Lee Peter Bee, DO, DAB, CR6896 (2026)

DECISION

Petitioner is excluded from participation in Medicare, Medicaid, and all federal health care programs pursuant to section 1128(a)(1) and (3) of the Social Security Act (Act) (42 U.S.C. § 1320a-7(a)(1), (3)) effective December 19, 2024.  Petitioner’s exclusion for the minimum period of five years is required by section 1128(c)(3)(B) of the Act (42 U.S.C. § 1320a-7(c)(3)(B)).  Exclusion for an additional seven years, for a total minimum exclusion of 12 years,1 is not unreasonable based on the existence of four aggravating factors and no mitigating factor.

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I.  Background

The Inspector General (IG) notified Petitioner by letter dated November 29, 2024, that he was excluded from participating in Medicare, Medicaid, and all federal health care programs for a minimum of 12 years.  The IG cited section 1128(a)(1) and (3) of the Act as the authority for Petitioner’s exclusion based on his convictions in the United States District Court, Southern District of Illinois (district court) 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)); and

A felony criminal offense related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of a health care item or service (Act § 1128(a)(3)).

The IG extended the five-year minimum period of exclusion to a total of 12 years citing the existence of four aggravating factors and no mitigating factor.  IG Exhibit (Ex.) 1.  The IG sent Petitioner a notice dated March 6, 2025, advising that the IG considered a slightly different aggravating factor than that listed in the November 29, 2024 notice, but the change in the description of the aggravating factor caused no change in the 12-year period of exclusion.  IG Ex. 6.

Petitioner requested a hearing before an administrative law judge (ALJ) on January 28, 2025 (RFH).  On February 11, 2025, I convened a prehearing conference by telephone at which counsel for both parties were present.  The IG requested to file a motion for summary judgment and a briefing schedule was agreed to by counsel.  Following the prehearing conference, I issued on February 11, 2025, a “Prehearing Conference Order and Schedule for Filing Briefs and Documentary Evidence” (Prehearing Order) that memorialized the matters discussed and agreed to during the prehearing conference.

On March 25, 2025, the IG filed a motion for summary judgment with IG Exs. 1 through 10.  On May 12, 2025, Petitioner filed an opposition to the IG motion for summary judgment with Petitioner’s exhibits A, B, C, and D.  The IG filed a reply brief on May 20, 2025.

On June 10, 2025, I denied the IG’s motion for summary judgment and set this case for hearing.  On September 10, 2025, the IG filed IG Exs. 1 through 12.  On October 1, 2025, Petitioner filed Petitioner’s Exhibits (P. Exs.) 1 through 5.  The parties filed a joint stipulation of undisputed facts on October 20, 2025.  The IG filed amended IG Exs. 11 and 12 on January 5, 2026.

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A hearing was convened on January 7, 2026, and a transcript (Tr.) was prepared and provided to the parties.  At the hearing, counsel for Petitioner stated that Petitioner does not dispute that he was convicted as alleged by the IG, that the IG has bases to exclude Petitioner pursuant to section 1128(a)(1) and (3) of the Act, or that the aggravating factors considered by the IG do exist in this case.  Tr. 23-24.  The IG does not dispute that Petitioner did cooperate with the United States Attorney.  Tr. 24-26.

On March 6, 2026, after the hearing in this case, the IG filed IG Exs. 13 through 16 with an unopposed motion to do so.

On March 17, 2026, Petitioner filed P. Ex. 6 with an opposed motion to do so.

The parties filed post-hearing briefs on March 17, 2026 (IG Br. and P. Br., respectively).  Petitioner filed a post-hearing reply brief on April 4, 2026 (P. Reply).  The IG filed a post hearing reply brief on April 6, 2026.

An administrative law judge (ALJ) determines the admissibility of evidence and is not bound by the Federal Rules of Evidence but refers to them as appropriate.  42 C.F.R. § 1005.17(a)-(b).  I must exclude irrelevant or immaterial evidence.  42 C.F.R. § 1005.17(c).  Under the Federal Rules of Evidence, the test for whether evidence is relevant is whether the evidence has “any tendency to make a fact more or less probable than it would be without the evidence” and “the fact is of consequence in determining the action.”  Fed. R. Evid. 401.  The only issues before me are whether there is a basis to exclude Petitioner and whether the period of exclusion is unreasonable.  42 C.F.R. § 1002.2007(a)(1).  The elements that trigger exclusion under section 1128(a)(1) of the Act are whether: Petitioner was convicted of a criminal offense; whether the offense was related to the delivery of an item or service; and whether the delivery of the item or service was under Medicare or a state health care program such as Medicaid.  Act § 1128(a)(1); 42 C.F.R. § 1001.101(a).  The elements that trigger exclusion under section 1128(a)(3) of the Act are whether:  Petitioner was convicted of an offense that occurred after August 21, 1996; Petitioner was convicted of a felony; the offense of which Petitioner was convicted was related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct; and the offense of which Petitioner was convicted was committed in connection with the delivery of a health care item or service or with respect to an act or omission in a health care program, other than Medicare or Medicaid, operated or financed by a federal, state, or local government agency.  Act § 1128(a)(3); 42 C.F.R. § 1001.101(c).  As explained in greater detail later in this decision, the scope of my review of whether the period of exclusion is unreasonable is limited.  In determining whether the period of a mandatory exclusion greater than five years is unreasonable, I consider whether the IG considered as aggravating, factors other than those established by 42 C.F.R. § 1001.101(b) and whether the IG failed to consider mitigating factors established by 42 C.F.R. § 1001.201(c).  Petitioner bears the burden of

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proof and the burden of persuasion on any affirmative defenses or mitigating factors, and the IG bears the burden on all other issues.  42 C.F.R. § 1005.15(c); Prehearing Order ¶ 4.  If the evidence does not show the IG considered as aggravating a factor not authorized by 42 C.F.R. § 1001.101(b) or failed to consider a mitigating factor authorized by 42 C.F.R. § 1001.101(c), I may not substitute my judgment for that of the IG in determining the reasonable period of exclusion.

I reminded the parties at hearing that exhibits submitted before the ruling on summary judgment would not be considered.  Tr. 27-28.  Petitioner did not object to my consideration of IG Exs. 1 through 12 and they were admitted as evidence at hearing.  Tr. 28.  The IG objected to my consideration of P. Exs. 2, 3, and 5 arguing that they were not relevant to any issue that I may decide.  Tr. 29.  The IG objections to P. Exs. 2, 3, and 5 were overruled at hearing and P. Exs. 1 through 5 were admitted as evidence.  Tr. 29-38.

IG Exs. 13 through 16 filed post-hearing are copies of email between counsel for the IG and attorneys with the United States Attorney’s office in the Southern District of Illinois and the Eastern District of Missouri and other attorneys with the Department of Justice, dated in March 2026.  The IG indicates in the motion to admit IG Exs. 13 through 16 that the emails were obtained by the IG to respond to Petitioner’s testimony at the hearing.  The Inspector General’s Unopposed Motion to Admit IG Exhibits 13-16 Into the Hearing Record at 3-4 (IG Motion).  Therefore, the emails are offered by the IG after the hearing as rebuttal evidence.  My review of the emails show that each contains questions by counsel for the IG and responses by the individuals queried by the IG.  The emails are really the written statements of the individuals responding to the IG’s questions.  I informed the parties in my Ruling Denying the Inspector General’s Motion for Summary Judgment; Order Establishing the Schedule for Prehearing Development; and Order Setting Hearing Date para. II.C.6 that written statements could be submitted in lieu of live direct testimony but must be in the form of an affidavit under oath or as a written declaration executed in accordance with 28 U.S.C. § 1746; that the witness must be produced at hearing for cross-examination; and that failure to produce the witness would result in the written statement being stricken upon motion of the opposing party.  However, the IG represents in its motion that Petitioner was consulted and after review of IG Exs. 13 through 16 indicated Petitioner did not oppose their admission as evidence.  IG Motion at 3.  Petitioner made no separate objection to IG Exs. 13 through 16.2  I conclude that Petitioner has waived any objection to my consideration of IG Exs. 13 through 16.  The IG’s regulations require that oral testimony at hearing be under oath.

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42 C.F.R. § 1005.16(a).  But 42 C.F.R. § 1005.16(b) states that written statements may be admitted to the record at the discretion of the ALJ and does not specifically require such statements be under oath, except in the case of an expert witness statement.  I conclude that IG Exs. 13 through 16 are relevant; their authenticity has not been challenged; and any objection has been waived.  Accordingly, IG Exs. 13 through 16 are admitted and considered as evidence.  Nevertheless, I recognize the hearsay nature of the documents and that the statements contained in the document have not been tested by cross-examination.  I am also not bound by opinions expressed that Petitioner’s cooperation did not satisfy the requirements of 42 C.F.R. § 1001.102(c).

P. Ex. 6 offered by Petitioner after the hearing is an order of a federal district court in the case of Jerry Dale Leech resetting a sentencing hearing.  Petitioner indicates in the motion to admit the exhibit that it bolsters Petitioner’s hearing testimony regarding his cooperation with law enforcement in the prosecution of Leech.  Petitioner represents that the IG objected to the motion to admit the exhibit.  Petitioner’s Motion to Admit Exhibit 6 at 2.  The IG argues in its reply brief that P. Ex. 6 is not relevant and must be excluded.  But P. Ex. 6 shows that Leech was prosecuted and bolsters Petitioner’s testimony in that regard.  Therefore, P. Ex. 6 is relevant, and it is admitted.

II.  Discussion

A.  Applicable Law

Section 1128(f) of the Act (42 U.S.C. § 1320a-7(f)) establishes Petitioner’s rights to a hearing by an ALJ and judicial review of the final action of the Secretary of Health and Human Services (the Secretary).

Pursuant to section 1128(a)(1) of the Act, the Secretary must exclude from participation in any federal health care program any individual 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.  A state health care program includes a state Medicaid program.  Act § 1128(h) (42 U.S.C. § 1320a-7(h)).  The Secretary has promulgated regulations implementing this provision of the Act.  42 C.F.R. § 1001.101(a).

The Secretary must also exclude from participation in any federal health care program:

Any individual or entity that has been convicted for an offense which occurred after [August 21, 1996], under Federal or State law, in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program (other than those specifically described in [section 1128(a)(1)]) operated by or

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financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.

Act § 1128(a)(3) (42 U.S.C. § 1320a-7(a)(3)).  The Secretary has promulgated regulations implementing this provision of the Act.  42 C.F.R. § 1001.101(c).

Pursuant to section 1128(i) of the Act (42 U.S.C. § 1320a-7(i)), an individual is convicted of a criminal offense when:  (1) a judgment of conviction has been entered against them by a federal, state, or local court whether or not an appeal is pending or the record has been expunged; (2) there is a finding of guilt by a court; (3) a plea of guilty or no contest is accepted by a court; or (4) the individual has entered into any arrangement or program where judgment of conviction has been withheld.  42 C.F.R. § 1001.2.

Exclusion for a minimum period of five years is mandatory for any individual or entity convicted of a criminal offense for which exclusion is required by section 1128(a) of the Act.  Act § 1128(c)(3)(B) (42 U.S.C. § 1320a-7(c)(3)(B)).  Pursuant to 42 C.F.R § 1001.102(b), an individual’s period of exclusion may be extended based on the presence of specified aggravating factors.  Only if the aggravating factors justify an exclusion of longer than five years, however, are mitigating factors considered as a basis for reducing the period of exclusion to no fewer than five years.  42 C.F.R. § 1001.102(c).

In this proceeding, the standard of proof is a preponderance of the evidence.  42 C.F.R. § 1001.2007(c).  Petitioner bears the burden of proof and the burden of persuasion on any affirmative defenses or mitigating factors, and the IG bears the burden on all other issues.  42 C.F.R. § 1005.15(c); Prehearing Order ¶ 4.  There may be no collateral attack of the conviction that is the basis for the exclusion.  42 C.F.R. § 1001.2007(d).

B.  Issues

The Secretary has by regulation limited my scope of review to two issues:

Whether the IG has a basis for excluding Petitioner from participation in Medicare, Medicaid, and all federal health care programs; and

Whether the length of the proposed period of exclusion is unreasonable.

42 C.F.R. § 1001.2007(a)(1).

C.  Findings of Fact, Conclusions of Law, and Analysis

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Findings of Fact

On July 25, 2023, an information was filed in the district court charging Petitioner with two counts of health care fraud in violation of 18 U.S.C. § 1347.  IG Ex. 3; Jt. Stip. at 2 ¶ 6.

On June 8, 2023, Petitioner signed a plea agreement in which he agreed to plead guilty to two counts of health care fraud in violation of 18 U.S.C. § 1347 as charged in the Information.  Petitioner agreed that each count could be punished by up to 10 years in prison, three years of supervised release, and a fine of $250,000.  IG Ex. 4 at 1-2, 12; Jt. Stip. at 2 ¶¶ 7-8.  The plea agreement was filed in the district court on July 25, 2023.  IG Ex. 4 at 1; Jt. Stip. at 2 ¶¶ 7-8.  Pursuant to 18 U.S.C. § 3559(a), violation of 18 U.S.C. § 1347 is a Class C felony.  Petitioner acknowledged in the plea agreement that he was pleading guilty to felony offenses.  He also acknowledged that by pleading guilty he would likely be excluded from Medicare and the Illinois Medicaid programs.  IG Ex. 4 at 11 ¶ VI.1-2.  The United States Attorney and Petitioner agreed that Petitioner “voluntarily demonstrated a recognition and affirmative acceptance of personal responsibility for his criminal conduct.”  IG Ex. 4 at 4 ¶ 5.  The United States Attorney agreed to recommend a reduced sentence based on Petitioner’s acceptance of responsibility and that he timely notified the United States Attorney of his intent to plead guilty which saved government resources.  IG Ex. 4 at 4 ¶ 5.

On July 25, 2023, Petitioner agreed to a stipulation of fact in support of his plea agreement.  Petitioner stipulated that beginning on or about January 1, 2015, and continuing until January 30, 2020, he “knowingly and willfully devised and conducted a scheme to defraud healthcare benefit programs, namely Medicare, Medicaid, and private insurance . . . in connection with the delivery of and payment for healthcare benefits and services.”  IG Ex. 2 at 2 ¶ 6.  The purpose of the scheme to defraud was for Petitioner to be paid for medical services that were not provided as billed.  IG Ex. 2 at 2 ¶ 7.  Petitioner admitted to filing materially false claims with Medicare, Medicaid, and private insurance and to receiving payments from Medicare, Medicaid, and private insurance to which he was not entitled.   IG Ex. 2 at 2-3 ¶¶ 8-10.  The parties stipulated that by pleading guilty Petitioner admitted to engaging in a scheme to defraud Medicare, Medicaid, and private insurance companies by billing for services that were not provided as claimed from January 1, 2015 through January 30, 2020.  Jt. Stip. at 2-3 ¶ 9.

On April 4, 2024, the district court imposed judgment accepting Petitioner’s guilty pleas to Counts 1 and 2 of the Information charging health care fraud in violation of 18 U.S.C. § 1347.  IG Ex. 5 at 1; Jt. Stip. at 3 ¶ 10.  The district court sentenced Petitioner to five months in prison on each count to run concurrently; followed by two years of supervised release for each count to run concurrently; and to pay restitution of $195,170.14 to the

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Centers for Medicare & Medicaid Services (CMS) and Blue Cross and Blue Shield of Illinois.  IG Ex. 5 at 2-6; Jt. Stip. at 3 ¶¶ 11-12.

On January 15, 2020, Petitioner signed a Consent Order with the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation.  Petitioner agreed to the indefinite suspension of his Illinois physician license for a minimum of 18 months retroactive to October 17, 2019.  The Consent Order resolved a pending state disciplinary proceeding considering allegations that Petitioner took unused and/or expired medications from patients and redistributed that medication to other patients of his practice.  Petitioner did not admit or deny any misconduct according to the terms of the Consent Order.  IG Ex. 7; Jt. Stip. at 1 ¶ 2; P. Ex. 1 at 3.

Effective February 19, 2020, Petitioner’s eligibility to participate in the Illinois Medicaid program was terminated because Petitioner was not properly licensed to practice medicine in Illinois or his medical license was revoked, suspended, or terminated.  IG Ex. 8; Jt. Stip. at 2 ¶ 4.

On February 3, 2022, Petitioner signed a settlement agreement with the Missouri State Board of Registration for the Healing Arts to resolve the issue of whether Petitioner’s Missouri physician license was subject to discipline.  The Missouri disciplinary action was based on the Illinois indefinite suspension of Petitioner’s Illinois physician license.  The Missouri Board placed Petitioner’s Missouri physician’s license on probation for two years permitting him to continue practicing subject to agreed conditions.  IG Ex. 9; Jt. Stip. at 2 ¶ 5.

On May 12, 2024, Petitioner signed a consent agreement with The State Medical Board of Ohio in lieu of further formal administrative proceedings.  Petitioner’s Ohio physician license was suspended for an indefinite period of no fewer than 30 days pursuant to the agreement.  IG Ex. 10; Jt. Stip. at 3 ¶ 13.  The alleged misconduct under consideration by the Ohio Board is not in evidence.

On November 29, 2024, the IG notified Petitioner that he was excluded from participation in all federal health care programs for a minimum of 12 years.  The IG cited section 1128(a)(1) and (3) of the Act as authority for the exclusion.  The IG cited Petitioner’s felony conviction in the district court as the basis for the exclusion.  The IG cited four aggravating factors for extending the minimum period of exclusion from five to 12 years:

The acts for which Petitioner was convicted caused or were intended to cause a loss to a government agency or program or one or more entities of $50,000 or more.  The IG cited that the district court ordered restitution of $195,100 as evidence of the amount of the loss.

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The acts for which Petitioner was convicted occurred over one year or more, specifically from January 2015 to January 2020.

The sentence imposed by the district court included incarceration.

Petitioner was subject to other adverse action by a federal, state or local government based on the same set of circumstances that serves as the basis for the imposition of the exclusion, i.e., Petitioner’s conviction by the district court.  The IG cited actions by agencies in Illinois, Missouri, and Ohio.

IG Ex. 1; Jt. Stip. at 3 ¶ 15-17.

On March 6, 2025, the IG notified Petitioner that the November 29, 2024 notice of exclusion was amended by deleting the fourth mitigating factor cited in that notice.  The IG substituted as an aggravating factor that Petitioner had a prior criminal, civil, or administrative sanction record.  The IG cited the actions of agencies in Illinois, Missouri, and Ohio.  IG Ex. 6.

The IG was required by 42 C.F.R. § 1001.2001(a) to notify Petitioner of the IG’s intent to exclude Petitioner and permit Petitioner the opportunity to submit documentary evidence and written argument related to whether the exclusion was warranted and related issues before the IG could issue the November 29, 2024 notice of exclusion.  Petitioner denied during testimony at hearing that he received the IG’s notice of intent to exclude him.  Tr. 99.  However, the request for hearing indicates that the IG notice of intent to exclude dated April 23, 2024, was received and Petitioner responded on May 23, 2024.  RFH at 1.

The parties stipulated that the IG communicated with the United States Attorney in the Southern District of Illinois by email.  The parties stipulated that the emails show Petitioner cooperated with the United States Attorney.  Jt. Stip. at 3-4 ¶¶ 14, 19-21.  In an email on September 9, 2024, Assistant United States Attorney (AUSA) Gross stated that Petitioner’s “cooperation has not yet resulted in the prosecution of any additional entities or individuals.”  Jt. Stip. at 3 ¶ 14; IG Ex. 11 at 1.  The September 9, 2024 email stated that Petitioner had participated in multiple proffer sessions with the United States Attorneys in the Southern District of Illinois and the Eastern District of Missouri and the Criminal Fraud Section of the Department of Justice.  The email stated that Petitioner provided information regarding his former employer related to allegations of fraud he witnessed as an employee.  The email stated that Petitioner’s “cooperation was extensive and he cooperated even after entry of his plea” and “[h]is cooperation was timely and evaluated as truthful and complete.”  IG Ex. 11 at 1; Jt. Stip. at 4 ¶ 19.  In an April 11, 2025 email to Petitioner’s counsel, AUSA Gross indicated that she understood the need for consideration of Petitioner’s cooperation in the district court case.  She recommended

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that Petitioner move to unseal two sentencing memorandum supplements filed by Petitioner and the government in Petitioner’s case in order to file those documents in this case.  P. Ex. 2.  There is no evidence that Petitioner filed a motion to unseal documents filed in his case.  In a June 16, 2025 email from AUSA Gross to counsel for the IG, AUSA Gross stated that she was “not aware of any changes in [Petitioner’s] cooperation” or “additional cooperation” since her September report to the IG.  IG Ex. 12; Jt. Stip. at 4-5 ¶ 21.

The post-hearing email communication between IG counsel and AUSA Gross clarifies that Petitioner participated in the following interviews or proffer sessions:  March 22, 2023 (United States Attorney, Southern District of Illinois), November 13, 2023 (United States Attorney, Eastern District of Missouri), March 1, 2024 (Department of Justice Civil Fraud Section and the United States Attorney, Middle District of Florida), and March 28, 2024 (Department of Justice Criminal Fraud Section).  AUSA Gross stated that the United States Attorney, Southern District of Illinois filed a motion in Petitioner’s sentencing proceeding recommending a reduced sentence based on Petitioner’s cooperation.  But she stated Petitioner’s cooperation had not resulted in the prosecution of an additional entities or individuals.  AUSA Gross stated Petitioner’s “cooperation was timely and was evaluated as truthful and complete.”  IG Ex. 13.

A representative of the Department of Justice Civil Division Fraud Section informed counsel for the IG by email dated March 4, 2026, that Petitioner was interviewed in connection with an ongoing investigation of another individual.  The email states the interview of Petitioner did not reveal new allegations or leads for investigation.  IG Ex. 14.

A representative of the Department of Justice Criminal Division Fraud Section stated in her email to counsel for the IG on March 5, 2026, that Petitioner’s interview did not lead to any convictions, exclusions, new investigations or reports, or civil penalties.  IG Ex. 16.

Petitioner’s supervised early release was terminated by the district court early.  Jt. Stip. at 5 ¶¶ 22-23; P. Ex. 5.  Petitioner was not in Federal Bureau of Prisons custody as of September 18, 2024.  P. Ex. 3.

Petitioner presented his affidavit as P. Ex. 4.  Petitioner conceded was convicted in the district court of two counts of health care fraud.  He states he cooperated extensively in the federal investigation of himself and others, he was a whistleblower, and due to his cooperation and whistleblowing others were disciplined by the government.  P. Ex. 4.

Petitioner testified at the hearing that he pleaded guilty in the district court to two counts of health care fraud occurring between January 1, 2015 and January 30, 2020.  Tr. 66, 73.

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He testified that he cooperated with the government in an action against ChenMed.  He testified that he worked for ChenMed and filed a whistleblower complaint with the Department of Justice.  He testified to meeting multiple times with Department of Justice or United States Attorney representatives and that there was an ongoing multi-agency task force.  Tr. 47-77.  He testified that his cooperation “led to open investigation” against Optum, Humana, and ChenMed.  He testified that CMS made changes in certain policies and procedures on account of the information he provided.  Tr. 77.  He testified he cooperated in both Missouri and Florida in investigations against multiple Missouri physicians and that the investigations were ongoing.  He testified that he could not discuss active investigations because he was told he could not.  Tr. 77-78.  On cross-examination Petitioner testified that he filed multiple whistleblower complaints, the first in Illinois on March 21, 2023, another in Missouri on July 3, 2025, and another in Missouri in December 2025.  He declined to provide details because they were active investigations.  Tr. 93-95.  He testified that he was told by investigators that he was the first and only person who brought the information to their attention.  But he could not recall the names of people involved in the interview because they did not tell him their names.  He testified some of the interviews were in person and some by video conference.  Tr. 100-02.  On redirect examination, Petitioner identified three physicians against whom he provided information and testified that “[i]t helped with the sentencing of those two physicians” but he also asserted his information led to the final prosecution of two of the physicians.  Tr. 105-06.  Petitioner explained that a proffer session was a meeting with investigators from five or six federal agencies that he and his criminal defense attorney attended and the purpose was to find out what information he could offer in exchange for a sentence reduction.  He said he participated in four interviews in person and three by teleconference.  He testified that he responded to interviewers’ questions under oath.  He testified that he was never provided an investigative report by investigators who questioned him during proffer sessions, and he did not know if his criminal defense attorneys were provided copies of such reports.  Tr. 108-12.  He testified he assisted CMS by identifying billing codes subject to abuse by upcoding and CMS changed related regulations or rules the next year.  He testified that there is an ongoing, nationwide investigation related to two large insurance companies related to upcoding.  He assumed that the information he provided to CMS was being used based on the number of questions and time, the fact the record was sealed, he was told not to speak about it, and there were two teams involved.  Tr. 114-15.  He testified that he relied on his criminal defense attorney to take care of his case.  Tr. 119.  He testified that during sentencing the district court asked him if he cooperated with the government voluntarily and there was a plea agreement.  He could not recall other comments by the district court about his cooperation.  Tr. 123.  Regarding P. Ex. 2, Petitioner testified that documents 18 and 20 from Petitioner’s district court record are supplements to the plea agreement that show he provided the government with extensive information for ongoing investigations that he cannot discuss.  Tr. 126.

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I find credible Petitioner’s assertions that he cooperated with investigators and prosecutors.  But I do not find that I can draw any inference that his cooperation rose to the level of the cooperation necessary to find a mitigating factor authorized by 42 C.F.R. § 1001.102(c).  Petitioner’s testimony that his cooperation led to the opening of investigations against ChenMed, Humana, and Optum; that CMS changed policy and procedures on account of information he provided; that investigators told him he was the first/only source for information; and any other assertions by Petitioner as to the impact of cooperation cannot be accepted as credible as there is inadequate evidence of his basis for knowledge of the impact of his cooperation.  Petitioner could not recall at the hearing who he spoke to during proffer sessions or he asserted he could not provide details due to ongoing investigations.  Petitioner testified he was never provided an investigative report.  Petitioner testified that he relied upon his criminal defense attorney to handle his case.  He did not know if his criminal defense attorney was provided investigative reports.  He asserted that he provided extensive information that was described in the supplements to his plea agreement, but he did not assert that any of the information had the specific results required for a mitigating factor under 42 C.F.R. § 1001.102(c)(3).  Pursuant to 42 C.F.R. § 1005.15(c), the ALJ has discretion to allocate the burden of proof as the ALJ deems appropriate when exclusion is pursuant to 42 C.F.R. § 1001.101.  I advised the parties in the Prehearing Order that Petitioner had the burden of going forward with the evidence and the burden of persuasion on any affirmative defenses or mitigating factors.  Prehearing Order ¶ 4.  Therefore, it was Petitioner’s burden to bring before me evidence to show it was more likely than not, i.e., a preponderance of the evidence, that his cooperation resulted in at least one of the effects required for there to exist a mitigating factor under 42 C.F.R. § 1001.102(c)(3).  Under 42 C.F.R. § 1005.9(a) a party may move for the issuance of a subpoena to compel appearance and testimony of one with relevant information necessary for the party’s presentation of its case.  Petitioner’s testimony indicates that there were federal investigators/prosecutors and his own criminal defense attorneys who may have had relevant information to support his claims about the results of his cooperation.  But Petitioner requested no subpoenas.  Further, the email that the IG presented (IG Exs. 11-16) are acceptable as rebuttal evidence and sufficient to rebut Petitioner’s general assertions that his cooperation had results required for me to find that there was a mitigating factor under 42 C.F.R. § 1001.102(c)(3).  I find that Petitioner’s testimony is insufficiently weighty and credible for me to find facts or infer that Petitioner’s cooperation, more likely than not, had any of the results required for the existence of a mitigating factor recognized by 42 C.F.R. § 1001.102(c)(3).

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Conclusions of Law and Analysis

1.  Petitioner’s request for hearing was timely and I have jurisdiction.

There is no dispute that Petitioner’s request for hearing was timely filed.  Accordingly, I have jurisdiction pursuant to section 1128(f) of the Act and 42 C.F.R. pt. 1005.

2.  Section 1128(a)(1) and (3) of the Act require Petitioner’s exclusion from participation in Medicare, Medicaid, and all other federal health care programs.

The IG cites section 1128(a)(1) and (3) of the Act as the authority requiring Petitioner’s exclusion from Medicare, Medicaid, and any federal health care programs.  IG Ex. 1.  Petitioner concedes that there is a basis for his exclusion pursuant to section 1128(a)(1) and (3) of the Act.  RFH; P. Br. at 2, 9.  The parties stipulated prior to the hearing that the only issue before me is whether the IG failed to consider the mitigating factor under 42 C.F.R. § 1001.102(c)(3).  Joint Stipulation of Issues Presented for Hearing.

Exclusion Pursuant to Section 1128(a)(1)

Congress requires that the Secretary exclude an individual or entity if the individual or entity is:  (1) convicted of a criminal offense (misdemeanor or felony); (2) the criminal offense is related to the delivery of an item or service; and (3) the delivery of the item or service is under Medicare or any state health care program such as Medicaid.  Act § 1128(a)(1).  Petitioner does not dispute that the elements that trigger exclusion under section 1128(a)(1) of the Act are present in this case.

There is no dispute that on April 4, 2024, Petitioner’s guilty pleas to two counts of health care fraud in violation of 18 U.S.C. § 1347 were accepted by the district court; the district court found Petitioner guilty and entered a judgment of conviction.  IG Ex. 5 at 1; Jt. Stip. at 3 ¶ 10.  Therefore, Petitioner was convicted within the meaning of section 1128(i) of the Act.

Petitioner admitted in the stipulation of facts executed in support of his guilty plea that his scheme to defraud Medicare, Medicaid, and private health insurance was in connection with the delivery of and payment for healthcare benefits and services.  IG Ex. 2 at 2 ¶ 6.  The parties stipulated that by pleading guilty Petitioner admitted to engaging in a scheme to defraud Medicare, Medicaid, and private insurance companies by billing for services that were not provided as claimed from January 1, 2015 through January 30, 2020.  Jt. Stip. at 2-3 ¶ 9.  Therefore, Petitioner’s crimes were related to the failure to deliver services for which Petitioner billed Medicare, Medicaid, and a private insurance company.  The district court ordered Petitioner to pay restitution to CMS.  IG Ex. 5 at 2-

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6; Jt. Stip. at 3 ¶¶ 11-12.  The order to pay restitution is further evidence of the relationship of Petitioner’s offenses to the failure to deliver a health care item or service under Medicare.

The Board has long held that the statutory terms describing an offense do not control whether that offense is “related to” the delivery of a health care item or service under Medicare or a state health care program for purposes of exclusion pursuant to section 1128(a)(1) of the Act.  See, e.g., Dewayne Franzen, DAB No. 1165 (1990) (inquiry is whether conviction is related to Medicaid fraud, not whether the petitioner was convicted of Medicaid fraud).  An ALJ must examine whether there is a “common sense connection or nexus between the offense and the delivery of an item or service under the program.”  Scott D. Augustine, DAB No. 2043 at 5-6 (2006) (citations omitted).  To determine whether there is such a nexus or common-sense connection, “evidence as to the nature of an offense may be considered,” such as the “facts upon which the conviction was predicated.”  Robert C. Hartnett, DAB No. 2740 at 7 (2016) (quoting Berton Siegel, D.O., DAB No. 1467 at 6-7 (1994)).  The bar to a petitioner collaterally attacking the conviction underlying an exclusion does not preclude review of the facts and circumstances on which the conviction was based.  An ALJ may consider extrinsic evidence to determine the events which formed the basis for the offense.  Narendra M. Patel, M.D., DAB No. 1736 (2000).  The terms “related to” and “relating to” in section 1128(a) of the Act simply mean that there must be a nexus or common-sense connection.  Friedman v. Sebelius, 686 F.3d 813, 820 (D.C. Cir. 2012) (describing the phrase “relating to” as “deliberately expansive words,” “the ordinary meaning of [which] is a broad one,” and one that is not subject to “crabbed and formalistic interpretation”) (internal quotes omitted); Quayum v. U.S. Dep’t of Health & Human Servs., 34 F.Supp.2d 141, 143 (E.D.N.Y. 1998).  I conclude that the undisputed facts establish the required connection, rational link, or nexus between Petitioner’s criminal offense and the delivery of a health care item or service, under Medicare and Medicaid.  W. Scott Harkonen, MD, DAB No. 2485 (2012), aff’d, Harkonen v. Sebelius, No. C 13-0071 PJH, 2013 WL 5734918 (N.D. Cal. Oct. 22, 2013).

I conclude that all elements triggering mandatory exclusion under section 1128(a)(1) of the Act are satisfied and the IG is required to exclude Petitioner.

Exclusion Pursuant to Section 1128(a)(3)

Although mandatory exclusion is triggered under section 1128(a)(1) of the Act and one basis for mandatory exclusion is all that is required, the IG also cites section 1128(a)(3) of the Act as the basis for mandatory exclusion.  Under section 1128(a)(3) of the Act, Congress has mandated exclusion from any federal health care program if:  (1) an individual or entity is convicted of a criminal offense under federal or state law; (2) the offense of which the individual or entity was convicted was a felony; (3) the criminal

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offense occurred after August 21, 1996 (the date of enactment of the Health Insurance Portability and Accountability Act of 1996); (4) the criminal offense was committed in connection with the delivery of a health care item or service or with respect to any act or omission in a health care program other than Medicare or Medicaid, that is operated or financed by the federal, state, or a local government; and (5) the criminal offense was related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.  I conclude that the elements that trigger mandatory exclusion under section 1128(a)(3) of the Act are also satisfied in this case.

Petitioner was convicted of two felony counts of health care fraud.  IG Ex. 5 at 1; Jt. Stip. at 3 ¶ 10.  The parties stipulated Petitioner’s offenses occurred from January 1, 2015 through January 30, 2020, which is after August 21, 1996.  Jt. Stip. at 2-3 ¶ 9.  Petitioner’s offenses involved billing Medicare, Medicaid, and a private health insurance company for medical services Petitioner did not deliver and as already discussed, the offenses are connected to the delivery of a health care service.  The Board’s approach to analysis of the connection, rational linkage, or nexus between the criminal conduct of which one is convicted and the relationship to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct is fundamentally no different than the nexus analysis discussed for Petitioner’s exclusion pursuant section 1128(a)(1) of the Act.  I conclude that the undisputed facts establish the required connection, rational link, or nexus in this case and trigger mandatory exclusion under section 1128(a)(3) of the Act.

There is a basis for Petitioner’s exclusion pursuant to section 1128(a)(1) and (3) of the Act and Congress mandates his exclusion from participation in any federal health care program.  I have no discretion not to exclude Petitioner in this case as I am bound to follow the federal statutes and regulations.  42 C.F.R. § 1005.4(c)(1).

3.  Section 1128(c)(3)(B) of the Act requires a minimum exclusion of five years for any exclusion pursuant to section 1128(a) of the Act.

I have concluded that a basis exists to exclude Petitioner pursuant to section 1128(a)(1) and (3) of the Act.  Therefore, the IG must exclude Petitioner for the minimum period of five years required by Congress in section 1128(c)(3)(B) of the Act.  There is no discretion to impose a lesser period of exclusion.  The remaining issue is whether it is unreasonable to extend Petitioner’s exclusion by an additional seven years for a total exclusion of 12 years.

4.  Four aggravating factors established by 42 C.F.R. § 1001.102(b) exist in this case that were considered by the IG as a basis to extend the period of exclusion beyond five years.

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The IG cited four aggravating factors and no mitigating factor in extending Petitioner’s period of exclusion from the mandatory minimum five-year exclusion to 12 years.  IG Exs. 1, 6; Jt. Stip. at 3 ¶¶ 15-17.  Petitioner does not argue that the IG considered an aggravating factor authorized by 42 C.F.R. § 1001.102(b) that does not exist.  Petitioner’s argument is that the IG failed to consider the mitigating factor authorized by 42 C.F.R. § 1001.102(c)(3).  P. Br. at 13-21.  Undisputed aggravating factors are discussed briefly.

a.  Petitioner’s offenses resulted in a loss of $50,000 or more to one or more government agencies or programs.  42 C.F.R. § 1001.102(b)(1).

The IG may consider as an aggravating factor that the acts of which one was convicted caused, or were intended to cause, a financial loss of $50,000 or more to a government agency or program, or to one or more other entities.  42 C.F.R. § 1001.102(b)(1).

The district court ordered that Petitioner pay $138,932.67 as restitution to CMS and $56,237.47 to Blue Cross Blue Shield of Illinois – total restitution of $195,170.14.  IG Ex. 5 at 6; Jt. Stip. at 3 ¶ 12.  The Board has previously accepted that an amount ordered as restitution constitutes proof of the amount of financial loss.  Jeremy Robinson, DAB No. 1905 at 11 (2004); Craig Richard Wilder, DAB No. 2416 at 9 (2011); Juan de Leon, Jr., DAB No. 2533 at 5 (2013); Laura Leyva, DAB No. 2704 at 9 (2016).  Therefore, the court order to pay restitution is good and undisputed evidence that Petitioner’s offenses caused the loss of more than $50,000 by one or more government agencies or programs.  Petitioner also admitted in his plea agreement that the loss was more than $150,000.  IG Ex. 4 at 4.

I conclude that the aggravating factor authorized by 42 C.F.R. § 1001.102(b)(1) exists in this case.

b.  The acts that resulted in Petitioner’s conviction were committed over a period of one year or more.  42 C.F.R. § 1001.102(b)(2).

The IG may consider as an aggravating factor that the acts for which one is convicted occurred for a year or more.  42 C.F.R. § 1001.102(b)(2).  In the present case, Petitioner admitted as part of his plea agreement that his offenses began on or about January 1, 2015, and continued until at least January 30, 2020.  IG Ex. 2 at 2; Jt. Stip. at 2 ¶ 9.

The Board has previously discussed the purpose of the aggravating factor under 42 C.F.R. § 1001.102(b)(2), saying that it reflects “the Secretary’s recognition that an individual whose lapse in integrity occurs over a period of one or more years poses a far greater threat to federal health care programs and beneficiaries than an individual ‘whose

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lapse in integrity is short-lived.’”  Hussein Awada, M.D., DAB No. 2788 at 8 (2017) (quoting Donald A. Burstein, Ph.D., DAB No. 1865 at 8 (2003)).  Petitioner’s acts were not short-lived and were committed over a period of more than a year.

The undisputed facts Petitioner admitted by his guilty plea establish the existence of this aggravating factor, which was properly considered by the IG.

c.  Petitioner was sentenced to be incarcerated.  42 C.F.R. § 1001.102(b)(5).

An aggravating factor that may be considered under 42 C.F.R. § 1001.102(b)(5) is that the sentence imposed by the district court included incarceration.

The district court sentenced Petitioner to five months of incarceration for each of the two counts of fraud to run concurrently.  IG Ex. 5 at 2; Jt. Stip. at 3 ¶ 11.

A period of incarceration of any duration may be considered by the IG as an aggravating factor justifying extending the period of exclusion beyond the five-year minimum.  See Jason Hollady, M.D., DAB No. 1855 at 9 (2002) (holding that a prison sentence of as little as nine months is “relatively substantial” for exclusion purposes.).

I conclude that this aggravating factor exists in this case.

d.  Petitioner had a prior administrative sanction record.  42 C.F.R. § 1001.102(b)(6).

The IG originally notified Petitioner on November 29, 2024, that the fourth aggravating factor it considered was authorized by 42 C.F.R. § 1001.102(b)(9), i.e., that Petitioner was subject to other adverse action by a federal, state, or local government agency or board based on the same set of circumstances that served as the basis for the exclusion, i.e., the conviction.  IG Ex. 1.  However, on March 6, 2025, the IG notified Petitioner that it considered the aggravating factor authorized by 42 C.F.R. § 1001.102(b)(6), rather than the factor authorized by 42 C.F.R. § 1001.102(b)(9).  Under 42 C.F.R. § 1001.102(b)(6), the IG may consider as an aggravating factor that the convicted individual or entity had a prior criminal, civil, or administrative sanction record.  The IG cited the sanction actions of state agencies in Illinois, Missouri, and Ohio.  IG Ex. 6.

The evidence shows and it is undisputed by Petitioner that he had a history of sanctions in Illinois, specifically the indefinite suspension of his medical license in 2020, and termination of his eligibility to participate in Illinois Medicaid in 2020.  IG Exs. 7, 8; Jt. Stip. at 1-2 ¶¶ 2, 5; P. Ex. 1 at 3.  In Missouri, Petitioner’s medical license was placed on probation for two years in 2022.  IG Ex. 9; Jt. Stip. at 2 ¶ 5.

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I conclude that the aggravating factor authorized by 42 C.F.R. § 1001.102(b)(6) exists in this case.

5.  No mitigating factor established by 42 C.F.R. § 1001.102(c) exists in this case that the IG failed to consider in determining the period of exclusion.

Petitioner’s argument in this case is that the IG failed to consider a mitigating factor under 42 C.F.R. § 1001.102(c)(3).  Petitioner argues that because the IG failed to consider a mitigating factor, the 12-year exclusion is unreasonable and I should reassess or redetermine the reasonable period of exclusion, which Petitioner advocates should be no more than five years.  P. Br. 8-14, P. Reply 1-8.

If any of the aggravating factors authorized by 42 C.F.R. § 1001.102(b) are cited by the IG to justify an exclusion of longer than five years, as in this case, then mitigating factors may be considered as a basis for reducing the period of exclusion to no fewer than five years.  42 C.F.R. § 1001.102(c).  The only authorized mitigating factors that I may consider are listed in 42 C.F.R. § 1001.102(c).

The mitigating factor related to cooperation with federal or state officials is established by 42 C.F.R. § 1001.102(c)(3), which provides:

(3) The individual’s or entity’s cooperation with Federal or State officials resulted in—

(i) Others being convicted or excluded from Medicare, Medicaid and all other Federal health care programs,

(ii) Additional cases being investigated or reports being issued by the appropriate law enforcement agency identifying program vulnerabilities or weaknesses, or

(iii) The imposition against anyone of a civil money penalty or assessment under [42 C.F.R. pt. 1003].

42 C.F.R. § 1001.102(c)(3).

Petitioner’s argument is that his cooperation meets the requirement of 42 C.F.R. § 1001.102(c)(3)(i) and (ii) because it is more likely than not that his cooperation resulted in others being convicted or additional cases being investigated and that his cooperation with CMS resulted in changed regulations, policies, or procedures to address program

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vulnerabilities or weaknesses.  P. Br. 8-14, P. Reply 1-8.   Petitioner does not assert that a civil money penalty was imposed against anyone based on his cooperation and the mitigating factor under 42 C.F.R. § 1001.102(c)(3)(iii) is not at issue.

The evidence clearly shows that Petitioner cooperated with federal prosecutors and law enforcement as well as CMS.  But the regulation is very specific, providing that a mitigating factor exists only if cooperation with federal or state officials “resulted in” one of the results specified by the regulation.  42 C.F.R. § 1001.102(c)(3).  The results specified are:  (1) others being convicted or excluded from Medicare; (2) additional cases being investigated or reports issued identifying program vulnerabilities or weaknesses; or (3) the imposition of a civil money penalty pursuant to 42 C.F.R. pt. 1003.  In addressing the second result under 42 C.F.R. § 1001.102(c)(3)(ii), during rulemaking the IG responded to a comment that the IG expected that the mitigating factor would be found only where law enforcement officials open a new case investigation or issue the report specified.  63 Fed. Reg. 46,676, 46,681 (Sep. 2, 1998).  The IG response indicates that the IG intended to find a mitigating factor under 42 C.F.R. § 1001.102(c)(3) when one of the specified results occurred due to the cooperation, not when the cooperation merely aided the investigation, prosecution, conviction, or the imposition of a civil money penalty.  In Rehabilitation Ctr. at Hollywood Hills, LLC, the Board commented that “[t]he I.G. has indicated that mitigation based on cooperation contemplates an actual, positive outcome; the act of ‘cooperating’ is not itself sufficient.”  DAB No. 3001 at 14 n.8 (2020).  The Board similarly applied 42 C.F.R. § 1001.102(c)(3)(ii) in Stacy R. Gale, DAB No. 1941 at 7 (2004), concluding that 42 C.F.R. § 1001.102(c)(3) required the result specified by the regulation not mere cooperation with law enforcement.

I apply the interpretation of 42 C.F.R. § 1001.102(c)(3) that one of the results listed in that regulation must have occurred for there to be a mitigating factor for the IG to consider.  The evidence shows that Petitioner did cooperate with law enforcement and, it is likely that his cooperation aided law enforcement and prosecutors.  But aiding law enforcement and prosecutors is not sufficient to be the mitigating factor described by 42 C.F.R. § 1001.102(c)(3)(i) and (ii).  The evidence, including Petitioner’s testimony, does not show it more likely than not that Petitioner’s cooperation resulted in:  (1) others being convicted or excluded from Medicare, Medicaid, and all other federal health programs; (2) additional cases being investigated; or (3) reports being issued by appropriate law enforcement agencies that identify program vulnerabilities or weaknesses.  The evidence discussed under the Findings of Fact section does not show that Petitioner personally had a basis to know the results of his cooperation.  There is also no testimony or other evidence from prosecutors, investigators, Petitioner’s criminal defense counsel, or the district court that support an inference that it is more likely than not that Petitioner’s cooperation caused one of the results required by 42 C.F.R. § 1001.102(c)(3)(i) and (ii).  I conclude that Petitioner has failed to meet his burden to show that there was a mitigating factor authorized by 42 C.F.R. § 1001.102(c)(3) that the IG failed to consider.

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6.  Exclusion for 12 years is not unreasonable in this case.

The Secretary requires by regulation that the ALJ determine whether the length of exclusion imposed is “unreasonable,” if a period greater than the minimum period is imposed by the IG.  42 C.F.R. § 1001.2007(a)(1)-(2).  The Board has interpreted the regulations as significantly limiting the scope of ALJ review.  The regulation states that the ALJ must determine whether the length of exclusion imposed is “unreasonable,” without definition of what is unreasonable or direction for how to determine whether a period of exclusion is unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii).  The drafters of the regulation explained that the intent of the regulation is to ensure that if the IG’s proposed period of exclusion is “within a reasonable range based on demonstrated criteria, the ALJ has no authority” to change the period of exclusion.  57 Fed. Reg. 3298, 3321 (Jan. 29, 1992).  The drafters provided no explanation of what are “demonstrated criteria.”

The Board has determined that the role of the ALJ in exclusion cases is to conduct a de novo review of the facts related to the basis for the exclusion and the existence of aggravating and mitigating factors identified at 42 C.F.R. § 1001.102(b) and (c) and determine whether the period of exclusion imposed by the IG falls within a “reasonable range.”  Edwin L. Fuentes, DAB No. 2988 at 7-10 (2020); Juan de Leon, Jr., DAB No. 2533 at 4-5; Wilder, DAB No. 2416 at 8; Joann Fletcher Cash, DAB No. 1725 at 17 n.6 (2000).  The Board explained that, in determining whether a period of exclusion is “unreasonable,” the ALJ is to consider whether such period falls “within a reasonable range.”  Cash, DAB No. 1725 at 17 n.6.  The Board cautions that whether the ALJ thinks the period of exclusion is too long or too short is not the issue.  The ALJ may not substitute his or her judgment for that of the IG and may only change the period of exclusion in limited circumstances.

In John (Juan) Urquijo, DAB No. 1735 (2000), the Board concluded that if the IG considers an aggravating factor to extend the period of exclusion and that factor is not later shown to exist on appeal, or if the IG fails to consider a mitigating factor that is shown to exist, then the ALJ may decide the appropriate extension of the period of exclusion beyond the minimum.

In Gary Alan Katz, R.Ph., DAB No. 1842 (2002), the Board suggested that when it is found that an aggravating factor considered by the IG is not proved before the ALJ, then some downward adjustment of the period of exclusion should be expected, absent some circumstances that indicate no such adjustment is appropriate.

In this case, the evidence does not show it more likely than not that the IG considered an aggravating factor that did not exist or failed to consider a mitigating factor that did exist.

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Therefore, I have no discretion to reassess the period of exclusion under current Board decisions.

Based on my de novo review, I conclude that a basis for exclusion exists and that the undisputed evidence establishes four aggravating factors and no mitigating factor.  The IG, in selecting a 12-year exclusion, did not consider aggravating factors shown not to exist or fail to consider a mitigating factor shown to exist.  IG Exs. 1, 6.  I conclude that a period of exclusion of 12 years is within a reasonable range and not unreasonable considering the existence of four aggravating factors and no mitigating factor.  No basis exists for me to reassess the period of exclusion.

Exclusion is effective 20 days from the date of the IG’s notice of exclusion to Petitioner.  42 C.F.R. § 1001.2002(b).

III.  Conclusion

For the foregoing reasons, Petitioner is excluded from participation in Medicare, Medicaid, and all federal health care programs for 12 years effective December 19, 2024.