Ritu Khanna, M.D., DAB CR6854 (2026)

DECISION

Petitioner, Ritu Khanna, M.D., is an Arizona physician, who participated in the Medicare program as a supplier of services.  Finding that she had been affiliated with a supplier that posed an undue risk of fraud, waste, or abuse to the Medicare program, the Centers for Medicare & Medicaid Services (CMS) has revoked her Medicare enrollment, imposed a ten-year re-enrollment bar, and added her name to the Medicare preclusion list.  42 C.F.R. § 424.535(a)(19); see 42 C.F.R. § 424.519.

Petitioner appealed.

I affirm CMS’s determination.  I find that CMS is authorized to revoke Petitioner’s Medicare enrollment, pursuant to 42 C.F.R. § 424.535(a)(19), and to add her name to the Medicare preclusion list because, based on her affiliation with the provider, Asclepius Hospice Care, LLC, her enrollment poses an undue risk of fraud, waste, and abuse.

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

Background

Page 2

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, 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,1 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.

CMS may revoke a supplier’s Medicare enrollment and billing privileges on one or more of the grounds set forth under 42 C.F.R. § 424.535(a).  So long as CMS shows that one of the regulatory bases exists, I must uphold the revocation.  Devine Solutions Group, LLC, d/b/a/ Quick Response EMS, DAB No. 3159 at 12 (2024); Thomas Falls, M.D., DAB No. 3056 at 8 (2022); William Garner, MD, DAB No. 3026 at 16 (2020); Eva Orticio Villamor-Goubeaux, DAB No. 2997 at 13 (2020); Wassim Younes, M.D. and Wassim Younes, M.D., P.L.C., DAB No. 2861 at 8 (2018); Norman Johnson, M.D., DAB No.

Page 3

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.  I may not substitute my discretion for that of CMS in determining whether the revocation is appropriate.  Johnson, DAB No. 2779 at 11, citing Care Pro Home Health, Inc., DAB No. 2723 at 9 n.8 (2016); Abdul Razzaque Ahmed, M.D., DAB No. 2261 at 19 (2009), aff’d., Ahmed v. Sebelius, 710 F. Supp.2d 167 (D. Mass. 2010).

Procedural Background.  Here, by letter dated June 12, 2024, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that her Medicare privileges were revoked, effective July 12, 2024.  The letter explained that the contractor revoked Petitioner’s Medicare privileges because she had an affiliation with Asclepius Hospice Care, LLC, an entity previously enrolled in the Medicare program.  Asclepius’s Medicare billing privileges were revoked pursuant to 42 C.F.R. § 424.535(a)(8)(ii) – abuse of billing privileges.  The contractor determined that Petitioner’s affiliation with Asclepius posed an undue risk of fraud, waste, or abuse to the Medicare program and that Petitioner’s participation in Medicare should therefore be revoked.  CMS Ex. 3 at 1; see CMS Ex. 4; 42 C.F.R. §§ 424.519(i); 424.535(a)(19).

The contractor imposed a ten-year reenrollment bar, effective 30 days after the postmark date of the notice, pursuant to 42 C.F.R. § 424.535(c).  CMS Ex. 3 at 1.

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.  Id. at 1-2.

Petitioner requested reconsideration.  CMS Ex. 5.

In a reconsidered determination, dated June 17, 2025, a CMS hearing officer upheld the revocation under sections 424.519 and 424.535(a)(19).  Citing section 424.519, she found that, as a managing employee and corporate director of Asclepius, Petitioner had an affiliation to the supplier through a “disclosable event” and that the affiliation “pose[d] an undue risk of fraud, waste, or abuse.”  CMS Ex. 9 at 8.

The hearing officer also upheld the ten-year reenrollment bar and the determination to include Petitioner’s name on CMS’s preclusion list.  Id. at 8-9.

Decision based on the written record.  CMS moves for summary judgment, which Petitioner opposes.

My initial order instructs the parties to list any proposed witnesses and to submit their written direct testimony.  Acknowledgment and Prehearing Order at 4, 5 (¶¶ 4(c)(iv), 8);

Page 4

see CRD Procedures ¶ 16b.  The order also directs the parties to indicate which, if any, of the opposing side’s witnesses the party wishes to cross-examine and explains that an in-person hearing is needed only if a party wishes to cross-examine the opposing side’s witnesses.  Order at 5, 6 (¶¶ 9, 10).  CMS lists no witnesses.  Petitioner lists three witnesses and provides their written declarations.  P. Exs. 2, 4, 6.  CMS, however, has not asked to cross-examine any of these witnesses.  Because there are no witnesses to be further examined or cross-examined, an in-person hearing would serve no purpose, and I may decide this case based on the written record.  See CRD Procedures ¶ 19b.2

Exhibits.  CMS submits its motion and brief (CMS Br.) with nine exhibits (CMS Exs. 1-9).  Petitioner submits her response and brief (P. Br.) with ten exhibits (P. Exs. 1-10).

In the absence of any objections, I admit into evidence CMS Exs. 1-9 and P. Exs. 1-10.  

Issues

1. Did CMS have the authority to revoke Petitioner’s Medicare enrollment pursuant to 42 C.F.R. § 424.535(a)(19)?
2. Did CMS have the authority to include Petitioner on the CMS Preclusion List pursuant to 42 C.F.R. §§ 422.2, 422.222, 423.100, and 423.120(c)(6)?

I have no authority to review the length of the reenrollment bar.  Brian O’Conner, DAB No. 3140 at 8 (2024).

Discussion

1. CMS properly revoked Petitioner Khanna’s Medicare enrollment under 42 C.F.R. §§ 424.535(a)(19) because her affiliation with the supplier, Asclepius Hospice Care, LLC, poses an undue risk of fraud, waste and abuse.3

Page 5

Revocation of enrollment: disclosure requirements.  Section 1866(j)(5) of the Act increases the disclosure requirements for Medicare providers and suppliers.  That provision requires that providers/suppliers disclose the following information:

any current or previous affiliation (directly or indirectly) with a provider of medical or other items or services or supplier that has uncollected debt, has been or is subject to a payment suspension under a Federal health care program . . . , has been excluded from participation under the program under this title, the Medicaid program under title XIX, or the CHIP [Children’s Health Insurance Program] program under title XXI, or has had its billing privileges denied or revoked.

Act § 1866(j)(5)(A) (Emphasis added).  The Act also authorizes CMS (acting on behalf of the Secretary) to deny Medicare enrollment if it determines that the disclosed affiliation “poses an undue risk of fraud, waste, or abuse.”  Act § 1866(j)(5)(B).

Consistent with the statute, the regulations authorize CMS to revoke a supplier’s Medicare enrollment and billing privileges if she has or has had an affiliation, under section 424.519, that “poses an undue risk of fraud, waste, or abuse to the Medicare program.”  42 C.F.R. § 424.535(a)(19).

Affiliation defined.  For purposes of applying section 424.519 (discussed below), an “affiliation” means any of the following:

1. A five percent or greater direct or indirect ownership interest in another organization.
2. A general or limited partnership interest (regardless of percentage) in another organization.
3. An interest in which she exercises operational or managerial control over, or directly or indirectly conducts the day-to-day operations of an organization, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the organization.
4. An interest in which an individual is acting as an officer or director of a corporation.
5. Any reassignment relationship under section 424.80.

42 C.F.R. § 424.502 (Definition of Affiliation).

The regulation specifically defines a “managing employee” as:

Page 6

general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, under contract or through some other arrangement, whether or not the individual is a W-2 employee of the provider or supplier.  For purposes of this definition, this includes, but is not limited to, a hospice or skilled nursing facility administrator and a hospice or skilled nursing facility medical director.

42 C.F.R. § 424.502 (Definition of Managing employee (1)).

Disclosable events defined.  Sections 424.519 and 424.502 define “disclosable events.”  A disclosable event (for purposes of section 424.519) includes situations in which a supplier has been subject to payment suspension under a federal health care program or when it has had its Medicare, Medicaid, or CHIP enrollment denied, revoked, or terminated.  42 C.F.R. § 424.502 (Definition of Disclosable event (2), (4)).

When CMS requests it, an enrolling or revalidating provider or supplier must disclose “any and all affiliations” that it or any of its owning or managing employees has or had, within the previous five years, with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event (as defined in section 424.502).  CMS will request such disclosures when it has determined that the provider or supplier may have at least one such affiliation.  42 C.F.R. § 424.519(b).

The regulation then lists the information that the provider/supplier must disclose about each reported affiliation.  These include general identifying information, reasons for the disclosure, data regarding the affiliation relationship (e.g., length; type; degree of affiliation; if ended, the reason it ended).  42 C.F.R. § 424.519(c).

When it receives the information, CMS determines whether any of the disclosed affiliations pose an undue risk of fraud, waste, or abuse.  In making this determination, CMS considers the following factors:  1) the duration of the affiliation; 2) whether the affiliation still exists and, if not, how long ago it ended; 3) the degree and extent of the affiliation; 4) the reason for its termination (if applicable); and 5) additional information about the disclosable event.  42 C.F.R. § 424.519(f).

If CMS determines that a particular affiliation poses an undue risk of fraud, waste, or abuse, it denies the provider/supplier’s enrollment application under section 424.530(a)(13), or it revokes the provider’s/supplier’s Medicare enrollment under section 424.535(a)(19).  42 C.F.R. § 424.519(g).

Page 7

Revocation of Asclepius Hospice Care’s Medicare billing privileges.  Asclepius Hospice Care, LLC, was an Arizona hospice that briefly participated in the Medicare program as a provider of services.  As a new provider, Asclepius was subject to a “Provisional Period of Enhanced Oversight” review of the hospice services for which it billed the Medicare Program.  Pursuant to this enhanced oversight, the contractor reviewed the ten claims that the hospice submitted between October 26, 2023, and January 31, 2024.4  All ten were denied.  In six instances, the contractor determined that the information provided did not support a terminal prognosis of six months or less; in two instances, the requirement for a face-to-face encounter had not been met, and the narrative summary provided minimal clinical findings; and, in two instances, the notice of election did not meet statutory or regulatory requirements.  CMS Ex.1; CMS Ex. 2 at 5.

In a letter dated May 17, 2024, the contractor advised Asclepius that, pursuant to 42 C.F.R. § 424.535(a)(8)(ii), its Medicare billing privileges were revoked and its provider agreement terminated, effective June 16, 2024, because the hospice had abused its billing privileges.  CMS Ex. 2.  CMS imposed a ten-year reenrollment bar and placed the hospice on the preclusion list.  Id.

The revocation of Asclepius’s Medicare billing privileges was a disclosable event that prompted CMS to review Petitioner Khanna’s affiliation (if any) with the hospice and to determine whether that affiliation poses an undue risk of fraud, waste, or abuse to the Medicare program.  42 C.F.R. §§ 424.519, 424.535(a)(19).

Petitioner’s affiliation with Asclepius Hospice Care, LLC.  In its Medicare enrollment documents, Asclepius listed Petitioner Khanna as a corporate director and managing employee.  CMS Ex. 7 at 5.  In a written agreement, signed by Petitioner Khanna on June 1, 2023, she agreed to serve as the hospice’s medical director, “providing, as needed and as available, clinical administrative services to [the hospice].”  CMS Ex. 5 at 35-39.  She agreed to comply with all federal, state, and local laws, rules and regulations” that apply to delivering services.  Id.

Petitioner argues that she did not have an “affiliation” with Asclepius.  Although she concedes, as she must, that she became the hospice’s medical director, she denies that she ever served as a managing employee or corporate director and accuses CMS of conflating her title as “medical director” with the position of corporate director.  P. Br. at 6.  But, because she was the provider’s medical director, she was, by law, affiliated with it.  The regulation, on its face, includes the hospice’s medical director in the definition of managing employee.  42 C.F.R. §424.502 (Definition of Managing employee (1)) (managing employee “includes . . . a hospice . . . medical director.”).

Page 8

Petitioner’s efforts to distance herself from the hospice – characterizing the relationship as “brief and insignificant” – cannot change the nature of that affiliation.

Moreover, as medical director, her relationship should not have been “brief and insignificant.”  She was responsible for the “medical component of the hospice’s patient care program.”  42 C.F.R. § 418.102(d).  Her duties included “review[ing] the clinical information for each hospice patient and provid[ing] written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course.”  42 C.F.R. § 418.102(b) (emphasis added).  In signing the contract with Ascelepius, she agreed to assist in “directing and supervising the clinical operations.”  She was thus responsible for the medical component of the hospice’s patient care program, “as required by the Medicare Conditions of Participation for hospice care (42 C.F.R. Part 418).”  CMS Ex. 5 at 36.

Petitioner’s efforts to distance herself from Asclepius establish that she was not fulfilling her obligations under the contract and the hospice regulations.  The reasons the contractor denied the hospice’s claims – because the information did not support a terminal prognosis of six months or less; requirements for face-to-face encounters were not met; and clinical findings were inadequate – are attributable to the medical director’s lack of involvement.  See CMS Ex. 2.  These were her responsibilities.

As CMS noted, the “degree and extent of affiliation between a hospice and its medical director are significant.”  CMS Ex. 9 at 6.  Yet, during her year-long affiliation with the hospice (June 1, 2023 to June 12, 2024), she failed to perform the duties of medical director.  CMS reasonably found “that there is a risk that she cannot be counted on to own or direct a Medicare enrolled entity in a way that does not compromise the integrity of the Medicare program.”  CMS Ex. 9 at 6.  Thus, her affiliation with Asclepius posed an undue risk of fraud, waste, or abuse.  42 C.F.R. § 424.519(f).

Because CMS has grounds for revoking Petitioner’s Medicare enrollment under section 424.535(a)(19), I must sustain the revocation.

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 the 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

Page 9

No. 2672 at 9-12 (2016); accord, William Garner, MD, DAB No. 3026 at 16 (2020), Lilia Gorovits, MD, DAB No. 2985 at 15-16 (2020).

3. CMS acted within its authority when it added Petitioner to its preclusion list because her Medicare 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,” particularly with respect to prescription drug abuse.5  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; or
• 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.

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. 16,642-16,643 (Apr. 16, 2018) (explaining that appeals are limited to the individual’s inclusion on the preclusion list).

As discussed above, CMS revoked Petitioner’s Medicare enrollment because it correctly determined that, as medical director, she had been affiliated with the hospice, Asclepius, whose Medicare billing privileges were revoked because it had abused those billing privileges.  As the provider’s medical director, she was responsible for preventing most of the billing irregularities.  CMS reasonably determined that, based on that affiliation,

Page 10

Petitioner posed an “undue risk of fraud, waste, or abuse” to the Medicare program and revoked her enrollment.  Posing an “undue risk of fraud, waste, or abuse” is necessarily detrimental to the best interests of the Medicare program and its beneficiaries.  Because her enrollment was revoked for conduct deemed detrimental to the best interests of the Medicare program and its beneficiaries and because she is under a reenrollment bar, CMS is 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), aff’d, 420 F. Supp.3d 1100 (D. Haw. 2019); 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)).

Conclusion

I affirm CMS’s determinations.

CMS justifiably revoked Petitioner Khanna’s Medicare enrollment and imposed a reenrollment bar because, based on her affiliation with Asclepius Hospice Care, LLC, her enrollment poses an undue risk of fraud, waste, and abuse.  42 C.F.R. § 424.535(a)(19).

CMS was authorized to include Petitioner on the preclusion list because her Medicare enrollment was revoked for conduct detrimental to the best interests of the Medicare program, and because she is under a reenrollment bar.

I have no authority to review the lengths of the reenrollment bar nor Petitioner’s time on the preclusion list.