Shazia Wadood, M.D., DAB CR6812 (2026)

DECISION

The Centers for Medicare & Medicaid Services (CMS) has revoked Petitioner’s Medicare enrollment pursuant to 42 C.F.R. §§ 24.535(a)(3) and 424.535(a)(9).  She appealed the revocation, and her appeal has been reassigned to me. 

Petitioner, Shazia Wadood, M.D., is a physician, who practiced in Michigan and participated in the Medicare program as a supplier of services.  For 11 months in 2016, she improperly billed the Medicaid program, and, because of this, on February 4, 2022, she was convicted of obtaining money under false pretenses, a felony.  Based on her conviction, the Michigan Department of Licensing and Regulatory Affairs suspended her medical license.  Petitioner did not report either adverse action – the felony conviction or the license suspension – to the Medicare contractor. 

Based on her felony conviction and her failure to report the adverse legal actions, the Medicare contractor, Wisconsin Physicians Service Insurance Corporation, acting on behalf of CMS, revoked Petitioner’s Medicare billing privileges, imposed a ten-year reenrollment bar, and added her name to the Medicare preclusion list. 

Petitioner appealed. 

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I affirm CMS’s determination.  I find that CMS is authorized to revoke Petitioner’s Medicare billing privileges and to add her name to the Medicare preclusion list because:  1) within the ten years preceding this action, Petitioner Wadood was convicted of a felony that CMS reasonably determined is detrimental to the best interests of the Medicare program and its beneficiaries; and 2) Petitioner failed to report the conviction and subsequent suspension of her medical license to the Medicare contractor.  42 C.F.R. §§ 424.535(a)(3), 424.535(a)(9). 

I have no authority to review the length of the reenrollment bar. 

Statutory and Regulatory Background.  The Medicare program, Title XVIII of the Social Security Act (Act), is a federally-subsidized insurance program that provides health care benefits to the elderly, disabled, and those suffering from end stage renal disease.  Medicare is divided into four parts: 

• Part A is the hospital insurance program. It covers hospital services, post-hospital extended care, home health services, and hospice care.  Act § 1811 (42 U.S.C. § 1395c);
• Part B, which is voluntary, is the supplementary medical insurance program, covering physician, outpatient, home health, and other services. Act § 1832 (42 U.S.C. § 1395k);
• Part C is the Medicare Advantage program, which allows its participants to enroll in “Medicare + Choice” plans, managed by organizations, such as health maintenance organizations, that receive a fixed payment for each enrollee. Act § 1851 (42 U.S.C. § 1395w-21); and
• Part D is the voluntary prescription drug benefit program. Act § 1860D (42 U.S.C. § 1395w-101). 

The Medicare program is administered by CMS, acting on behalf of the Secretary of Health and Human Services.  CMS contracts with Medicare administrative contractors, who process and pay reimbursement claims and perform other duties necessary to carry out program purposes.  Act § 1842 (42 U.S.C. § 1395u).  Contractors pay claims to “providers” (Part A) and “suppliers” (Part B).  Physicians and other practitioners who furnish healthcare services may participate in the program as “suppliers” of services; however, they must enroll in the program in order to receive Medicare payments.  Act § 1861(d), (q), (r) (42 U.S.C. § 1395x(d), (q), (r)); 42 C.F.R. §§ 400.202, 424.505. 

Section 424.535(a) authorizes CMS to revoke a supplier’s Medicare enrollment and billing privileges on one or more of the grounds set forth under that subsection.  So long 

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as CMS shows that one of the regulatory bases exists, I must uphold the revocation.  Eva Orticio Villamor-Goubeaux, DAB No. 2997 at 13 (2020); Wassim Younes, M.D. & Wassim Younes, M.D., P.L.C., DAB No. 2861 at 8 (2018) (citing Patrick Brueggeman, D.P.M., DAB No. 2725 at 15 (2016)). 

Procedural Background.  Here, by letter dated February 2, 2023, the Medicare contractor advised Petitioner that her Medicare privileges were revoked, effective February 4, 2022.  CMS Ex. 10.  The letter explained that the contractor revoked Petitioner’s Medicare privileges for two reasons: 

1. 1) pursuant to 42 C.F.R. § 424.535(a)(3), because Petitioner Wadood was convicted of a felony, as defined in 42 C.F.R. § 1001.2 (“False Pretenses – $1,000 or More but Less than $20,000”); and
2. 2) pursuant to 42 C.F.R. § 424.535(a)(9), because Petitioner did not notify CMS, within 30 days, of two adverse legal actions – the felony conviction and the September 20, 2022 suspension of her medical license – as required by 42 C.F.R. § 424.516(d)(1).

CMS Ex. 10 at 2.  The contractor imposed a ten-year reenrollment bar (until February 5, 2032), pursuant to 42 C.F.R. § 424.535(c).  CMS Ex. 10 at 4. 

The letter also advised Petitioner that the contractor added her to CMS’s preclusion list, as authorized by 42 C.F.R. §§ 422.2, 422.222, 423.100, and 423.120(c)(6).  It explained that, if Petitioner requested reconsideration, this action would become effective on the date the reconsidered determination was issued.  CMS Ex. 10 at 3. 

Petitioner requested reconsideration.  CMS Ex. 7.  In a reconsidered determination, dated June 8, 2023, a CMS hearing officer upheld the revocation under sections 424.535(a)(3) and 424.535(a)(9).  Specifically, she found that: 

• Petitioner had been convicted of a felony detrimental to the best interests of the Medicare program and its beneficiaries under section 424.535(a)(3); and
• Petitioner did not report her felony conviction nor her medical license suspension to the Medicare contractor or CMS, as required by section 424.535(a)(9).

CMS Ex. 1 at 9. 

The hearing officer also upheld the ten-year reenrollment bar and the determination to include Petitioner’s name on CMS’s preclusion list.  Id. 

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Decision based on the written record.  The parties agree that this matter may be decided based on the written record.  CMS’s List of Proposed Witnesses (E-file #8); P. Br. at 2.1 

Exhibits.  CMS submits its brief (CMS Br.) with 11 exhibits (CMS Exs. 1-11).  Petitioner submits her own brief (P. Br.) with five exhibits (P. Exs. 1-5). 

In the absence of any objections, I admit into evidence CMS Exs. 1-11.  

CMS objects to my admitting P. Exs. 2-4 and pages 2-3 of P. Ex. 1.  CMS argues that 42 C.F.R. § 498.56(e) precludes my admitting these documents because Petitioner did not submit them at the reconsideration level and has not shown good cause for failing to do so.  The Medicare contractor gave Petitioner ample notice of the requirement.  The February 2 notice letter warned: 

• [I]f you have additional information that you would like a Hearing Officer to consider during the reconsideration or, if necessary, an Administrative Law Judge (ALJ) to consider during a hearing, you must submit that information with your request for reconsideration.  This is your only opportunity to submit information during the administrative appeals process unless an ALJ allows additional information to be submitted. 

CMS Ex. 6 at 3 (emphasis added).  

Unless I find that good cause exists for Petitioner’s submitting the documents, for the first time, at this level of review, I must exclude the evidence.  For the following reasons, I decline to admit P. Exs. 1-4. 

• P. Ex. 1 at 2-3 is the Order of Probation from Petitioner’s criminal case, dated June 8, 2022. As good cause, Petitioner complains that her former lawyer “inexplicably did not include [it with] the reconsideration request.”  P. Request to Admit New Evidence at 3-4 (E-file #9a).  That her attorney arguably erred in not submitting a document does not constitute good cause.  See Norman Johnson, M.D., DAB No. 2779 at 18 (2017). 

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• Petitioner also suggests that, because the document is “substantially similar” to a document that was properly submitted at the reconsideration stage, it should be admitted.  P. Request to Admit New Evidence at 4.  Petitioner has not explained why such similarity would constitute good cause, and I find that it does not. 
  
  I therefore decline to admit P. Ex. 1 at 2-3.  Notably, my excluding P. Ex. 1 at 2-3 does not in any way alter Petitioner’s ability to argue her case; the contents of that document, if not the document itself, are in the record at CMS Ex. 2 at 1.
• I also decline to admit P. Ex. 1 at 1, the Order of Conviction and Sentence. That document is already in the record at CMS Ex. 8 at 2.  The Standing Order here advised that “Petitioner must not submit documents that CMS has already submitted as proposed exhibits.”  Standing Order at 3 (¶ 5(e)(iii)).
• Ex. 2 is a letter, dated February 23, 2022, from Petitioner to the state licensing board, advising of her felony conviction. As good cause, Petitioner again blames her former lawyer for the “mistake” of not submitting the document at the reconsideration stage.  P. Request to Admit New Evidence at 4-5.  Again, a lawyer’s purported error does not constitute good cause.  As the Board has pointed out, Petitioner is accountable for her lawyer’s omissions.  Norman Johnson, M.D., DAB No. 2779 at 18.  
  
  In any event, the document is irrelevant.  Petitioner was required to report her conviction to the Medicare Contractor.  42 C.F.R. § 424.516(d)(1)(ii).  Whether she reported it to anyone else did not relieve her of that obligation.
• Ex. 3 is a Consent Order between Petitioner and the state licensing board, dissolving the order of license suspension. The Consent Order is dated May 3, 2023, about a month before the Medicare contractor issued its reconsidered determination, but about a month after Petitioner submitted her request for reconsideration (March 31, 2023).  Petitioner concedes that the underlying agreement between the parties that led to the consent order was entered into on March 13, 2023, more than two weeks before she submitted her request for reconsideration but argues that the order was conditioned on approval by the Chair of the disciplinary subcommittee, which did not occur until May 3.  P. Request to Admit New Evidence at 3.  She does not explain why she could not have submitted the document when she received it, while her reconsideration request was pending before the Contractor Hearing Officer. 
  
  CMS also points out that the reinstatement of Petitioner’s medical license is irrelevant to the issues before me:  whether, within the preceding ten years, she was convicted of a felony that CMS reasonably finds detrimental to the best interest of the Medicare program; and whether she timely reported that conviction 

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• and her license suspension to the Medicare contractor.  See Akram A. Ismail, M.D., DAB No. 2429 at 10-11 (2011) (finding that a license suspension must be reported when that sanction is imposed).  I agree.  Even if the timing of the Consent Order justified Petitioner’s failure to submit it at the reconsideration level (and I’m not convinced that it did), the document is irrelevant and should not be admitted.  42 C.F.R. § 498.60(b)(1) (directing the ALJ to admit documents that are relevant and material).
• Ex. 4 is a short biography of Kate Massey, the person to whom Petitioner purportedly reported her adverse legal action. I agree with Petitioner that this document need not even be admitted as an exhibit; it is a publicly available document of which I could take notice, if it were relevant.  But the document is not relevant for the same reason P. Ex. 2 is not relevant.  Reporting her conviction to anyone other than the Medicare Contractor did not relieve Petitioner of her reporting obligations under 42 C.F.R. § 424.535(a)(9). 

I admit into evidence P. Ex. 5. 

Discussion

1. 1. CMS properly revoked Petitioner Wadood’s Medicare enrollment under 42 C.F.R. §§ 424.535(a)(3) and 424.535(a)(9) because, within ten years preceding the revocation, she was convicted of a felony that CMS reasonably finds detrimental to the best interests of the Medicare program; and because she failed to report, to the Medicare Contractor, her conviction and the subsequent suspension of her medical license.2

Revocation of enrollment.  CMS may revoke a supplier’s Medicare enrollment and billing privileges if, within the preceding ten years, the supplier was convicted of a “felony offense that CMS determines is detrimental to the best interests of the Medicare program and its beneficiaries.”  42 C.F.R. § 424.535(a)(3)(i); see also Act §§ 1842(h)(8), 1866(b)(2)(D).  Offenses for which billing privileges may be terminated include – but are not limited to – financial crimes such as extortion, embezzlement, income tax evasion, insurance fraud, and similar crimes.  42 C.F.R. § 424.535(a)(3)(ii)(B).  

CMS may also revoke Medicare privileges if a supplier does not comply with the reporting requirements specified in section 424.516(d).  42 C.F.R. § 424.535(a)(9).  Under section 424.516(d), physicians must report to their Medicare Contractor, within 30 days, “[a]ny adverse legal action.”

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Petitioner Wadood’s conviction and license suspension.  Petitioner Wadood was charged with billing the Medicaid program for emergency services from January 4 to December 3, 2016, when, in fact, she had provided routine services.  CMS Ex. 4 at 2; CMS Ex. 11 at 1.   On February 4, 2022, she pleaded guilty to obtaining money under false pretenses, in violation of Mich. Comp. Laws § 750.218(4)(a).  CMS Ex. 8 at 2. The Court accepted her plea and sentenced her to four months probation.  CMS Ex. 2; CMS Ex 8 at 2. 

On September 20, 2022, the Michigan Department of Licensing and Regulatory Affairs summarily suspended Petitioner’s medical license.  The order of suspension finds that, pursuant to Mich. Comp. Laws § 333.16233(5), “public health, safety, or welfare” required the emergency action.  CMS Ex. 3. 

Petitioner did not report her conviction nor her license suspension to the Medicare Contractor. 

Legal basis for revocation.  The Departmental Appeals Board has consistently held that an administrative law judge’s review of CMS’s determination to revoke a supplier’s Medicare enrollment is limited to deciding whether CMS has established one or more of the grounds specified in section 424.535(a).  William Garner, M.D., DAB No. 3026 at 16 (2020); Norman Johnson, M.D., DAB No. 2779 at 11 (2017), and cases cited therein.  Although CMS itself has the discretion to consider “unique or mitigating circumstances in deciding whether, or how, to exercise its revocation authority,” I do not.  Norman Johnson, DAB No. 2779 at 11 (citing Care Pro Home Health, Inc., DAB No. 2723 at 9 n.8 (2016)).  I may not substitute my discretion for that of CMS in determining whether the revocation is appropriate.  Id. (quoting Abdul Razzaque Ahmed, M.D., DAB No. 2261 at 19 (2009), aff’d., Ahmed v. Sebelius, 710 F. Supp. 2d 167 (D. Mass. 2010)). 

Here, because CMS has grounds for revoking Petitioner’s Medicare enrollment under either section 424.535(a)(3) or section 424.535(a)(9), I must sustain the revocation. 

Petitioner, however, asserts that, in reporting to the Director of the Michigan Medicaid Program, and not to the Medicare contractor, she was following her lawyer’s advice.  I have already rejected this position. 

Petitioner also argues that, because the Director of the Michigan Medicaid Program is “affiliated” with CMS, she fulfilled her obligation to report when she reported her conviction and pending license suspension to her.  P. Br. at 3.  But the regulation is unambiguous:  within 30 days, physicians must report, to their Medicare contractor, any adverse legal action.  42 C.F.R. § 424.516(d)(1)(ii).  It is long settled that those who participate in the Medicare program are responsible for knowing its rules.  See Heckler v. Cmty. Health Servs. of Crawford Cnty., Inc., 467 U.S. 51, 63 (1984); New Grove Manor, 

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DAB No. 3090 at 15 (2023); Francis J. Cinelli, Sr., D.O., DAB No. 2834 at 10 (2017); Hartford HealthCare at Home, Inc., DAB No. 2787 at 8-9 (2017). 

Petitioner’s request for remand.  Petitioner does not complain that CMS abused its discretion in revoking her Medicare enrollment and adding her to the preclusion list for ten years.  P. Br. at 2.  Instead, she asserts that, in making its determinations, CMS “was missing key information” about her medical license, which had been reinstated.  She speculates that CMS would have reached a different conclusion had it been aware of the license reinstatement and asks that I remand the case to give CMS the opportunity to consider this purportedly new information.  P. Br. at 5-7.  

The regulations authorize me to remand a case to CMS for consideration of a new issue.  42 C.F.R. § 498.56(d).  However, the information Petitioner wants CMS to consider is not new.  Before the contractor issued its reconsidered determination, Petitioner’s license had been reinstated.  She failed to bring that fact to the Hearing Officer’s attention at that time. 

Moreover, the evidence is not relevant.  CMS’s determinations were based on Petitioner’s felony conviction and her failure to report, not on the loss of her medical license.  That her license was reinstated does not negate or diminish either of those factors and is not a legitimate basis for a remand.  

2. 2. I have no authority to review CMS’s determination to impose a ten-year reenrollment bar. 

When a supplier’s billing privileges are revoked, she may not participate in the Medicare program until the end of its reenrollment bar, which must be for a minimum of one year but no more than ten years (except under circumstances that don’t apply here), depending on the severity of the underlying offense.  42 C.F.R. § 424.535(c)(1).  Here, CMS imposed a ten-year reenrollment bar.  Because the length of a reenrollment bar is not listed as an appealable determination, I have no authority to review it.  42 C.F.R. § 498.3(b); Linda Silva, P.A., DAB No. 2966 at 11 (2019); Vijendra Dave, M.D., DAB No. 2672 at 9-12 (2016); accord, William Garner, M.D., DAB No. 3026 at 16 (2020), Lilia Gorovits, M.D., P.C., DAB No. 2985 at 15-16 (2020). 

3. 3. CMS acted within its authority when it added Petitioner to its preclusion list because her Medicare billing privileges were revoked for conduct detrimental to the best interests of the Medicare program, and she is under a reenrollment bar. I have no authority to review CMS’s determination as to the length of time she remains on the preclusion list. 

The preclusion list.  Effective January 1, 2019, CMS implemented a “preclusion list” as part of its effort to “prevent fraud, waste, and abuse, and to protect Medicare enrollees,” 

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particularly with respect to prescription drug abuse.3  Pursuant to 42 C.F.R. § 422.2 (Part C) and 42 C.F.R. § 423.100 (Part D), CMS’s “preclusion list” includes individuals and entities that: 

• are currently revoked from Medicare enrollment, are under an active reenrollment bar, and CMS determines that the underlying conduct leading to the revocation is detrimental to the best interests of the Medicare program;
• have engaged in behavior for which CMS could have revoked the prescriber, individual, or entity had it been enrolled in the Medicare program, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program; or
• have been convicted of a felony within the previous ten years that CMS deems detrimental to the best interests of the Medicare program.

Review of Petitioner’s inclusion on the preclusion list.  My review here is limited to whether CMS had the authority to include Petitioner on the preclusion list.  42 C.F.R. § 498.3(b)(20); see 83 Fed. Reg. 16,440, 16,642-43 (Apr. 16, 2018) (explaining that appeals are limited to the individual’s inclusion on the preclusion list).  

As discussed above, Petitioner was convicted of a crime that is detrimental to the best interests of the Medicare program and its beneficiaries.  Her Medicare enrollment has been revoked and she is currently under a reenrollment bar.  CMS was therefore authorized to add her to the Medicare preclusion list.  42 C.F.R. §§ 422.2, 423.100.  I must uphold its determination to do so.  See Wendell Foo, M.D., DAB No. 2904 at 3 (2018); Wassim Younes, M.D., P.L.C., DAB No. 2861 at 8 (2018) (citing Patrick Brueggeman, D.P.M., DAB No. 2725 at 15 (2016)). 

Having determined that CMS properly added Petitioner to the preclusion list, I have no authority to review CMS’s determination as to how long she remains there.  See 42 C.F.R. § 498.3(b); Vijendra Dave, M.D., DAB No. 2672 at 9-12 (2016) (limiting ALJ review to the determinations in section 498.3(b)).  

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Conclusion

CMS justifiably determined that Petitioner Wadood was convicted of a felony detrimental to the best interests of the Medicare program and its beneficiaries; it may therefore revoke her Medicare enrollment and billing privileges and impose a reenrollment bar.  In the alternative, CMS may revoke Petitioner’s Medicare enrollment because she did not timely report adverse legal actions to the Medicare contractor. 

CMS was also authorized to include Petitioner on the preclusion list.  I have no authority to review the lengths of the reenrollment bar nor her time on the preclusion list. 

For these reasons, I affirm CMS’s determinations.