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                              Abel E. Bello, MD and Beldor Group, LLC, DAB CR5541 (2020)
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Abel E. Bello, MD and Beldor Group, LLC, DAB CR5541 (2020)








  
  
    

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





Abel E. Bello, MD
	(NPI: 1891094579 / PTANs: II471V, II471U),
	and
	Beldor Group, LLC
	(NPI: 1902259724 / PTANs: JC343A, JC343B)
	Petitioners,
v.
Centers for Medicare & Medicaid Services.
Docket No. C-18-551Decision No. CR5541February 26, 2020

        
              
    

      DECISION
Petitioner Abel E. Bello, MD (Petitioner Bello) reassigned his right to file claims with and receive payment from Medicare to Beldor Group, LLC (Petitioner Beldor) effective June 14, 2017, with retrospective billing pursuant to the reassignment permitted beginning May 15, 2017.1
**Page 2**
I. Procedural History
On June 14, 2017, Petitioner Bello signed a Centers for Medicare & Medicaid Services (CMS) form CMS-855B Medicare enrollment application to enroll his physician practice group, Petitioner Beldor, in Medicare. CMS Exhibit (Ex.) 1 at 103, 118, 107, 135. Petitioner Bello also signed a CMS-855R on June 14, 2017, to reassign his right to file claims with and receive payments from Medicare to Petitioner Beldor. CMS Ex. 1 at 95-98.
First Coast Service Options, Inc., a Medicare administrative contractor (MAC), notified Petitioner Bello by letter dated October 20, 2017, that his initial Medicare enrollment application (actually Petitioner Bello's reassignment application (CMS Br. at 2; CMS Ex. 1 at 95-98))2
 was approved effective June 14, 2017. CMS Ex. 1 at 25-27. The MAC also advised Petitioner Beldor that its initial Medicare enrollment application was approved, also effective June 14, 2017. CMS Ex. 1 at 29-30.
Petitioner Bello requested reconsideration by letters dated November 25, 2017 and December 6, 2017, on behalf of himself and Petitioner Beldor. Petitioner Bello argued the effective date of his enrollment as a solo practitioner should have been August 3 or 5, 2016, when his reassignment to Palm Beach General Surgery (Palm Beach Surgery) ended and he started Petitioner Beldor. CMS Ex. 1 at 5-11.
The MAC issued a reconsidered determination on December 13, 2017. The MAC upheld the effective date determination of June 14, 2017.3
 The reconsidered determination explains that the MAC received a CMS-855R from Petitioner Bello to reassign his rights to file claims with and receive payment from Medicare to Petitioner Beldor and that it
**Page 3**
was not possible for the reassignment to be effective before Petitioner Beldor was actually enrolled in Medicare.4
 CMS Ex. 1 at 1-4.
Petitioner Bello requested a hearing (RFH) on behalf of himself and Petitioner Beldor on February 13, 2018. The case was assigned to me and an Acknowledgment and Prehearing Order (Prehearing Order) was issued on February 16, 2018. On March 6, 2018, CMS filed a motion to dismiss that was denied on March 20, 2018. On March 19, 2018, CMS filed a motion for summary judgment and CMS Exs. 1 through 4. Petitioners filed a response in opposition to the CMS motion for summary judgment and a cross-motion for summary judgment on March 30, 2018 (P. Br.). Petitioners filed a list of proposed exhibits, with Petitioners' exhibits (P. Exs.) 1 through 4 duplicating CMS Exs. 1 through 4. Petitioners also listed P. Ex. 5 described as a "Provider Enrollment Chain & Ownership System (PECOS) Electronic Verification Summary of Petitioners' CMS Submissions from August 2016 to present." Petitioners do not object to my consideration of CMS Exs. 1 through 4 and they are admitted. It is not necessary to also admit P. Exs. 1 through 4 as they are duplicates of CMS Exs. 1 through 4 and there is no need to admit cumulative evidence. P. Ex. 5 was not filed by Petitioners. The description of P. Ex. 5 does not appear to fit the documents filed at the end of Petitioners' opposition and cross-motion (P. Br. Exhibits A and B) which bear the markings CMS Ex. 1 pages 19-22. Therefore, it is not possible for me to admit or consider the proposed P. Ex. 5, which has not been offered as evidence.
II. Discussion
**A. Applicable Law**
Section 1831 of the Social Security Act (the Act) (42 U.S.C. § 1395j) establishes the supplementary medical insurance benefits program for the aged and disabled known as Medicare Part B. Payment under the program for services rendered to Medicare-eligible
**Page 4**
beneficiaries may only be made to eligible providers of services and suppliers.5
 Act §§ 1835(a) (42 U.S.C. § 1395n(a)); 1842(h)(1) (42 U.S.C. § 1395(u)(h)(1)). Administration of the Part B program is through the MACs. Act § 1842(a) (42 U.S.C. § 1395u(a)).
The Act requires the Secretary of Health and Human Services (the Secretary) to issue regulations that establish a process for the enrollment of providers and suppliers, including the right to a hearing and judicial review of certain enrollment determinations. Act § 1866(j) (42 U.S.C. § 1395cc(j)). Pursuant to 42 C.F.R. § 424.505,6
 a provider or supplier must be enrolled in the Medicare program and be issued a billing number to have billing privileges and to be eligible to receive payment for services rendered to a Medicare-eligible beneficiary.
The Medicare beneficiary, one who is entitled to benefits under Medicare Part A or enrolled under Part B, is the individual covered by Medicare and entitled to request payment for Medicare-covered health care items and services. Act § 1802. The assignment of the right to file a claim for Medicare coverage of health care charges from a Medicare beneficiary to a Medicare-enrolled provider or supplier is limited. The regulations provide that the reassignment of the right to file a Medicare claim from an
**Page 5**
enrolled provider or supplier to another is very limited. 42 C.F.R. pt. 424, subpt. F. Medicare will only pay amounts due to a supplier to another as provided in 42 C.F.R. § 424.80(b). Payment by Medicare to an employer is permitted when required as a condition of employment. 42 C.F.R. § 424.80(b)(1). Payment to an entity is permitted if there is a contractual arrangement under which the entity bills for the supplier's services. 42 C.F.R. § 424.80(b)(2). Medicare will also pay an entity pursuant to a reassignment by a supplier. 42 C.F.R. § 424.80(b)(3). An "entity" is a person, group, or facility that is enrolled in Medicare. 42 C.F.R. § 424.71. Accordingly, payment by Medicare pursuant to a reassignment is only permitted to a person, group, or facility that is enrolled in Medicare.
The Secretary has issued regulations that establish the right to a hearing and judicial review of certain enrollment determinations. Act § 1866(j) (42 U.S.C. § 1395cc(j)). Pursuant to sections 1866(h)(1) and (j)(8), a provider or supplier whose enrollment application or renewal application is denied is entitled to an administrative hearing and judicial review. Appeal and review rights in provider and supplier cases are specified by 42 C.F.R. §§ 424.545 and 498.5.
**B. Issues**
Whether I have jurisdiction to review the determination by CMS or a MAC of the effective date of reassignment of the right to file claims with and to receive payment from Medicare;
Whether summary judgment is appropriate; and
The effective date of reassignment.
**C. Findings of Fact, Conclusions of Law, and Analysis**
My conclusions of law are set forth in bold text followed by my findings of undisputed fact and analysis.
**1. There is authority to conduct review in this case.**
Petitioners seek review of the MAC's reconsidered determination of the effective date of Petitioner Beldor's right to file claims with and obtain payment from Medicare for care and services delivered to Medicare-eligible beneficiaries by Petitioner Bello pursuant to Petitioner Bello's reassignment of his billing privileges to Petitioner Beldor.
The Secretary promulgated the regulations at 42 C.F.R. §§ 424.545 and 498.5 that specify review and appeal rights in provider and supplier cases. The Secretary has not specifically stated that a supplier has a right to ALJ review of a CMS or MAC
**Page 6**
determination related to reassignment of the right to file claims with and receive payment from Medicare, including the effective date of reassignment. 42 C.F.R. §§ 424.70-.90, 424.545, 498.3(b), 498.5. However, 42 C.F.R. § 498.3(b)(15), provides that "[t]he effective date of a Medicare provider agreement or supplier approval" is an initial determination subject to review by an ALJ. The Board has given an expansive interpretation to 42 C.F.R. § 498.3(b)(15) and found a right to ALJ review of the effective date of enrollment in Medicare, the effective date of the reactivation of billing privileges, and the effective date of the reassignment of billing privileges. *See, e.g., Victor Alvarez, M.D.*, DAB No. 2325 at 3-12 (2010) (determination of effective date of enrollment in Medicare is an initial determination subject to ALJ review and Board appeal); *Urology Group of NJ, LLC*, DAB No. 2860 at 6 (2018) (no right to review of a CMS or MAC determination to deactivate billing privileges but right to review of the determination of the effective date of reactivation); *Gaurav Lakhanpal, MD*, DAB No. 2951 (2019) (Board conducted review of a reassignment effective date). However, the only determination of CMS or the MAC that is subject to my review in a provider and supplier case is the reconsidered determination. *See* 42 C.F.R. § 498.5(*l*)(1)-(2); *Neb Group of Ariz. LLC*, DAB No. 2573 at 9.
**2. Summary judgment is appropriate.**
I have concluded, based on the rationale of the Board in prior cases, that Petitioners have a right to ALJ review of the determination of the effective date of reassignment of his right to file claims with and receive payment from Medicare. A hearing on the record before an ALJ is required under the Act. Act §§ 205(b), 1866(h)(1), (j); *Crestview Parke Care Ctr. v. Thompson*, 373 F.3d 743, 748-51 (6th Cir. 2004). The procedures governing hearings in provider and supplier enrollment cases are at 42 C.F.R. pt. 498. A party may waive appearance at an oral hearing but must do so affirmatively in writing. 42 C.F.R. § 498.66. Petitioners have not waived oral hearing.
Both CMS and Petitioners request summary judgment. Summary judgment is not automatic but is limited to certain specific conditions. The regulations do not establish or recognize a summary judgment procedure. However, the Board has long accepted that summary judgment is an acceptable procedural device in cases adjudicated pursuant to 42 C.F.R. pt. 498. *See, e.g.*, *Crestview Parke*, 373 F.3d at 748-51; *Ill. Knights Templar Home*, DAB No. 2274 at 3-4 (2009); *Garden City Med. Clinic*, DAB No. 1763 (2001); *Everett Rehab. & Med. Ctr.*, DAB No. 1628 at 3 (1997). The Board has also recognized that the Federal Rules of Civil Procedure do not apply in administrative adjudications such as this, but the Board has accepted that Fed. R. Civ. P. 56 and related cases provide useful guidance for determining whether summary judgment is appropriate. Furthermore, a summary judgment procedure was adopted as a matter of judicial economy within my authority to regulate the course of proceedings and made available to the parties in the litigation of this case by my Prehearing Order. The parties were given notice by the Prehearing Order that summary judgment is an available procedural device and that the
**Page 7**
law as it has developed related to Fed. R. Civ. P. 56 will be applied. Prehearing Order ¶¶ III.D & G.
Summary judgment is appropriate when there is no genuine dispute as to any issue of material fact for adjudication and/or the moving party is entitled to judgment as a matter of law. In determining whether there are genuine issues of material fact for trial, the reviewer must view the evidence in the light most favorable to the non-moving party, drawing all reasonable inferences in that party's favor. The party requesting summary judgment bears the burden of showing that there are no genuine issues of material fact for trial and/or that it is entitled to judgment as a matter of law. Generally, the non-movant may not defeat an adequately supported summary judgment motion by relying upon the denials in its pleadings or briefs but must furnish evidence of a dispute concerning a material fact, i.e., a fact that would affect the outcome of the case if proven. *See Anderson v. Liberty Lobby, Inc.*, 477 U.S. 242, 248 (1986); *Mission Hosp. Reg'l Med. Ctr.*, DAB No. 2459 at 5 (2012) (and cases cited therein); *Experts Are Us, Inc.*, DAB No. 2452 at 5 (2012) (and cases cited therein); *Senior Rehab. & Skilled Nursing Ctr.*, DAB No. 2300 at 3 (2010) (and cases cited therein).
The standard for deciding a case on summary judgment and an ALJ's decision-making in deciding a summary judgment motion differs from that used in resolving a case after a hearing. On summary judgment, the ALJ does not make credibility determinations, weigh the evidence, or decide which inferences to draw from the evidence, as would be done when finding facts after a hearing on the record. Rather, on summary judgment, the ALJ construes the evidence in a light most favorable to the non-movant and avoids deciding which version of the facts is more likely true. *Holy Cross Vill. at Notre Dame, Inc.*, DAB No. 2291 at 5 (2009). The Board also has recognized that on summary judgment it is appropriate for the ALJ to consider whether a rational trier of fact could find that the party's evidence would be sufficient to meet that party's evidentiary burden. *Dumas Nursing & Rehab., L.P.*, DAB No. 2347 at 5 (2010). The Secretary has not provided in 42 C.F.R. pt. 498 for the allocation of the burden of persuasion or the quantum of evidence required to satisfy the burden. However, the Board has provided some persuasive analysis regarding the allocation of the burden of persuasion in cases subject to 42 C.F.R. pt. 498. *Batavia Nursing & Convalescent Ctr.*, DAB No. 1904 (2004), *aff'd*, *Batavia Nursing & Convalescent Ctr. v. Thompson*, 129 F. App'x 181 (6th Cir. 2005).
In this case, I conclude that Petitioners have not shown that there is a genuine dispute as to any material fact as discussed hereafter pertinent to determination of the correct effective date of Petitioner Bello's reassignment of his right to file claims with and receive payment from Medicare The facts are undisputed and CMS is entitled to judgment as a matter of law. Accordingly, I conclude that summary judgment is appropriate.
**Page 8**
**3. The effective date of Petitioner Bello's reassignment of his right to file claims with and receive payment from Medicare was June 14, 2017, because that was the effective date of Petitioner Beldor's enrollment.**
**4. The beginning of the 30-day period of retrospective billing privileges on the reassigned claims is May 15, 2017.**
**a. Undisputed Facts**
The parties were advised in the Prehearing Order ¶ II.G that, for purposes of ruling on a motion for summary judgment, a fact alleged and not specifically denied will be accepted as true and offered evidence will be considered admissible and true absent a specific objection. The following findings of fact are based upon the undisputed or conceded facts, or facts asserted by Petitioners that are accepted as true for purposes of summary judgment. I do not make credibility determinations, weigh the evidence, or decide which inferences to draw from the evidence on summary judgment. The evidence is viewed in the light most favorable to Petitioners with all inferences drawn in Petitioners' favor.
Petitioners assert the following facts that are accepted as true for purposes of summary judgment:
Petitioner Bello was enrolled in Medicare as a physician at all relevant times.
On August 5, 2016, Petitioner Bello left his previous employer and opened Petitioner Beldor.
On October 5, 2016, Petitioner Bello attempted to file a reassignment application using PECOS, but he admits that he submitted an incorrect type of application that was rejected. Petitioners concede that the rejected application is not legally sufficient to establish an effective date of billing privileges.7
**Page 9**
On January 20, 2017, Petitioner Bello filed using PECOS an application to reassign his billing privileges that was the correct type of application.
Petitioner Bello was instructed to wait 120 days to permit processing of his application and on June 2, 2017, he was notified he needed to correct the January 20, 2017 application within 30 days.8
Petitioner Bello submitted corrections as requested on June 14, 2017 and, as alleged by Petitioners, the application submitted on January 20, 2017, was processed to completion.
P. Br. at 2-4, 7.
Petitioner Bello, as President of Petitioner Beldor, signed and dated a Medicare enrollment application (CMS-855B) on June 14, 2017, to enroll Petitioner Beldor in Medicare. CMS Ex. 1 at 103, 118, 135; CMS Ex. 2. Petitioners do not dispute that this was the first application to enroll Petitioner Beldor in Medicare. There is no evidence of an earlier application to enroll Petitioner Beldor in Medicare.
Petitioner Bello signed and dated a Medicare reassignment application (CMS-855R) on June 14, 2017, to reassign his billing privileges to Petitioner Beldor. CMS Ex. 1 at 95-98; CMS Ex. 2. For purposes of summary judgment, I accept Petitioner Bello's assertions that this reassignment application was submitted as requested by the MAC to correct the January 20, 2017 reassignment application. CMS Ex. 1 at 19-22.
The MAC reconsidered determination shows, and there is no dispute by Petitioners, that Petitioner Beldor was given an effective date of enrollment in Medicare of June 14, 2017. The MAC determined that the effective date of the reassignment from Petitioner Bello to
**Page 10**
Petitioner Beldor was June 14, 2017, because the reassignment could not occur before Petitioner Beldor was enrolled in Medicare. CMS Ex. 1 at 3.
**b. Analysis**
Based on my analysis of Board interpretive rules in various decisions, I conclude Petitioners do have a right to my review of the reconsidered determination of the effective date of Petitioner Bello's reassignment of his right to file claims with and receive payment from Medicare. The Secretary's regulations address how to determine the effective date of Medicare billing privileges for physicians in 42 C.F.R. § 424.520(d). However, the regulations do not specify how to determine an effective date for an authorized reassignment of Medicare claims, i.e., the right to file claims and receive payment from Medicare, for a physician already enrolled in Medicare. 42 C.F.R. pt. 424, subpt. F. CMS has addressed the determination of the effective date of a reassignment by policy or interpretive rules in effect at the time of the reconsidered determination and found in the Medicare Program Integrity Manual (MPIM), CMS Pub. 100-08, chap. 15, § 15.5.20 (rev. 717, eff. May 15, 2017). MPIM § 15.5.20A requires that a CMS-855R be completed and filed by an individual that wants to reassign benefits to an eligible entity or to terminate a reassignment. Both the party seeking to reassign (reassignor) and the party to whom reassignment is intended (reassignee) must be enrolled in Medicare. A party seeking to reassign that is not enrolled may submit a CMS-855I concurrently with the CMS-855R to accomplish enrollment and reassignment. If the party receiving the reassignment is not enrolled, that party must file the appropriate version of form CMS-855. MPIM § 15.5.20A. The MPIM § 15.5.20E.3 provides:
If the Form CMS-855R is accompanied by an initial Form CMS-855I or submitted as a "stand-alone" form (that is, a Form CMS-855R is submitted as a new reassignment, such as when an enrolled physician who is operating as a sole proprietor joins a group practice and reassigns his benefits to the group), the effective date of enrollment and the reassignment shall be consistent with the 30-day rule (i.e., the later of the date of filing or the date the reassignor first began furnishing services at the new location) specified in section 15.17 of this chapter.
MPIM § 15.5.20E.3. MPIM § 15.17 incorporates the provisions of 42 C.F.R. §§ 424.520(d) and 424.521(a), the regulations that govern determination of the effective date of enrollment and that authorize a period of retrospective billing for physicians, non-physician practitioners, physician and non-physician practitioner organizations, and ambulance suppliers.
**Page 11**
The effective date of enrollment in Medicare of a physician, nonphysician practitioner, and physician and nonphysician practitioner organization is governed by 42 C.F.R. § 424.520(d). The effective date of enrollment for a physician or nonphysician practitioner may only be the **later** of two dates: the date when the physician or nonphysician practitioner filed an application for enrollment that was subsequently approved by a Medicare contractor charged with reviewing the application on behalf of CMS; or the date when the physician or nonphysician practitioner first began providing services at a new practice location. 42 C.F.R. § 424.520(d). An application is "filed" when it is received by the MAC. *Alexander C. Gatzimos, MD, JD, LLC*, DAB No. 2730 (2016).
An enrolled physician or nonphysician practitioner may retrospectively bill Medicare for services provided to Medicare-eligible beneficiaries up to 30 days prior to the effective date of enrollment, if circumstances precluded enrollment before the services were provided. Retrospective billing for up to 90 days prior to the effective date of enrollment is permitted only in the case of a Presidentially-declared disaster pursuant to 42 U.S.C. §§ 5121-5206. 42 C.F.R. § 424.521(a).
Petitioner Bello correctly states in his brief that Petitioner Beldor is a physician practitioner organization that cannot deliver physician services to Medicare-eligible beneficiaries. However, Petitioner Beldor could bill for physician services delivered by Petitioner Bello after there was a valid reassignment. Petitioner Bello also recognizes that a physician practice organization is an "entity" enrolled in Medicare as a sole proprietorship or an organization. 42 C.F.R. § 424.502; P. Br. at 7-8. Petitioner Bello does not recognize in his brief that pursuant to 42 C.F.R. § 424.71 an "entity" is a person, group, or facility that is enrolled in Medicare. Therefore, Petitioner Bello does not recognize that Petitioner Beldor was not an entity that could receive Petitioner Bello's reassignment of his Medicare claims until Petitioner Beldor's enrollment was effective on June 14, 2017. 42 C.F.R. § 424.80(b)(3) (as an exception to the general prohibition, an entity may be paid by Medicare pursuant to a valid reassignment).
Petitioner Bello argues in his request for reconsideration, his hearing request, and in his brief and cross-motion that the MAC erred in this case because he requested an effective date of reassignment to Petitioner Beldor of August 3, 2016 or August 5, 2016. CMS Ex. 1 at 5-11; RFH; P. Br. at 2. Petitioner Bello is under the mistaken impression that he must be given the effective date of reassignment that he requested from the MAC. He correctly notes that the effective date or enrollment will generally be the date on which the MAC receives the enrollment application it processes to completion. P. Br. at 2, 8. However, Petitioner Bello overlooks the requirement that his reassignment could not occur in this case until Petitioner Beldor was enrolled in Medicare and that did not occur
**Page 12**
until June 14, 2017.9
 On the facts of this case, the date of receipt of the reassignment application, which I have accepted for purposes of summary judgment, was January 20, 2017, is not determinative as a matter of law because Petitioner Beldor was not enrolled in Medicare prior to June 14, 2017.
Pursuant to 42 C.F.R. § 424.521(a), retrospective billing is permissible for only 30 days, in this case, beginning on May 15, 2017. Retrospective billing for 90 days is not permitted except in the case of a Presidentially-declared disaster, which did not occur in this case.
Petitioners' remaining arguments may be construed to be a request for equitable relief. But, I have no authority to grant equitable relief. *US Ultrasound*, DAB No. 2302 at 8 (2010). I am also required to follow the Act and regulations and have no authority to declare statutes or regulations invalid. *1866ICPayday.com, L.L.C.*, DAB No. 2289 at 14 (2009).
III. Conclusion
For the foregoing reasons, I conclude that, because the effective date of enrollment of Petitioner Beldor is June 14, 2017, Petitioner Bello's reassignment of his right to file claims with and receive payment from Medicare to Petitioner Beldor was effective June 14, 2017, with retrospective billing pursuant to the reassignment permitted beginning May 15, 2017.


          /s/
        Keith W. Sickendick

                      Administrative Law Judge
      1. This case was originally docketed listing only Petitioner Bello and not his physician practice organization, Beldor Group, LLC. It is clear from the request for hearing filed February 13, 2018, that review was requested on behalf of both parties. Both parties, the reassignor and the reassignee, are arguably affected parties within the meaning of 42 C.F.R. § 498.2 and have the right to review of the effective date of reassignment of Petitioner Bello's billing privileges. The issue not addressed on reconsideration and not raised in the request for hearing is the effective date of Petitioner Beldor's enrollment in Medicare. back to note 1
                      2. The use of "initial Medicare enrollment application" rather than reassignment application may have been a clerical error. However, there is no dispute Petitioner Bello was already enrolled in Medicare and the application approved by the MAC was the CMS-855R reassignment application. CMS Br. at 2. back to note 2
                      3. The reconsidered determination is not a model of clarity in that it does not specifically distinguish between the effective date of reassignment to Petitioner Beldor and the effective date of enrollment of Petitioner Beldor. However, in order to determine the effective date of reassignment it was necessary for the MAC to determine the effective date of enrollment. Therefore, the reconsidered determination is treated as upholding a June 14, 2017 effective date for both the reassignment of Petitioner Bello's billing privileges to Petitioner Beldor, and the effective date of the initial enrollment of Petitioner Beldor. back to note 3
                      4. The reconsidered determination states Petitioner Bello requested to assign his billing privileges to "Antebellum Anesthesia, LLC," which is obviously a clerical error. CMS Ex. 1 at 3. The evidence clearly shows that on June 14, 2017, Petitioner Bello applied to reassign his billing privileges to Petitioner Beldor. CMS Ex. 1 at 95-98. The reconsidered determination also states that the MAC received Petitioners' application on June 16, 2017, but that must also be a clerical error as the MAC granted effective dates of June 14, 2017, and as discussed hereafter, the effective date is the date of receipt by the MAC. CMS Ex. 1 at 3. back to note 4
                      5. Petitioner Bello is a "supplier" under the Act and the regulations. A "supplier" furnishes services under Medicare and the term supplier applies to physicians or other practitioners and facilities that are not included within the definition of the phrase "provider of services." Act § 1861(d) (42 U.S.C. § 1395x(d)). A "provider of services," commonly shortened to "provider," includes hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, home health agencies, hospice programs, and a fund as described in sections 1814(g) and 1835(e) of the Act. Act § 1861(u) (42 U.S.C. § 1395x(u)). The distinction between providers and suppliers is important because they are treated differently under the Act for some purposes. back to note 5
                      6. Citations are to the 2016 revision of the Code of Federal Regulations (C.F.R.), which was in effect at the time of the initial determination, unless otherwise indicated. An appellate panel of the Departmental Appeals Board (Board) concluded in Mark A. Kabat, D.O., DAB No. 2875 at 9-11 (2018) that the applicable regulations are those in effect at the time of the initial determination. However, the Board previously concluded that the only determination subject to my review in a provider and supplier enrollment case such as this is the reconsidered determination. Neb Group of Ariz. LLC, DAB No. 2573 at 9 (2014). In this case, the regulations did not change between the issuance of the initial and reconsidered determinations. back to note 6
                      7. In his request for reconsideration, Petitioner Bello complains that there was a gap in his billing privileges, i.e., his right to bill Medicare and receive payment for services delivered to Medicare-eligible beneficiaries, between termination of his reassignment to Palm Beach Surgery (his previous employer) and the effective date of his reassignment to Petitioner Beldor. CMS Ex. 1 at 9-10. CMS evidence shows that Petitioner Bello filed an unspecified type of application on about October 5, 2016, that was approved on November 7, 2016. CMS Ex. 1 at 13-15. The application appears to have ended Petitioner Bello's reassignment to Palm Beach Surgery, effective August 5, 2016. CMS Ex. 1 at 12. The CMS evidence is consistent with Petitioner Bello's assertions in his reconsideration request that he left Palm Beach Surgery on August 5, 2016 and ended his reassignment to that employer. CMS Ex. 1 at 6, 9; RFH. However, it is not necessary to resolve that issue for a decision in this case. Whether Petitioner Bello could have submitted claims to Medicare for services rendered during the "gap period" under his own billing number as a solo practitioner was not addressed on reconsideration and is not an issue resolved by this decision. back to note 7
                      8. The evidence does not show that the application filed in January 2017 was rejected because Petitioner failed to meet the 30-day deadline imposed by the MAC and I draw no inference adverse to Petitioner on summary judgment. back to note 8
                      9. Petitioners do not dispute that the application to enroll Petitioner Beldor was received by the MAC on or about June 14, 2017, or that the effective date of enrollment of Petitioner Beldor was properly determined to be June 14, 2017. back to note 9 Back to top
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