Jose Manuel Goyos, DAB CR6856 (2026)

DECISION

The Inspector General of the United States Department of Health and Human Services (IG) excluded Jose Manuel Goyos (Petitioner) from participation in Medicare, Medicaid, and all other federal health care programs for a minimum period of 62 years pursuant to section l 128(a)(l) of the Social Security Act (Act) (42 U.S.C. § 1320a-7(a)(l)). 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 62-year exclusion is not unreasonable based on the presence of three aggravating factors and no mitigating factors.

I.  Background and Procedural History

By notice letter dated May 30, 2025, the IG informed Petitioner that he was being excluded from participating in Medicare, Medicaid, and all federal health care programs for a minimum period of 62 years pursuant to section 1128(a)(1) of the Act.  42 U.S.C. § 1320-a7(a)(1).  The exclusion was imposed due to Petitioner’s conviction, in the United States District Court for the Southern District of Florida (District Court), “of a criminal offense related to the delivery of an item or service under Medicare or a State health care

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program, including the performance of management or administrative services relating to the delivery of items or services under any such program.”  IG Exhibit (Ex.) 1.  The IG initially identified three aggravating factors that served as the basis for extending Petitioner’s 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 June 17, 2025.  Petitioner filed supporting documents along with his request for hearing.  Departmental Appeals Board Electronic Filing System (DAB E-File) Doc. No. 1b.1

On July 10, 2025, the CRD issued my Standing Pre-Hearing Order (Standing Order) and an Acknowledgement Letter, acknowledging receipt of Petitioner’s hearing request.  The letter notified the parties that a telephone prehearing conference was scheduled for August 12, 2025, at 10:00 a.m. EST.  On the date of the prehearing conference, an attorney representative appeared on behalf of the IG and Petitioner appeared pro se.  The parties agreed to a briefing schedule.  On August 20, 2025, an Order Following Prehearing Conference and Setting Briefing Schedule (August 20, 2025 Order) was issued and it included dates for the parties to submit their prehearing exchanges.

On September 30, 2025, the IG filed a brief (IG Br.) along with 11 exhibits (IG Exs. 1-11).

Based on the dates agreed upon at the prehearing conference, and again detailed in the August 20, 2025 Order, Petitioner’s prehearing exchange was due on November 25, 2025.  However, to date, Petitioner has not submitted a prehearing exchange, nor has he submitted any documents indicating that he abandoned this appeal.  Because neither party proposes any witnesses, an in-person hearing would serve no purpose.  Therefore, the record is now closed, and I will decide this case based on the evidence before me.  See Anil Hanuman, DAB No. 3080 at 11-12 (2022); Emery Cnty. Care & Rehab. Ctr., DAB No. 3006 at 5-8 (2020); James Brian Joyner, M.D., DAB No. 2902 at 12 (2018); see Civil Remedies Division Procedures (CRDP) ¶ 16(b).

The IG filed a Notice of No-reply on December 8, 2025.

II.  Admission of Exhibits and Decision on the Written Record

Absent objection, IG Exs. 1-11 are admitted into evidence.  All evidence will be given the proper weight and consideration.

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As stated in the August 20, 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.  August 20, 2025 Order at 5; CRPD § 19(d).  Neither party proposed witnesses.  Therefore, this case will be decided based on the record before me.

III.  Issues

The issues to be decided are:  

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).

Whether the 62-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

Petitioner began working at a call center in Florida in May 2020.  The call center placed cold calls to Medicare beneficiaries and lied to obtain consent to receive medically unnecessary genetic testing.  IG Ex. 4 at 130; IG Ex. 2 at 41.  After receiving consent, the call center would generate orders for medically unnecessary genetic testing and send those orders to telemedicine companies for doctors’ signature.  In exchange, the telemedicine companies received bribes and kickbacks from the call center.  IG Ex. 2 at 40.  Medicare paid over $12.3 million in claims for these genetic tests.  IG Ex. 2 at 41.

Eventually, the call center switched to the “doctor chase” model where they would make calls to doctors and medical providers to convince them to sign medically unnecessary orders for genetic testing.  Id.  Petitioner and his co-defendants then billed the doctors’ orders to Medicare through shell laboratories owned and controlled by the co-defendants but did not process any of the genetic tests.  Petitioner was eventually promoted to manager of the “doctor chase” department.  IG Ex. 3 at 93.  As manager, Petitioner was involved in creating a website for the company and a handbook to assist new hires.  IG Ex. 2 at 42; IG Ex. 4 at 122.

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The laboratories submitted approximately $67.4 million in false and fraudulent claims to Medicare.  Medicare paid approximately $53 million of those claims.  IG Ex. 2 at 44.  Petitioner was paid approximately $126,105 for his role in the scheme.  Id.  

On May 30, 2023, Petitioner was charged by superseding indictment with one count of Conspiracy to Commit Health Care Fraud and Wire Fraud, five counts of Health Care Fraud, and one count of Conspiracy to Commit Money Laundering.  IG Ex. 5.  Petitioner requested a jury trial and was convicted of one count of wire fraud and one count of conspiracy to commit money laundering (laundering proceeds over $10,000).  IG Ex. 8. He was found not guilty of the remaining charges.  Id.  Petitioner was sentenced to 180 months of incarceration for Count One of the indictment and to 120 months for Count 14, to run concurrently.  IG Ex. 10 at 2.  Upon release, Petitioner is subject to three years of supervised release and was found to be jointly and severally liable for $53,051,391.00 in restitution.  IG Ex. 10 at 3, 6.

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.  Additionally, the IG has the burden of proving the existence of three aggravating factors as identified in the notice letters.

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).  Here, Petitioner is challenging both the basis and the length of his exclusion.  P. Request for Hearing (RFH).

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VII.  Analysis and Conclusions of Law

1. Petitioner was convicted of a criminal offense related to the delivery of an item or service under the Medicare program, which subjects him to a mandatory exclusion from all federal healthcare programs.

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.  Act § 1128(a)(1) (42 U.S.C. § 1320a-7(a)(1)); 42 C.F.R. § 1001.101(a).  Under the Act, an individual is considered to have been convicted of a criminal offense “when a judgment of conviction has been entered against the individual or entity by a Federal, State, or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to the criminal record has been expunged.”  Act § 1128(i)(1) (42 U.S.C. § 1320a-7(i)(1)); see also 42 C.F.R. § 1001.2 (paragraph (a) under the definition of “Convicted”).  Here, it is undisputed that a jury found Petitioner guilty of two counts of the superseding indictment and the District Court imposed judgment on December 6, 2024.  IG Exs. 8, 10.

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).

The Board has ruled that “when determining whether a requisite nexus exists, an ALJ may consider ‘evidence as to the nature of the offense,’ including the ‘facts upon which the conviction was predicated.’”  Janice Cassandra Wrenn, DAB No. 3118 (2023) (quoting Summit S. Shah, M.D., DAB No. 2836 at 7 (2017)).  Petitioner contests that he meets the criteria for exclusion and mentions the jury verdict which found him not guilty of health care fraud.  P. RFH at 1.  However, being acquitted of health care fraud does not negate that there is a nexus to the delivery of an item or service under Medicare.  The Superseding Indictment shows that Petitioner, along with his co-conspirators, knowingly participated in a scheme using interstate wire communications to cause the submission of false and fraudulent claims to Medicare for medically unnecessary genetic testing.  IG Ex. 5 at 11-12.  Petitioner was convicted of conspiracy to commit wire fraud in relation to that scheme, clearly showing a nexus between the conviction and the delivery of an item or service under Medicare.  Travers v. Shalala, 20 F.3d 993, 998 (9th Cir. 1994).  Additionally, the District Court identified the Centers for Medicare and Medicaid Services as the victim for purposes of restitution.  IG Ex. 2 at 50.  Therefore, the evidence proves that the IG has a legal basis to impose an exclusion against Petitioner.

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2. The IG identified three aggravating factors that support an exclusion beyond the five-year minimum.

Exclusions imposed under section 1128(a)(1) carry a five-year mandatory minimum exclusion period.  Act § 1128(c)(3)(B) (42 U.S.C. § 1320a-7(c)(3)(B)); 42 C.F.R. § 1001.102(a).  The IG may extend the five-year exclusion period based on the application of the aggravating factors listed in 42 C.F.R. § 1001.102(b).  If any of the aggravating factors set forth in 42 C.F.R. § 1001.102(b) justifies an exclusion longer than five years, mitigating factors listed at 42 C.F.R. § 1001.102(c) may be considered as a basis for reducing the period of exclusion to no less than five years.  In this case, the IG has proposed a 62-year exclusion based on three aggravating factors.

The IG identified the following aggravating factors as a basis for imposing a 62-year exclusion against Petitioner:  The acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government agency or program of $50,000 or more; the acts that resulted in the conviction, or similar acts, were committed over a period of one year or more; and the sentence imposed by the court included incarceration.  IG Ex. 1; 42 C.F.R. § 1001.102(b)(1)-(2), (5).  Each factor is discussed below.

1. The acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government program of $50,000 or more.

The first aggravating factor identified by the IG is the acts resulting in the conviction caused a financial loss to a government program of $50,000 or more.  42 C.F.R. § 1001.102(b)(1).  The District Court ordered Petitioner to pay $53,051,300 in restitution, jointly and severally along with his co-defendants and co-conspirators.  IG Ex. 10.  The District Court made it clear that Petitioner was convicted of “a wire fraud conspiracy that knowingly devised or participated in a scheme to defraud Medicare.”  IG Ex. 2 at 12.  Petitioner argues that his conviction only pertained to a single check totaling $24,986 and that the court’s restitution order is not a determination of actual loss.  P. RFH.

However, Petitioner has not provided any proof that the restitution amount ordered by the District Court is different than the amount included on the judgment entry.  It is well-established that an amount ordered as restitution constitutes proof of the amount of financial loss to a government program.  Yolanda Hamilton, DAB No. 3061 at 12-14 (2022).  The restitution amount used by the IG is the amount ordered by the District Court and is over 1,000 times the $50,000 threshold.  IG Ex. 10 at 6.  The regulation is clear that the entire amount of restitution is considered under this aggravating factor.  42 C.F.R. § 1001.102(b)(1) (“the entire amount of financial loss to . . . programs . . . will be considered regardless of whether full or partial restitution has been made.”). . . .  Therefore, the IG has established that the restitution amount may be used as an aggravating factor justifying the extension of the minimum exclusion duration.

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2. The acts that resulted in Petitioner’s conviction, or similar acts, were committed over a period of one year or more. 

The second aggravating factor identified by the IG is the acts that resulted in the conviction, or similar acts, were committed over a period of one year or more.  42 C.F.R. § 1001.102(b)(2).  “[T]he purpose of this aggravating factor ‘is to distinguish between petitioners whose lapse in integrity is short-lived from those who evidence a lack of such integrity over a longer period . . . .’” Vinod Chandrashekhar Patwardhan, M.D., DAB No. 2454 at 7 (2012) (quoting Donald A. Burstein, Ph.D., DAB No. 1865 at 8 (2003)).  Petitioner argues that this aggravating factor has not been established.  P. RFH.  However, the trial court established that Petitioner entered into the conspiracy around May 18, 2020, when he was a federal inmate on release to a halfway house and that his participation ended when federal law enforcement officers raided the facility in July 2021.  IG Ex. 2 at 39.  Participating in criminal activity for over one year is indicative of deliberate participation and is not merely a temporary lapse in judgment.  The IG has proven the existence of a second aggravating factor which is significant and supports an enhancement to the mandatory minimum five-year exclusion.

3. The District Court sentenced Petitioner to 180 months of incarceration.

The third aggravating factor identified by the IG is the sentence imposed by the District Court included incarceration.  42 C.F.R. § 1001.102(b)(5).  It is undisputed that the District Court sentenced Petitioner to 180 months of incarceration.  Petitioner argues that the incarceration imposed by the District Court should not be considered in extending the length of his exclusion, arguing that, “the factor is already captured within the statutory framework of the conviction and should not be used to conflate the exclusion . . . .”  P. RFH.  However, criminal sentencing and administrative exclusions have very different objectives.  “The goals of criminal law generally involve punishment and rehabilitation of the offender, possibly deterrence of future misconduct by the same or other persons, and various public policy goals,” whereas “[e]xclusions imposed by the [IG] . . . are civil sanctions, designed to protect the beneficiaries of health care programs and the federal fisc, and are thus remedial in nature rather than primarily punitive or deterrent.”  Henry L. Gupton, DAB No. 2058 at 7 (2007), aff’d, Henry L. Gupton v. Leavitt, 575 F. Supp. 2d 874 (E.D. Ill. 2008); see also Gracia L. Mayard, DAB No. 2767 at 9 (2017) (noting that “criminal justice policy is irrelevant” in the exclusion context).  The substantial prison term reflects the seriousness of Petitioner’s offense, justifying a longer period of exclusion.  Gracia L. Maynard, M.D., DAB No. 2767 at 8 (2017).

3. Petitioner has not identified any mitigating factors that may be considered.

Petitioner argues that the IG failed to consider several mitigating factors including his efforts to implement compliance procedures in the business; that he was acquitted of the

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most serious allegations; the courts acknowledgment of no personal enrichment or lavish lifestyle; and his lack of prior criminal record.  P. RFH at 2.

The regulations provide only three mitigating factors that may be considered to reduce an exclusion to no less than five years if aggravating factors are present:  (1) a petitioner was convicted of three or fewer misdemeanor offenses and the resulting financial loss to the program was less than $5,000; (2) the record in the criminal proceedings demonstrates that the court determined that a petitioner had a mental, physical, or emotional condition before or after the commission of the offense that reduced their culpability; and (3) a petitioner’s cooperation with federal or state officials resulted in others being convicted or excluded, additional cases being investigated, or a civil money penalty being imposed.  42 C.F.R. § 1001.102(c).

Petitioner has not identified any mitigating factors that may be considered in determining the length of his exclusion. Additionally, I find Petitioner’s claim of a lack of prior criminal record to be quite disingenuous.  When Petitioner began working at the call center at issue in this case, he was a federal inmate on release to a halfway house, and as a condition of supervised release, he was prohibited from working at call centers due to a previous mail fraud conviction.  IG Ex. 2 at 40.

4. Based on three aggravating factors and no mitigating factors, I find that the 62-year exclusion imposed by the IG is not unreasonable.

In determining whether the length of exclusion is unreasonable, I must determine whether the length of the exclusion falls into a “reasonable range” based on the facts and circumstances of this case.  The regulations provide that the IG’s proposed exclusion must be upheld as long as the length of exclusion is not unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii).  It is important to note that it is the quality of the aggravating (or mitigating) factors that is most important when considering the length of exclusion and not the sheer number of aggravating factors that are present in a given case.  The Secretary stated in the preamble to the final rule establishing the exclusion regulations that:  

We do not intend for the aggravating and mitigating factors to have specific values; rather, these factors must be evaluated based on the circumstances of a particular case.  For example, in one case many aggravating factors may exist, but the subject’s cooperation with the OIG may be so significant that it is appropriate to give that one mitigating factor more weight than all of the aggravating.  Similarly, many mitigating factors may exist in a case, but the acts could have had such a significant physical impact on program beneficiaries that the existence of that one aggravating factor

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must be given more weight than all of the mitigating factors.  The weight accorded to each mitigating and aggravating factor cannot be established according to a rigid formula, but must be determined in the context of the particular case at issue.

57 Fed. Reg. 3298, 3314-15 (Jan. 29, 1992).

The IG argues that because Petitioner has not offered any “cognizable reason” as to why the length of his exclusion is unreasonable, it must be upheld.  IG Br. at 14.  This is incorrect.  While it is clear that an exclusion beyond the mandatory minimum five years is supported by the evidence of three aggravating factors under 42 C.F.R. § 1001.102(b)(1)-(2), (5), a 62-year exclusion is quite lengthy, and I must determine if it falls within a reasonable range.

Though case comparisons typically have limited value, I find it helpful to discuss Board decisions in which unusually long exclusion periods have been proposed.  In Alonso, the Board upheld a 42-year exclusion based on the revocation of a social work license, a $26,155,133 restitution obligation, 40 months of incarceration, and participation in the fraudulent scheme for two years, with the existence of one mitigating factor.  Erik X. Alonso, DAB No. 3186 (2025).

The Sheth case involved over $12,376,310 million in fraudulent activity that lasted for six years, resulted in 60 months of incarceration, and suspension of the physician’s medical license.  Sushil Sheth, M.D., DAB No. 2491 (2012).  At the time when the Sheth case was decided, the threshold for financial loss to a government program was $5,000 dollars.  Thus, Sheth was singlehandedly responsible for the program loss that was over 2,400 times the $5,000 threshold.  The IG imposed a 95-year exclusion.  On appeal, the Board ruled that a 95-year exclusion period was unreasonable, but it found a 60-year exclusion reasonable.  Id. 

Here, Petitioner engaged in a fraudulent billing scheme, along with his co-conspirators, that resulted in the submission of over $53 million in false and fraudulent claims to Medicare, more than the Sheth and Alonso cases combined.  IG Ex. 2 at 7.  This is a significant amount of fraud, particularly for programs designed to provide healthcare to some of this country’s most vulnerable populations.  Additionally, the Board has held that “it is entirely reasonable to consider a program loss amount substantially larger than” the threshold program loss amount to be “an ‘exceptional aggravating factor’ to be accorded significant weight.”  Laura Leyva, DAB No. 2704 at 9-10 (2016).  Here, the financial loss attributed to Petitioner is over 1,000 times the $50,000 threshold.  This is a staggering amount of fraud to the Medicare program.

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Petitioner was sentenced to 180 months of incarceration, a considerably longer period of incarceration than either of the aforementioned cases in which the individuals received 42- and 60-year exclusions.  The Board has determined that a prison sentence of as little as nine months is considered to be relatively substantial for exclusion purposes.  Jason Hollady, M.D., DAB No. 1855 at 12 (2002).  The amount of fraud, the length of participation in the fraudulent scheme, and the considerable length of incarceration are significant aggravating factors which justify an exclusion substantially longer than the mandatory minimum.

Lastly, the purpose of an exclusion is to protect federal health care programs from fraud and abuse.  Manocchio v. Kusserow, 961 F.2d 1539, 1541-42 (11th Cir. 1992).  For exclusions, the trustworthiness of the excluded individual is a key question.  See Morgan v. Sebelius, 934 F.3d 535, 538 (4th Cir. 2012) (“[T]he legislative history to § 1320-7(a)(3) as it was originally enacted indicates that it was specifically intended to protect federal programs from untrustworthy individuals.”); see also Susan Malady, R.N., DAB No. 1816 at 9 (2002).  As the IG noted, there are serious concerns regarding Petitioner’s trustworthiness as evidenced by his participation in this scheme that defrauded the Medicare program of tens of millions of dollars.

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 62-year exclusion from participation in Medicare, Medicaid, and all other federal health care programs is not unreasonable based on the circumstances of this case, which include three aggravating factors and no mitigating factors.