Rebecca N. Dejos Cedro, DAB CR6714 (2025)

DECISION

The Inspector General (IG) of the United States Department of Health and Human Services excluded Rebecca N. Dejos Cedro (Petitioner) from participation in Medicare, Medicaid, and all other federal health care programs for a minimum period of six years, pursuant to section 1128(a)(1) of the Social Security Act (Act) (42 U.S.C. § 1320a-7(a)(1)).  For the reasons discussed below, it is determined that the IG had a basis to exclude Petitioner from program participation, and a mandatory exclusion must be imposed.  Based on the facts and evidence presented in this case, I find that a six-year exclusion is not unreasonable based on the presence of one aggravating factor and no mitigating factors.

I. Background and Procedural History

By notice letter dated October 31, 2024, the IG informed Petitioner that she was being excluded from participation in Medicare, Medicaid, and all other federal health care programs for a minimum period of six years pursuant to section 1128(a)(1) of the Act.  IG Exhibit (Ex.) 1 at 1.  The exclusion was imposed due to Petitioner’s conviction, in the Superior Court of California, County of Los Angeles (Superior Court), “of a criminal

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offense related to the delivery of an item or service under the Medicare or a State health care program, including the performance of management or administrative services relating to the delivery of items or services under any such programs.”  IG Ex. 1 at 1.  The IG identified one aggravating factor to extend the exclusion beyond the five-year mandatory minimum.  IG Ex. 1 at 1. 

The Civil Remedies Division (CRD) received Petitioner’s request for a hearing on December 30, 2024. 

On January 6, 2025, the CRD issued my Standing Pre-Hearing Order (Standing Order) and a letter, at my direction, acknowledging receipt of Petitioner’s hearing request.  The letter notified the parties that a telephone prehearing conference was scheduled for February 5, 2025, at 1:00 p.m. EST.  Due to an emergency, the conference was later rescheduled to February 20, 2025, at 1:00 p.m.  Both parties appeared for the prehearing conference and agreed to a briefing schedule.  Petitioner appeared pro se.  An Order Following Prehearing Conference and Setting Briefing Schedule (February 21, 2025 Order) was issued on February 21, 2025.  

On April 7, 2025, the IG filed a brief (IG Br.) along with seven exhibits (IG Exs. 1-7).  On May 9, 2025, Petitioner filed two briefs (P. Br.) on May 9, 2025.1  The briefs appear to be duplicative.  For clarity purposes, any references to P. Br. will reference the document filed as Departmental Appeals Board Electronic Filing System (DAB E-file) Docket (Dkt.) No. 9. 

On May 19, 2025, the IG filed a no-reply statement.  On May 29, 2025, Petitioner filed a Legal Demand to Reverse Wrongful Accusation (DAB E-file Dkt. No. 11) and a Legal Demand to Reverse Exclusion and Wrongful Accusation (DAB E-file Dkt. No. 12) in response to the IG’s no-reply statement.  

On June 16, 2025, Petitioner untimely filed three additional exhibits via DAB E-File, including a “Full Disclosure Hearing Brief,” “Professional Portfolio,” and a declaration.  DAB E-File Dkt. Nos. 13, 13a, and 14.  Petitioner’s deadline to file a declaration and exhibits was May 12, 2025.  The record closed on May 19, 2025, once the IG filed her no-reply statement.2   Therefore, the documents filed as DAB E-File Dkt. Nos. 13, 13a, and 14 are rejected due to untimeliness.  

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II. Admission of Exhibits and Decision on the Written Record

The IG indicated that an in-person hearing is not necessary to resolve this matter.  IG Br. at 7.  Petitioner did not state a position on whether an in-person hearing is necessary to resolve this matter.  

As stated in the prehearing conference and the February 21, 2025 Order, a hearing will be held only if a party asks to cross-examine a witness for whom the opposing party has provided written direct testimony and the witness’ proposed testimony is found to be relevant and non-cumulative.  February 21, 2025 Order at 5; Civil Remedies Division Procedures § 19(d).  Neither party identified witnesses.  Therefore, a hearing is not necessary, and this matter will be decided on the written record. 

Absent objection, IG Exs. 1-7 are admitted into evidence.  Petitioner’s exhibits identified as DAB E-File Dkt. Nos. 11 and 12 are admitted into evidence.  All evidence will be given the proper weight and consideration. 

III. Issues

The issues to be decided are:  

1. Whether the IG had a basis to exclude Petitioner from participation in Medicare, Medicaid, and all other federal health care programs under section 1128(a)(1) of the Act.  42 C.F.R. § 1001.2007(a)(1)(i); and
2. Whether the six-year exclusion imposed by the IG is unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii). 

IV. Jurisdiction

I have jurisdiction to hear and adjudicate this case.  42 C.F.R. §§ 1001.2007(a)(1), 1005.2; see also 42 U.S.C. § 1320a-7(f)(1). 

V. Findings of Fact

1. Petitioner is a registered nurse who served as the Chief Executive Officer and administrator of Apple Healthcare, a home healthcare agency.  IG Ex. 3 at 3; IG Ex. 6 at 2, 4. 

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2. On August 5, 2021, the California Department of Justice filed a Felony Complaint for Arrest Warrant (Complaint) charging Petitioner with one count of Insurance Fraud Exceeding $950 (Count One) and one count of Soliciting or Accepting Fees for Patient Referrals (Count Two).  IG Ex. 2.  It was alleged that Petitioner paid a marketer, who also served as a confidential informant, $500 per patient for referring patients to Apple Healthcare.  IG Ex. 3 at 3-4.  The payments to the confidential informant were disguised as a salary to conceal the kickback arrangement for patient referrals.  IG Ex. 3 at 5.  Petitioner received payment from Medicare for several of the patients referred to Apple Healthcare by the confidential informant.  IG Ex. 3 at 5.  
3. Petitioner entered into a Plea Agreement pleading guilty to Count Two of the complaint.  IG Ex. 4 at 2.  Count Two states that:  

“Beginning on or about May 10, 2019 and continuing to on or about July 30, 2019, [Petitioner] was licensed under Division 2 of the Health and Safety Code, and offered, delivered, received, and accepted a rebate, refund, commission, preference, patronage dividend, discount, and other consideration as compensation or inducement for referring patients, clients, or customers residing in Los Angeles County and elsewhere to any person, all in violation of Business and Professions Code § 650(a), a felony.”  

IG Ex. 2 at 2.  The Plea Agreement was filed with the Superior Court on February 17, 2023.  IG Ex. 4 at 1.  

4. The parties requested that sentencing be deferred for one year after the entry of Petitioner’s guilty plea.  If Petitioner successfully completed 500 hours of community service before sentencing and complied with the terms of the plea agreement, then Count One would be dismissed and Count Two would be reduced to a misdemeanor.  Id. at 2.  
5. The Superior Court held Petitioner’s Probation and Sentencing Hearing on March 21, 2024.  IG Ex. 5.  The Court amended Count Two to a misdemeanor and noted that it was a conviction after plea.  Petitioner was sentenced to 12 months of summary probation and ordered to pay $150 in restitution.  Id.  
6. On July 24, 2024, the State of California Board of Registered Nursing (California Board) revoked Petitioner’s registered nurse license number, nurse practitioner certificate number, public health nurse certificate number, and nurse practitioner furnishing certificate number due to Petitioner’s criminal conviction.  IG Ex. 6 at

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4, 14, 25.  However, the revocation was stayed, and Petitioner was placed on probation for three years with several conditions.  Id. at 14-20. 

7. By letter dated August 14, 2024, the California Department of Health Care Services notified Petitioner that she was being indefinitely suspended from the Medi-Cal program due to her misdemeanor conviction in violation of Cal. Bus. & Prof. Code § 650(a).  IG Ex. 7. 

VI. Legal Authorities

The Secretary of the United States Department of Health and Human Services (Secretary) shall exclude an individual from participation in Medicare, Medicaid, and all other federal health care programs if that individual has been convicted of a criminal offense related to the delivery of an item or service under Medicare or any state health care program.  42 U.S.C. § 1320a-7(a)(1).  The Act requires a minimum exclusion period of five years when the exclusion is mandated under section 1320a-7(a).  42 U.S.C. § 1320a-7(c)(3)(B). 

In exclusion cases, the IG has the burden of proving the basis for the exclusion and the existence of any aggravating factors.  42 C.F.R. § 1005.15(c); Standing Order ¶ 6.  Petitioner has the burden of proving any affirmative defenses or factors to mitigate the length of the exclusion if aggravating factors have been established.  42 C.F.R. § 1001.102(c); Standing Order ¶ 6.  The standard of proof is a preponderance of the evidence, which means a fact is proven if the evidence shows that it is more likely true than not true.  42 C.F.R. §§ 1001.2007(c), 1005.15(d).  In this case, the IG must prove that Petitioner was convicted of an offense related to the delivery of an item or service under Medicare or a state health care program. 

An excluded individual may request a hearing before an administrative law judge (ALJ), but only on the issues of whether the IG had a basis for the exclusion and whether an exclusion longer than the required minimum period is unreasonable in light of any applicable aggravating and mitigating factors.  42 C.F.R. §§ 1001.2007(a), 1005.2(a). 

VII. Analysis and Conclusions of Law

1. Petitioner was convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program, which subjects her to a mandatory exclusion from all federal health care programs for a minimum of five years. 

To prevail, the IG must prove that Petitioner was convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program.  42 U.S.C. § 1320a-7(a)(1); 42 C.F.R. § 1001.101(a).  Under the Act, an individual is

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considered to have been convicted of a criminal offense when “a plea of guilty or nolo contendere by the individual or entity has been accepted by a Federal, State, or local court . . . or when the individual or entity has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld.”  Act § 1128(i)(3), (4) (42 U.S.C. § 1320a-7(i)(3), (4)); see also 42 C.F.R. § 1001.2 (paragraphs (a), (c), and (d) under the definition of “Convicted”).  It is undisputed that the Superior Court accepted Petitioner’s guilty plea and adjudicated her guilty on March 24, 2023.  

Next, to prove that Petitioner’s conviction was related to the delivery of an item or service under Medicare, the IG must show a nexus between the offense and the delivery of an item or service under Medicare.  The Departmental Appeals Board (Board) has repeatedly held that the phrase “related to” within the context of section 1128(a)(1) requires only that a common‑sense nexus exist between the offense and the delivery of an item or service under Medicare.  Summit S. Shah, M.D., DAB No. 2836 at 6 (2017) (citations omitted).  The underlying facts of Petitioner’s conviction show that Petitioner offered kickbacks for the referral of Medicare patients in violation of California law.  The evidence shows, and the IG has proven, that Petitioner’s conviction was related to the delivery of an item or service under Medicare.  Therefore, the IG had a legal basis to impose an exclusion against Petitioner. 

2. Petitioner’s arguments amount to a collateral attack on the underlying conviction, which is impermissible under the regulations. 

Though Petitioner does not dispute that she was convicted of the misdemeanor offense, she spends much of her brief attacking the facts and circumstances underlying the conviction.  Petitioner argues that the underlying conviction constituted entrapment, that there was no intent or mens rea, and the plea bargain that she agreed to was illegal.  See P. Br.  Petitioner also argues that the case that resulted in her conviction was a factual and legal impossibility.  P. Br. at 6.  Petitioner’s arguments amount to a collateral attack on her conviction, which is prohibited by the regulations. 

When the exclusion is based on the existence of a 
criminal conviction . . . or any other prior determination 
where the facts were adjudicated and a final decision 
was made, the basis for the underlying conviction . . . 
is not reviewable and the individual or entity may not 
collaterally attack it[,] either on substantive or procedural 
grounds[,] in this appeal.  

42 C.F.R. § 1001.2007(d).  Despite Petitioner’s arguments, she pleaded guilty to Count Two of the Criminal Information and was ultimately convicted of a misdemeanor.  The underlying facts surrounding Petitioner’s conviction are not reviewable in this forum. 

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3. The IG identified one aggravating factor to support an exclusion beyond the five-year minimum. 

If the circumstances that serve as the basis of the exclusion also resulted in any other adverse action by any federal, state, or local government, the IG may consider that as an aggravating factor.  42 C.F.R. § 1001.102(b)(9).  Here, the California Board found cause for discipline and determined that Petitioner’s “conviction for soliciting fees for patient referral occurred during her work as a registered nurse, and therefore is substantially related to the qualifications, functions, and duties of a registered nurse . . . .”  IG Ex. 6 at 10-11.  The California Board made the decision to stay the revocation and to place Petitioner on probation for three years.  Id. at 14.  Petitioner does not dispute that she was the subject of an adverse action by the California Board as a result of the criminal conviction that formed the basis for this exclusion.  Therefore, I find that the IG has proven the existence of an aggravating factor. 

4. Based on the one aggravating factor and lack of mitigating factors, I find that the six-year exclusion imposed by the IG is not unreasonable.  

To determine whether the length of exclusion is unreasonable, I must consider whether the length of the exclusion falls into a “reasonable range” based on the evidence before me.  It is undisputed that Petitioner was convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program and subject to an adverse action by the California Board.  Though Petitioner seemingly denies any responsibility in this proceeding, she admitted guilt in the criminal proceeding and accepted responsibility when she appeared before the California Board.  The California Board noted, “regarding her criminal conviction, respondent [Petitioner] admitted she made a mistake.”  IG Ex. 6.  I find that a six-year exclusion falls within a reasonable range, based on the underlying facts of Petitioner’s criminal conviction and the adverse action taken by the California Board.  

Lastly, in compliance with standard protocol, the IG was given the opportunity to respond to Petitioner’s brief, or to file a no reply statement.  February 21, 2025 Order ¶ 6c.  The IG filed a “Notice of No Reply” on May 19, 2025.  Petitioner incorrectly construed the IG’s response as a “win” for her “petition to reverse the exclusion” and as a “formal reversal action against the wrongful conviction leading to the wrongful revocation of all of her Professional Nursing Licenses.”  DAB E-file Dkt. No. 12 at 3.  However, Petitioner’s interpretation is incorrect.  The IG’s notice of no reply simply informs the ALJ and the opposing party that the IG is not submitting further argument in response to Petitioner’s brief and is resting her case on the arguments presented in the previously filed brief.  

Based on the circumstances and facts of this case, and the lack of mitigating factors, I find that a six-year exclusion is not unreasonable. 

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VIII.  Conclusion

For the foregoing reasons, I find that the IG has proven, by a preponderance of the evidence, that Petitioner was convicted of an offense that requires exclusion under section 1128(a)(1) of the Act.  I also find that a six-year exclusion from participation in Medicare, Medicaid, and all other federal health care programs, effective twenty days from October 31, 2024, is not unreasonable based on the circumstances of this case.