Romanth Waghmarae, M.D., CR6328 (2023)

DECISION

Petitioner, Romanth Waghmarae, M.D., challenges the determination of the effective date of reassignment of his Medicare billing privileges to his group practice, Integrative Pain & Wellness Associates, LLC (Integrative).  National Governmental Services (NGS), an administrative contractor for Respondent, the Centers for Medicare & Medicaid Services (CMS), determined April 27, 2020 to be the effective date of reassignment of Medicare billing privileges from Petitioner to Integrative with retrospective billing permitted from March 1, 2020.  Petitioner requested a hearing before an administrative law judge to dispute the effective date.  As explained herein, NGS correctly determined Petitioner’s reassignment effective date to be April 27, 2020, which I therefore affirm.

   I. Background

On September 20, 2019, NGS received a CMS-855B application from Petitioner intended to change Pain Management Associates of WNY, LLC’s legal business name to Integrative, and to add Petitioner as an Authorized Official and Director/Officer.  CMS Ex. 1.  NGS requested further information to complete the application.  CMS Ex. 4.  After Petitioner sent a revised application with the requested changes, NGS approved the application on December 3, 2019.  CMS Ex. 6.  NGS approved the change of information with an effective date of September 1, 2019.  Id. at 2.

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On October 28, 2019, Petitioner mailed a CMS-855B application to designate Heather Walker as a Delegated Official for Integrative.  CMS Ex. 8 at 9, 11.  NGS sought further information, CMS Ex. 9, in response to which Petitioner filed a revised application on December 5, 2019.  CMS Exs. 10-12.  On December 17, 2019, NGS again sought further information from Petitioner to develop the application.  CMS Ex. 13.  Petitioner failed to respond to the second information request, resulting in rejection of the application by NGS.  CMS Ex. 14.

Petitioner mailed a CMS-855R application intended to reassign his benefits to Integrative that NGS received on April 27, 2020.  CMS Ex. 17.  NGS eventually approved Petitioner’s application and allowed retrospective billing from March 1, 2020.  CMS Ex. 18-20.

On June 10, 2020, Petitioner sought reconsideration of NGS’ effective date determination, asking his reassignment be made effective from September 1, 2019, the date Integrative changed its name and designated Petitioner to be a part owner of the group.  CMS Ex. 22.  In a reconsidered determination dated August 27, 2020, NGS affirmed its effective date determination and reiterated the effective date for Petitioner’s reassignment was March 1, 2020,¹ in accordance with 42 C.F.R. § 424.521(a).  CMS Ex. 25 at 1-4.

Petitioner timely filed a request for hearing in the Civil Remedies Division and I was designated to hear and decide this case.  On October 28, 2020, I issued an Acknowledgment and Prehearing Order (Pre-Hearing Order) requiring the parties to file arguments and supporting documents in a pre-hearing exchange.  Pre-Hearing Order.  On December 2, 2020, CMS timely filed its Pre-Hearing Brief and Motion for Summary Judgment (CMS Br.) with 29 proposed exhibits (CMS Exs. 1-29).  On January 6, 2021, Petitioner timely filed a response to CMS’s summary judgment motion in its own Pre-Hearing Brief (P. Br.).  On January 21, 2021, CMS filed a motion for leave to file a reply to Petitioner’s response along with its reply (CMS Reply).  I grant CMS’s motion and have considered its reply.

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   II. Admission of Exhibits

Petitioner did not object to CMS’s proposed exhibits.  I admit CMS Exhibits 1 through 29 into evidence.  Petitioner submitted one proposed exhibit consisting of the sworn declaration of Integrity’s Executive Director, Jeffrey O. Dann.  Absent objection from CMS, I admit Petitioner’s Exhibit 1 into evidence.

   III. Decision on the Record

CMS did not request cross-examination of the witness proffered by Petitioner.  As a result, I need not hold an in-person hearing in this matter.  Pre‑Hearing Order ¶¶ 9-11; Civ. Remedies Div. P. §§ 16(b), 19(b).  I decide this case on the record before me, consisting of the parties’ written submissions and arguments.  Civ. Remedies Div. P. § 19(d).  CMS’s motion for summary judgment is denied as moot.

   IV. Issue

Whether NGS, acting on behalf of CMS, properly established April 27, 2020, as Petitioner’s effective date of enrollment for reassignment of his Medicare billing.

   V. Jurisdiction

I have jurisdiction to decide this case.  42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2); see also Soc. Sec. Act (Act) § 1866(j)(8) (codified at 42 U.S.C. § 1395cc(j)(8)).

   VI. Findings of Fact, Conclusions of Law, and Analysis

A.  Applicable Law

Petitioner participates in the Medicare program as a “supplier” of services.  Act § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for services furnished to program beneficiaries, a prospective supplier must be enrolled by CMS to participate in the program.  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; (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.  After a prospective supplier submits an approved Medicare enrollment application, CMS establishes an effective date for billing privileges and may permit retrospective billing pursuant to 42 C.F.R. § 424.521(a).

The effective date for billing privileges for suppliers like Petitioner 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.

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§ 424.520(d) (emphasis added).  The “date of filing” is the date that the Medicare contractor “receives” a signed enrollment application that the Medicare contractor can process to approval.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).

A Medicare beneficiary may assign the right to receive Medicare Part B benefits for covered medical services to an enrolled supplier who delivers those services.  Act § 1842(b)(3)(B)(ii) (42 U.S.C. § 1395u(b)(3)(B)(ii)); 42 C.F.R. § 424.55.  In certain circumstances, a supplier who has received an assignment of benefits may reassign those benefits to an employer, or to an individual or entity with which the supplier has a contractual arrangement.  Act § 1842(b)(6) (42 U.S.C. § 1395u(b)(6)); 42 C.F.R. § 424.80(b)(1)‑(2).  To reassign Medicare benefits, a supplier must submit and obtain CMS’s approval of a reassignment application.  Gaurav Lakhanpal, MD, DAB No. 2951 at 1-2 (2019) (citing 71 Fed. Reg. 20,754, 20,756 (Apr. 21, 2006)).  CMS applies the effective date rules at 42 C.F.R. §§ 424.520(d) and 424.521(a)(1) to reassignments of Medicare benefits.  See Medicare Program Integrity Manual (MPIM) (CMS Pub. 100-08) §§ 15.5.20(E)(3), 15.17.

B.  Analysis

1.  The effective date of Petitioner’s reassignment of Medicare billing privileges is April 27, 2020, the date NGS received the application it subsequently processed to approval.

Petitioner submitted a reassignment application received by NGS on April 27, 2020 that NGS ultimately processed to approval.  CMS Ex. 20.  The record before me reflects no receipt of an earlier reassignment application that NGS subsequently approved.  Petitioner argues his effective enrollment date should be September 1, 2019 and claims he should have received notice of the need to file a reassignment application when he submitted his enrollment application.  P. Br at 7-8; see also P. Ex. 1 at 2-3.  But NGS had no obligation to instruct Petitioner as to which application to submit.  Nor was it obligated to determine Petitioner meant to submit a reassignment application when he submitted an enrollment application, as these two applications serve different purposes.  See MPIM, Ch. 15.1.2.

There is no dispute NGS received a reassignment application from Petitioner on April 27, 2020, and that this is the earliest application NGS subsequently approved.  Consistent with 42 C.F.R. § 424.520(d), April 27, 2020 is therefore the correct effective date of reassignment for Petitioner’s billing privileges.  Urology Grp. of NJ, LLC, DAB No. 2860 at 7-9 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017); MPIM §§ 15.5.20(E)(3), 15.17.

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2.  I have no authority to consider Petitioner’s equitable arguments.

Petitioner does not claim to have filed a reassignment application before April 27, 2020.  He instead explains that NGS never instructed him to file a different application for reassignment, and that in any case CMS should have been put on notice of his intent to reassign when he submitted the form that changed the name of his practice and added him as an Individual with Ownership Interest within that practice.  P. Br. at 7-8.   Petitioner also points out that he applied for reassignment as soon as he became aware of the issue and asks to be reimbursed, as a matter of fairness, for the services he rendered to Medicare beneficiaries from September 1, 2019, to February 28, 2020. 

While I am sympathetic to Petitioner’s request to modify the reassignment effective date based on his lack of awareness of the need to apply for reassignment of his Medicare billing privileges, and to fairly compensate him for service he rendered to Medicare program beneficiaries, this request has no basis in law and is instead a plea for equitable relief, which I do not have the authority to grant.  See, e.g., US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither the [Administrative Law Judge (ALJ)] nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”); Pepper Hill Nursing & Rehab. Ctr., LLC, DAB No. 2395 at 11 (2011) (holding the ALJ and Board were not authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements). 

My jurisdiction is limited to review of CMS’s determination of the effective date of Petitioner’s reassignment application under 42 C.F.R. § 424.520(d).  As I have explained, NGS properly determined the effective date of reassignment to be April 27, 2020, as that was the date NGS received a reassignment application from Petitioner that it successfully approved.  NGS also granted Petitioner retrospective billing from March 1, 2020 pursuant to 42 C.F.R. § 424.521(a)(1)(ii).  Petitioner has received the maximum period of reassigned billing privileges possible that could result from the reassignment application he filed on April 27, 2020.²

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   VII. Conclusion

For the foregoing reasons, I affirm CMS’s determination of the effective date of Petitioner’s reassignment of Medicare billing privileges to be April 27, 2020, with retrospective billing permitted from March 1, 2020.

Endnotes

¹  NGS’s reconsidered determination mistakenly identifies March 1, 2020 as the “effective date” of Petitioner’s reassigned billing privileges.  CMS Ex. 25 at 4.  But the regulations distinguish between the effective date and the date from which retrospective billing is permitted.  See 42 C.F.R. §§ 424.520(d), 424.521(a)(1).  NGS correctly cites 42 C.F.R. § 424.520(d) for its assertion that Petitioner’s effective date is “the date the application was received and subsequently approved…”  CMS Ex. 25 at 3.  Consistent with that regulation, I use the term “effective date” in this decision to refer to the date NGS received an application from Petitioner it eventually approved, not the date from which it authorized retrospective billing.

²  42 C.F.R. § 424.521(a)(1)(ii) allows up to 90 days of retrospective billing, rather than the more typical 30 days, when a Presidentially declared disaster under the Stafford Act precludes a supplier’s enrollment in advance of providing services to Medicare beneficiaries.  But this provision does not permit application of a retrospective billing period earlier than March 1, 2020, the date from which NGS granted Petitioner retrospective billing.