Tiffinnee Williams, DAB CR6719 (2025)

DECISION

Petitioner Williams was a personal aide, who was supposed to provide services to a Medicaid beneficiary.  Even though she did not provide the services, she billed the Medicaid program for them.  She was caught, charged with Medicaid fraud, and pleaded guilty.

Based on her conviction, the Inspector General (IG) has excluded Petitioner from participating in Medicare, Medicaid, and all federal health care programs for a minimum period of five years, as authorized by section 1128(a)(1) of the Social Security Act (Act).  Petitioner appeals the exclusion.

For the reasons discussed below, I find that the IG properly excluded Petitioner Williams.  Because the statute mandates a minimum five-year exclusion, the length of her exclusion is, by law, reasonable.

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Background

In a letter dated December 31, 2024, the IG notified Petitioner that she was excluded from participating in all federal health care programs for a period of five years because she had been convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program.  The letter explained that section 1128(a)(1) of the Act authorizes the exclusion.  IG Ex. 1 at 1.

Petitioner timely requested review, and the matter is before me.

The IG submitted a written argument (IG Br.) and four exhibits (IG Exs. 1-4).  Petitioner submitted her own written argument (P. Br.) with multiple pages of documents that are not properly marked.  Each page is marked as a separate exhibit, but all 90 pages are submitted as one entry (E-file # 7).  Petitioner also mailed in – but did not upload into the e-file system –various photographs of the Medicaid beneficiary's apartment and possessions.  The IG submitted a reply brief.

In the absence of any objections, I admit into evidence IG Exs. 1-4.  I find that Petitioner's submissions, which address the facts underlying her conviction, are irrelevant and decline to admit them.  42 C.F.R. § 1005.17(c) ("The ALJ must exclude irrelevant or immaterial evidence.").

Hearing on the written record.  Neither party proposes any witnesses, so an in-person hearing would serve no purpose.  See IG Br. at 5; Order and Schedule for Filing Briefs and Documentary Evidence at 3-4 (¶ 7).  I therefore close the record and issue this decision based on the parties' submissions.

Discussion

1. Petitioner must be excluded from program participation for a minimum of five years because she was convicted of a criminal offense related to the delivery of an item or service under a state health care program.  Act § 1128(a)(1).1

Under section 1128(a)(1) of the Act, the Secretary of Health and Human Services must exclude an individual who has been convicted under federal or state law of a criminal offense related to the delivery of an item or service under Medicare or a state health care program.  42 C.F.R. § 1001.101(a).

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Petitioner was hired to provide home care services to a disabled Medicaid beneficiary.  Petitioner and her co-worker/husband were supposed to provide five hours of services per day (9:00 am to 10:00 am and 5:00 pm to 9:00 pm).  IG Ex. 4 at 1.  After the beneficiary complained that they were not showing up or providing services, a special agent with Ohio's Medicaid Fraud Control Unit investigated.  The beneficiary's building had a video monitoring system that recorded who entered and exited the building.  Review of the videos confirmed that, from August 2022 through April 2023, Petitioner Williams had not been going into the beneficiary's building.  IG. Ex. 4 at 1.  In an interview with the Special Agent, Petitioner Williams admitted that she did not provide the services to the beneficiary for which she billed the Medicaid program.  IG Ex. 4 at 1.  She billed $9,347.55 for services that she did not provide.  IG Ex. 4 at 2.

In a criminal complaint, Petitioner Williams was charged with one count of Medicaid fraud, in violation of Ohio Rev. Code § 2913.40(B).  IG Ex. 3.

On September 26, 2024, Petitioner pleaded guilty to Medicaid fraud.  Based on her stipulation of guilt, the court accepted her plea and found her guilty.  She was ordered to pay restitution.  IG Ex. 2.  Petitioner's conviction for Medicaid fraud is thus obviously related to the delivery of services under a state health care program.

Petitioner has not challenged any of this but claims that she and her husband/co-worker were simply trying to accommodate the beneficiary and didn't know they were doing anything wrong.  P. Br. at 1-3.  In some detail, she describes the services she allegedly provided to the beneficiary and points out that, in September, she will be able to have her conviction expunged.  P. Br. at 3.

Having pleaded guilty, Petitioner may not use this forum to argue that she was not, in fact, guilty of any crime.  The regulations preclude such a collateral attack on an underlying conviction:

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); Yolanda Hamilton, M.D., DAB No. 3061 at 9-10 (2022); Funmilola Mary Taiwo, DAB No. 2995 at 8 (2020); Delores L. Knight, DAB No. 2945 at 9 (2019); Marvin L. Gibbs, Jr., M.D., DAB No. 2279 at 8-10 (2009); Roy Cosby Stark, DAB No. 1746 (2000).

Nor does the prospect of an expungement alter the fact that Petitioner was "convicted" within the meaning of the statute and regulations.  A person is "convicted" when "a

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judgment of conviction has been entered" regardless of whether that judgment has been – or could be – expunged or otherwise removed.  Act § 1128(i)(1); 42 C.F.R. § 1001.2(a)(2); Henry L. Gupton, DAB No. 2058 at 9-10 (2007), aff'd sub nom. Gupton v. Leavitt, 575 F. Supp. 2d 874 (E.D. Tenn. 2008).

By statute and regulation, an exclusion brought under section 1128(a)(1) must be for a minimum period of five years.  Act § 1128(c)(3)(B); 42 C.F.R. § 1001.2007(a)(2).

Conclusion

For these reasons, I conclude that the IG properly excluded Petitioner from participation in Medicare, Medicaid, and all federal health care programs, and I sustain the five-year exclusion.