Health Law Daily Wrap Up, ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—DAB DECISIONS: Physician denied year-long retroactive Medicare billing after reassignment, (Mar 5, 2026)

By Robert Margolis, J.D.

The ALJ rejected a physician’s request for retrospective payment back to the date she started working for her practice group, more than one year prior to the date on which her accepted reassignment application was received.

Finding that “the regulations are clear, and their application is uncomplicated,” a Department of Health and Human Services Department Appeals Board Administrative Law Judge has held that a physician, was entitled to retrospectively bill and receive payment from Medicare only for services rendered on or after September 28, 2023, which is 60 days prior to the date her accepted application for reassignment of her billing rights to a practice group (Inland Imaging Associates, PS) was received by the Medicare administrative contractor (MAC). Under 42 C.F.R. § 424.522(a), the effective date of the physician’s reassignment of the right to file claims and seek payment from Medicare was 30 days prior to the MAC receiving her reassignment application, or October 28, 2023. Under 42 C.F.R. § 424.521(a)(1), the physician may retrospectively bill for up to 30 days prior to the effective date of her reassignment, or beginning September 28, 2023. The physician had argued that Inland should be able to bill Medicare for her services beginning August 1, 2022, the date she started working for Inland, since prior to that date she filed rejected applications for reassignment, but the ALJ followed the regulations in denying her request (Marian Shehata, MD v. CMS, DAB No. CR6630, Doc. No. C-24-500 (Mar. 7, 2025)).

Reassignment. The physician sought to reassign to Inland, a practice group or organization, her right to file claims with and receive payment from Medicare for services provided to Medicare-eligible beneficiaries. She filed Medicare enrollment applications with a MAC on April 26, 2022, January 12, 2023, October 3, 2023, and November 27, 2023, to accomplish the reassignment. The MAC rejected the first three applications, processing the November 27, 2023 application, and approving the reassignment of her Medicare claims and billing privileges to Inland effective October 28, 2023. She requested reconsideration of that determination, seeking that her reassignment effective date be changed to August 1, 2022, when she started working at Inland. A MAC hearing officer determined that the earliest date that reassignment privileges could be granted was October 28, 2023, which is 30 days prior to the MAC’s November 27, 2023, receipt of the application, citing 42 C.F.R. § 424.521(a)(1). The physician then filed a request for hearing before an ALJ. CMS filed a motion for summary judgment, which the ALJ granted, determining that under governing regulations, the MAC incorrectly calculated the date, but the physician was not entitled to retroactive billing rights back to her starting date at Inland.

Medicare billing rights. Qualified providers and suppliers of services to Medicare-eligible beneficiaries have a provider agreement or supplier approval (if required), are enrolled in Medicare, and are granted billing privileges. 42 C.F.R. pt. 424, subpt. P; pt. 489. A supplier, such as the physician, is permitted to reassign her rights to file a claim for payment for services rendered to a Medicare beneficiary when reassignment is required as a condition of employment. 42 C.F.R. § 424.80(b)(1). In 2021, CMS adopted 42 C.F.R. § 424.522(a), which provides that a reassignment of benefits is effective 30 days prior to the date the MAC received the reassignment application. Further, an enrolled physician may retrospectively bill Medicare for services provided to Medicare-eligible beneficiaries up to 30 days prior to the effective date of enrollment, where circumstances precluded enrollment before the services were provided. Retrospective billing is applicable to a reassignment application if all applicable Medicare requirements are met during the period of retrospective billing. 42 C.F.R. § 424.521(a)(1).

Applying the summary judgment standard used in federal court, the ALJ found no genuine issue of disputed fact and held that the application of the above-described rules set the earliest date for retrospective billing at September 28, 2023. The MAC received the accepted reassignment application on November 27, 2023, making October 28, 2023, the effective date of the physician’s reassignment to Inland. 42 C.F.R. § 424.522(a). Since retrospective billing is allowed up to 30 days prior to that reassignment effective date, the physician’s right to file claims based on delivery of Medicare-eligible services began on September 28, 2023.

The ALJ rejected the physician’s argument that Inland should be able to bill for her services on the date she began providing services there, August 1, 2022. She pointed out that two of three reassignment applications she filed on April 26, 2022, were accepted, and the MAC reviewing the third application (the one related to Inland), had all the information necessary to process that application as well. But under 42 C.F.R. § 424.525(d), the rejection of an application is not subject to appeal, and therefore the fate of any prior rejected application was not a matter the ALJ could consider.

She also argued the government should be estopped from treating October 28, 2023, as the effective date of reassignment, claiming the MAC unreasonably prolonged her enrollment for many months because it knew the information necessary to approve the Inland reassignment application from her other, accepted applications. But absent fraud or other misconduct by the MAC or CMS, and there was no evidence of any, estoppel is unavailable against the government.

Finally, while the ALJ accepted as true that due to the MAC’s rejections of the earlier applications there were more than $50,000 of unreimbursed claims, the physician’s argument that it would be unjust and unfair to strictly apply the regulations was unavailing. The ALJ noted he was bound to follow the regulations and had no authority to declare regulations invalid.

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