Skip to main content


U.S. flag
      An official website of the United States government
              Here’s how you know
        Here’s how you knowDot gov**Official websites use .gov**
                 A **.gov** website belongs to an official government organization in the United States.
                  HTTPS**Secure .gov websites use HTTPS**
                 A **lock** (A locked padlock) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. 
  Menu Close
          HHS Search block
    Search
        








  
  
    

  
      

                                      About HHS
    
                        
                              
      
      
      Programs & Services
    
                        
                              
      
      
      Grants & Contracts
    
                        
                              
      
      
      Laws & Regulations Breadcrumb
    Home
                              About
                              Agencies
                              DAB
                              Decisions
                              ALJ Decisions
                              2019
                              Michael Graves, M.D., DAB CR5317 (2019)
 Navigate to:
  Departmental Appeals Board (DAB)
    
                                                  
                                                    
            
      
      
      
      About DAB
                                            
            
            Organizational Overview
    
                                                  
                              
            
      
      
      
      Who are the Judges?
    
                                                  
                              
            
      
      
      
      DAB Divisions
    
                                                  
                              
            
      
      
      
      Contact DAB
    
                                                  
                                                    
            
      
      
      
      Filing an Appeal Online
                                            
            
            DAB E-File
    
                                                  
                              
            
      
      
      
      Medicare Operations Division (MOD) E-File
    
                                                  
                                                    
            
      
      
      
      Different Appeals at DAB
                                            
            
            Appeals to DAB Administrative Law Judges (ALJs)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Procedures
    
                                                                
                                                    
            
      
      
      
      Appeals to Board
                          
            
            Practice Manual
    
                                                  
                              
            
      
      
      
      Guidelines
    
                                                  
                              
            
      
      
      
      Regulations
    
                                                  
                              
            
      
      
      
      National Coverage Determination Complaints
    
                                                                
                                                    
            
      
      
      
      Appeals to the Medicare Appeals Council (Council)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Fully Integrated Duals Advantage (FIDA) Demonstration Project
    
                                                  
                                                    
            
      
      
      
      Alternative Dispute Resolution Services
                                            
            
            Sharing Neutrals
    
                                                  
                              
            
      
      
      
      ADR Training
    
                                                  
                              
            
      
      
      
      Other ADR Services
    
                                                  
                                                    
            
      
      
      
      DAB Decisions
                                            
            
            Board Decisions
    
                                                  
                              
            
      
      
      
      DAB Administrative Law Judge (ALJ) Decisions
    
                                                  
                              
            
      
      
      
      Medicare Appeals Council (Council) Decisions
    
                                    
                              
            
      
      
      
      Stakeholder Feedback
    
                                                  
                                                    
            
      
      
      
      Careers
                                            
            
            Open Career Opportunities
    
                                                  
                              
            
      
      
      
      Internships & ExternshipsText resize icon

                    




Michael Graves, M.D., DAB CR5317 (2019)








  
  
    

  
      
Department of Health and Human Services 
    DEPARTMENTAL APPEALS BOARD
          Civil Remedies Division





Michael Graves, M.D.
	(NPI: 1770880007 / PTAN: 431633ZLY),
	Petitioner,
v.
Centers for Medicare & Medicaid Services.
Docket No. C-17-1070Decision No. CR5317May 8, 2019

        
              
    

      DECISION
I affirm the reconsidered determination's conclusion that the effective date for the reassignment of Medicare benefits from Michael Graves, M.D. (Petitioner) to Epiphany Dermatology, PA (Epiphany) is January 30, 2017, with a retrospective effective date of December 31, 2016.
I. Background and Procedural History
Petitioner is a physician enrolled in the Medicare program. Petitioner submitted a CMS‐855R form seeking reassignment of Medicare benefits from Petitioner to Epiphany. A Centers for Medicare & Medicaid Services (CMS) contractor received the reassignment application on November 14, 2016. CMS Exhibit (Ex.) Ex. 10.
In a December 15, 2016 letter, the CMS contractor acknowledged receipt of Petitioner's reassignment application, but stated that the following information was missing: the effective date sought for the reassignment (section 1 of the application); information about the supplier to whom Petitioner was reassigning benefits (section 2 of the
**Page 2**
application); and information for the individual practitioner reassigning benefits (section 3 of the application). The letter also stated:
Please complete the missing elements of your application and sign and date a new blank certification statement in Section 6: Certification Statement and Signatures. Note if the only missing element is supporting documentation, a newly signed and dated certification statement is not required. Failure to provide all requested information will cause the application to be rejected.
CMS Ex. 9.
On December 20, 2016, Petitioner faxed a response in which he included the requested information. CMS Ex. 8; Petitioner (P.) Ex. 3. On January 3, 2017, in response to a phone call from a CMS contractor employee, Petitioner faxed a signature/certification statement page for the reassignment application. CMS Ex. 7. Petitioner signed in subsection A of section 6 of the application, but there was no signature in subsection B of section 6. CMS Ex. 7 at 2.
In a January 17, 2017 notice, the CMS contractor rejected Petitioner's reassignment application, noting that Petitioner provided all of the information that had been missing but filed an "INVALID" signature/certification statement page for the reassignment application. The notice stated that Petitioner "must complete a new Medicare enrollment application(s)." CMS Ex. 6; *see* P. Ex. 2.
Petitioner signed a new CMS-855R reassignment application on January 18, 2017, in which Petitioner requested a November 1, 2016 effective date for the reassignment. CMS Ex. 5. The CMS contractor received the second reassignment application on January 30, 2017. CMS Ex. 5 at 6. In a February 10, 2017 initial determination, the CMS contractor approved reassignment of Medicare benefits from Petitioner to Epiphany effective December 21, 2016. CMS Ex. 4.
Petitioner requested reconsideration, asserting that the effective date for reassignment should be November 1, 2016, based on the original application Petitioner filed. Petitioner argued that the CMS contractor should not have rejected the original application because Petitioner provided additional information to the CMS contractor. CMS Ex. 3.
In a June 6, 2017 reconsidered determination, the CMS contractor found that Petitioner's effective date of reassignment was January 30, 2017, with a retrospective effective date of December 31, 2016. CMS Ex. 1 at 3. In doing so, the reconsidered determination corrected the initial determination's effective date of December 21, 2016, explaining that the effective date was the date the CMS contractor received the second CMS-855R
**Page 3**
reassignment application from Petitioner. Further, the reconsidered determination indicated that a 30-day retrospective period was permitted, allowing a retrospective reassignment effective date of December 31, 2016. CMS Ex. 1 at 3. In response to Petitioner's argument that it had provided all the information requested in relation to the first CMS-855R reassignment application, the reconsidered determination stated:
A development response was received via facsimile on December 20, 2016; however, the response did not include new signatures as requested. Another development response was received on January 3, 2017 via facsimile; however, section 6B was still missing the required signature. On January 17, 2017, the application was closed as non-response rejected correctly per 42 CFR § 424.525 since no response was received.
CMS Ex. 1 at 2.
Petitioner requested a hearing to dispute the reconsidered determination, asserting that his original reassignment application should have been approved because he had timely responded to the CMS contractor's request for additional information. Judge Leslie A. Weyn was assigned to the case and, on September 8, 2017, issued an Acknowledgment and Prehearing Order (Order), which established a submission schedule for prehearing exchanges. In response, CMS filed a brief and CMS Exs. 1-10. Petitioner filed a brief and P. Exs. 1-4. On November 20, 2018, the case was transferred to me.
II. Decision on the Written Record
I admit CMS Exs. 1-10 and P. Exs. 1-4 into the record without objection. Order ¶ 7; Civil Remedies Division Procedures (CRDP) § 14(e).
I decide this case based on the written record because neither party identified any witnesses to testify in this case or submitted written direct testimony for any witnesses. Order ¶¶ 8-11; CRDP §§ 16(b), 19(b), (d).
III. Issue
Whether CMS had a legitimate basis to establish January 30, 2017, as the effective date for the reassignment of Medicare benefits.
**Page 4**
IV. Findings of Fact, Conclusions of Law, and Analysis
My findings of fact and conclusions of law are set forth in italics and bold font.
The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers. 42 U.S.C. §§ 1302, 1395cc(j). A "supplier" is "a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services" under the Medicare provisions of the Act. 42 U.S.C. § 1395x(d); *see also* 42 U.S.C. § 1395x(u).
A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services. 42 C.F.R. § 424.505. The terms "*Enroll/Enrollment*means the process that Medicare uses to establish eligibility to submit claims for Medicare‐covered items and services." 42 C.F.R. § 424.502. A supplier seeking billing privileges under the Medicare program must "submit enrollment information on the applicable enrollment application. Once the . . . supplier successfully completes the enrollment process . . . CMS enrolls the . . . supplier into the Medicare program." 42 C.F.R. § 424.510(a). CMS then establishes an effective date for billing privileges under the requirements stated in 42 C.F.R. § 424.520(d) and may permit a 30-day retrospective billing period under 42 C.F.R. § 424.521(a)(1).
For Medicare Part B claims, a beneficiary may assign his or her benefits to an enrolled physician or non-physician supplier providing services to that beneficiary. 42 U.S.C. § 1395u(b)(3)(B)(ii). 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. 42 U.S.C. § 1395u(b)(6); 42 C.F.R. § 424.80(b)(1)-(2). 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) §§ 15.5.20(E)(3), 15.17.
***On January 30, 2017, the CMS administrative contractor received Petitioner's application to reassign Medicare benefits (CMS-855R), which the CMS administrative contractor approved.***Petitioner submitted a CMS‐855R reassignment of Medicare benefits application, which a CMS contractor received on January 30, 2017. CMS Ex. 5. The CMS contractor ultimately approved this application. CMS Ex. 4; P. Ex. 4.
***Petitioner's reassignment of Medicare benefits to Epiphany is effective January 30, 2017, with a retrospective reassignment period effective December 31, 2016.*****Page 5**
The effective date for Medicare billing privileges for physicians, non‐physician practitioners, and physician or non‐physician practitioner organizations is the later of the "date of filing" or the date the supplier first began furnishing services at a new practice location. 42 C.F.R. § 424.520(d). The "date of filing" is the date that the Medicare contractor "receives" a signed enrollment application that the Medicare contractor is able to process to approval. 73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); *Donald Dolce, M.D.*, DAB No. 2685 at 8 (2016). Further, under the regulations, CMS may permit a 30‐day retroactive period of billing. 42 C.F.R. § 424.521(a)(1). CMS's published guidance for its contractors applies these effective date rules to reassignments of Medicare benefits. *See* MPIM §§ 15.5.20(E)(3), 15.17.
In the present case, the reassignment application that the CMS contractor was able to process to approval was the one received on January 30, 2017. The CMS contractor, in the reconsidered determination, then assigned a retroactive period of reassignment with an effective date of December 31, 2016. These actions are proper under 42 C.F.R. §§ 424.520(d) and 424.521(a)(1).
Petitioner's primary argument in this case is that the CMS contractor should not have rejected his first reassignment application because Petitioner responded to the request for additional information. However, as detailed above, the CMS contractor rejected the original reassignment application due to a lack of a second signature on the reassignment application. In any event, I have no authority to review the CMS contractor's rejection of Petitioner's original reassignment application and may only evaluate the effective date assigned based on the second reassignment application that the CMS contractor approved. 42 C.F.R. § 424.525(d).
V. Conclusion
I affirm the CMS contractor's reconsidered determination and conclude that Petitioner's effective date for reassignment of Medicare benefits to Epiphany is January 30, 2017, with a retrospective reassignment period effective date of December 31, 2016.
  
          /s/
        Scott Anderson

                      Administrative Law Judge Back to top
    Contact HHS
    
                        
                                            
      
      
      Careers
    
                        
                                            
      
      
      HHS FAQs
    
                        
                                            
      
      
      Nondiscrimination NoticeHHS Archive
    
                        
                                            
      
      
      Accessibility Statement
    
                        
                                            
      
      
      Privacy Policy
    
                        
                                            
      
      
      Viewers & PlayersBudget/Performance
    
                        
                                            
      
      
      Inspector General
    
                        
                                            
      
      
      Web Site Disclaimers
    
                        
                                            
      
      
      EEO/No Fear ActFOIA
    
                        
                                            
      
      
      The White House
    
                        
                                            
      
      
      USA.gov
    
                        
                                            
      
      
      Vulnerability Disclosure Policy
        Sign Up for Email Updates

Receive the latest updates from the Secretary, Blogs, and News Releases.

Sign Up
  HHS Headquarters
          200 Independence Avenue, S.W.
                  Washington, D.C. 20201
                  Toll Free Call Center: 1-877-696-6775​ Disclaimer Policy: Links with this icon () mean that you are leaving the HHS website. The Department of Health and Human Services (HHS) cannot guarantee the accuracy of a non-federal website.
                  Linking to a non-federal website does not mean that HHS or its employees endorse the sponsors, information, or products presented on the website. HHS links outside of itself to provide you with further information.
                  You will be bound by the destination website's privacy policy and/or terms of service when you follow the link.
                  HHS is not responsible for Section 508 compliance (accessibility) on private websites. For more information on HHS's web notification policies, see Website Disclaimers.
 Continue
                  Go back