law.

² CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).

³ The regulation provides that physicians may retrospectively bill for services for up to 30 days prior to the effective date of enrollment “if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries,” or for up to 90 days prior to the effective date or enrollment “if a Presidentially-declared disaster under the . . . Stafford Act precluded enrollment in advance of providing services to Medicare beneficiaries.”  CMS has apparently interpreted these provisions liberally.