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                              Clinton County Indiana, DAB CR5732 (2020)
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Clinton County Indiana, DAB CR5732 (2020)








  
  
    

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





Clinton County Indiana,
(PTAN: 979110),
Petitioner,

v.

Centers for Medicare & Medicaid Services.
Docket No. C-18-1285Decision No. CR5732October 8, 2020

        
              
    

      DECISION

Petitioner, Clinton County Indiana, is an Indiana supplier of ambulance services that participates in the Medicare program.  Its Medicare billing privileges were deactivated, and it subsequently applied to reenroll in the program.  The Centers for Medicare & Medicaid Services (CMS) granted the application, with an effective date of April 27, 2018, resulting in a nine-day coverage gap.

Petitioner characterizes the deactivation of its billing privileges as “ridiculous and an abuse of . . . discretion” and argues that the Medicare contractor did not provide sufficient time for it to submit the requested information.  It asserts that its situation is unique in that it is required to provide emergency services, regardless of its billing status, and asks to be reimbursed for the services rendered during the coverage gap.  My authority, however, is too limited to grant Petitioner the relief it seeks.

Because Petitioner filed its subsequently-approved enrollment application on April 27, 2018, I find that April 27 is the correct effective date for its enrollment.

Background

In a notice letter dated June 5, 2018, the Medicare contractor, Wisconsin Physicians Service Insurance Corporation, advised Petitioner that the contractor approved its

Page 2

revalidated Medicare enrollment application, with a gap in billing privileges from April 18 through 27, 2018.  CMS Ex. 13.

Petitioner requested reconsideration, complaining that the contractor’s confusing and inaccurate development letters caused its earlier application to be rejected.  CMS Ex. 14.

In a reconsidered determination, dated August 1, 2018, a contractor hearing officer found that the gap in billing was from April 18 *through 26, 2018*, but otherwise affirmed the initial determination.  CMS Ex. 16.  Petitioner appealed.

CMS moves 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 3, 5 (¶¶ 4(c)(iv), 8) (September 10, 2018).  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 16 exhibits (CMS Exs. 1-16).  Petitioner submits a brief in response (P. Br.).  In the absence of any objections, I admit into evidence CMS Exs. 1-16.  *See* Acknowledgment and Pre-hearing Order at 5 (¶ 7).

Discussion

***On April 27, 2018, Petitioner filed its subsequently-approved application to reactivate its billing privileges, and the effective date can be no earlier than that date.  42 C.F.R. § 424.520(d).***1

**Enrollment**.  Petitioner Clinton County 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.  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.

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

Page 3

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 an ambulance supplier, 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).

**Revalidation and deactivation**.  To maintain its billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of its enrollment information, a process referred to as “revalidation.”  42 C.F.R. § 424.515.  In addition to periodic revalidations, CMS may, at other times and for its own reasons, ask a supplier to recertify the accuracy of its enrollment information.  42 C.F.R. § 424.515(d)-(e).  Within 60 days of receiving CMS’s notice to recertify, the supplier must submit an appropriate enrollment application with complete and accurate information and supporting documentation.  42 C.F.R. § 424.515(a)(2).

If, within 90 days from receipt of CMS’s notice, the supplier does not furnish complete and accurate information and all supporting documentation, or does not resubmit and certify the accuracy of its enrollment information, CMS may deactivate its billing privileges, and no Medicare payments will be made.  42 C.F.R. §§ 424.540(a)(3), 424.555(b).  To reactivate, the supplier must complete and submit a new enrollment application.  42 C.F.R. § 424.540(b)(1).  It is settled that, following deactivation, section 424.520(d) governs the effective date of reenrollment.  *Howard M. Sokoloff, DPM, MS, Inc.*, DAB No. 2972 (2019); *Urology Grp. of NJ, LLC*, DAB No. 2860 (2018); *Willie Goffney, Jr., M.D.*, DAB No. 2763 at 7 (2017), *aff’d sub nom.* *Goffney v. Azar*, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

I have no authority to review a deactivation.  *Sokoloff*, DAB No. 2972 at 6; *Ark. Health Grp*., DAB No. 2929 at 7-9 (2019).

**Petitioner’s deactivation and reenrollment**.  In identical notice letters, dated January 10, 2018, the contractor directed Petitioner to revalidate its Medicare enrollment record by updating or confirming the information there.  The letters directed Petitioner to submit, no later than March 31, 2018, an updated paper CMS-855 Medicare enrollment application or to update through the PECOS system.  The letters warned that Petitioner’s failure to respond could result in deactivation of its Medicare enrollment, causing a gap in reimbursement.  CMS Ex. 1.

Page 4

On March 12, 2018, Petitioner filed its Medicare enrollment application (CMS 855B).  CMS Ex. 2.  The contractor determined that the application was incomplete and, in a letter dated March 19, 2018, asked Petitioner to submit additional documentation, which it listed.  CMS Ex. 3.  Petitioner responded on April 16, 2018, supplementing its March 12 submission and submitting additional documents.  CMS Ex. 5.  Nevertheless, the contractor determined that the application was still incomplete, and, in a notice dated April 19, 2018, advised Petitioner that it rejected the March 12 application.  CMS Ex. 6. 
In a second April 19 letter, the contractor advised Petitioner that its billing privileges were stopped, effective April 18, 2018, because it had not revalidated its enrollment record or had not responded to the contractor’s requests for information.  To revalidate, the letter instructed Petitioner to submit an updated paper enrollment application, or to revalidate through PECOS.  CMS Ex. 7.

On**April 27, 2018,** Petitioner filed another Medicare enrollment application, which, after requesting and receiving additional documentation, the contractor approved.  CMS Ex. 8.  Thus, pursuant to section 424.520(d), the date Petitioner filed its subsequently-approved enrollment application – April 27, 2018 – is the correct effective date of enrollment.  *Sokoloff*, DAB No. 2972; *Urology Grp.*, DAB No. 2860; *Goffney*, DAB No. 2763 at 7, *aff’d sub nom.* *Goffney v. Azar*, No. CV 17-8032 MRW.

**The issues that are not before me:  the deactivation and coverage lapse**.  As the discussion above shows, the case before me is straight-forward.  Petitioner, however, complains about the deactivation of its enrollment.  It concedes that it did not file complete information in response to the contractor’s request, but characterizes its failure to do so as a “minor oversight.”  In Petitioner’s view, the deactivation is arbitrary and capricious and not calculated to protect the Medicare program.  P. Br. at 2-3, 10-12.  Petitioner points out that an ambulance company, unlike other providers and suppliers, is required to provide emergency services, regardless of its billing status, so the deactivation has a greater impact.  P. Br. at 3-4.

Petitioner also complains that the contractor did not give it an adequate opportunity to supply the requested information.  Petitioner cites 42 C.F.R. § 424.540(a)(3) and argues that it was entitled to 90 days from the date of the March 19 notice letter.  P. Br. at 11-12.  In fact, that is not what the regulation says.  It authorizes CMS to deactivate if the supplier “does not furnish complete and accurate information . . . *within 90 calendar days of receipt of notification from CMS to submit an enrollment application* and supporting documentation, or resubmit and certify to the accuracy of its enrollment information.” (emphasis added).  On January 10, 2018, the contractor notified Petitioner to submit its updated enrollment application, and it did not do so within 90 days.

Page 5

In any event, it is well-settled that I have no authority to review the deactivation nor to grant Petitioner relief based on its equitable claims.  *Sokoloff*, DAB No. 2972 at 6; *Ark. Health Grp*., DAB No. 2929 at 7-9 and cases cited therein.  Nor may I grant Petitioner an earlier effective date based on policy arguments.  *Sokoloff*, DAB No. 2972 at 9.

Conclusion

Because Petitioner filed its subsequently-approved reenrollment application on April 27, 2018, CMS properly granted its Medicare reenrollment effective that date.




          /s/
        Carolyn Cozad Hughes

                      Administrative Law Judge
      1. I make this one finding of fact/conclusion of law. back to note 1
                      2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System). back to note 2 Back to top
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