Mansur Hsin-Chia Lee, DAB CR6930 (2026)

DECISION

Petitioner, Mansur Hsin-Chia Lee, M.D., is a California physician, who participated in the Medicare program as a supplier of services.  Finding that he 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 his Medicare enrollment, imposed a ten-year re-enrollment bar, and added his 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 section 1866(j)(5)(B) of the Social Security Act (Act) and 42 C.F.R. § 424.535(a)(19) because, based on his affiliation with the provider, Passion and Love Hospice, Inc., his enrollment in the Medicare program poses an undue risk of fraud, waste, and abuse.  For the same reason, CMS may add Petitioner’s name to the Medicare preclusion list.

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

Page 2

Background

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.  Salman M. Akbar, DAB No. 3227 at 9 (2025); 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. 2779 at 11(2017), and cases cited therein.

Page 3

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 a legally-sound revocation is appropriate.  Norman Johnson 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 May 15, 2025, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that his Medicare privileges were revoked, effective June 14, 2025.  The letter explained that the contractor revoked Petitioner’s Medicare privileges because he had an affiliation with Passion and Love Hospice, Inc., an entity previously enrolled in the Medicare program.  Passion and Love’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 – as  Passion and Love’s medical director – 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. 4 at 1; see 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).  Id.

The letter also advised Petitioner that the contractor added him to CMS’s preclusion list, as authorized by 42 C.F.R. §§ 422.2, 422.222 (Part C), 423.100, and 423.120(c)(6) (Part D).  It explained that, if Petitioner requested reconsideration, this action would become effective on the date the reconsidered determination was issued.  Id. at 1-2.

The untimely request for reconsideration.  The notice letter advised Petitioner of his right to request reconsideration, emphasizing that the reconsideration request must be received, in writing, within 65 days of the date of the notice letter (May 15, 2025).  CMS Ex. 1 at 2 (emphasis added).

Petitioner did not request reconsideration within 65 days.  In a letter dated September 4, 2025, Petitioner, through counsel, requested reconsideration, asserting that he did not receive the May 15 notice letter until August 6, 2025.  CMS Ex. 5.  In a response dated September 22, 2025, the Medicare contractor noted that the notice letter was delivered to Petitioner’s reported enrollment correspondence address on May 21, 2025.  The contractor found no good cause for Petitioner’s having missed the filing deadline.  CMS Ex. 18 at 1; see CMS Ex. 8 at 2 (listing Petitioner’s correspondence address).2

Page 4

Nevertheless, on September 26, 2025, Petitioner filed a second request for reconsideration.  CMS Ex. 6.

The federal court complaint.  On September 29, 2025, Petitioner filed a complaint in Federal District Court for the Central District of California, asking the Court to prohibit CMS from:  1) revoking his enrollment and billing privileges; 2) imposing a ten-year re-enrollment bar; and 3) placing him on the Preclusion List.  The Court dismissed the matter, finding that section 405(h) of the Social Security Act mandates that plaintiffs “exhaust the appropriate administrative channels before seeking judicial review.”  Lee v. Kennedy, Case No. 8:26-cv-00444-DOC-KES – Order Dismissing Case for Lack of Administrative Exhaustion (C.D. Calif. March 24 2026), quoting Neurostimulation, Inc. v. Azar, 977 F.3d 969, 975 (9th Cir. 2020).

During the course of the court litigation, CMS agreed that, notwithstanding the late filing, it would not reject Petitioner’s September 26 request for reconsideration but would review it.  CMS Ex. 11 at 5.

The reconsidered determination.  In a reconsidered determination, dated February 23, 2026, a CMS hearing officer upheld the revocation under sections 424.519 and 424.535(a)(19).  Citing section 424.519, she found that Petitioner’s affiliation with Passion and Love Hospice posed an undue risk of fraud, waste, or abuse to the Medicare program.  CMS Ex. 12 at 13.

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

Exhibits and witnesses.  CMS submitted its motion and brief (CMS Br.) with 18 exhibits (CMS Exs. 1-18).  CMS also filed a Reply brief (CMS Reply).  In the absence of any objections, I admit into evidence CMS Exs. 1-18.

CMS listed no witnesses.  E-file # 11a.

Petitioner submitted his own brief and opposition to summary judgment (P. Br.) with seven exhibits (P. Exs. 1-7).

Page 5

Petitioner listed three witnesses:  Anaga Nmagu, the CMS hearing officer; Candace Courtright, the contractor enrollment representative who issued the initial determination; and himself.  P. Witness list (e-file # 12k).  Petitioner asks that I issue subpoenas to compel the appearances of the CMS hearing officer and the contractor’s employee.  P. Requests for Subpoenas (e-file # 14, 15).

CMS objections to witness testimony.  CMS objects to Petitioner’s calling the CMS hearing officer and the contractor’s employee as witnesses. and to my admitting into evidence Hearing Officer Nmagu’s written declaration, P. Ex. 1.

• Anaga Nmagu is the Deputy Director in CMS’s Division of Provider Enrollment Appeals, Provider Enrollment & Oversight Group, Center for Program Integrity.  P. Ex. 1.  She was the hearing officer who issued the reconsidered determination in this matter.  CMS Ex. 12 at 15.  As part of the federal court case, she submitted a written declaration describing the administrative review process for suppliers whose Medicare enrollment has been revoked, which Petitioner submits as P. Ex. 1.  According to Petitioner, Hearing Officer Nmagu “would testify as to her involvement in the Initial Determination of May 15, 2025, and events occurring thereafter, including, but not limited to, her role as a witness in Dr. Lee’s federal court litigation.”  Petitioner’s Witness List at 1.
• Candace Courtwright is a Provider Enrollment Representative for the contractor, Noridian Healthcare Solutions.  She issued the initial determination, revoking Petitioner’s Medicare billing privileges.  CMS Ex. 4 at 4.  Petitioner asserts that she “would testify as to the role, if any, CMS had prior, during[,] and after the initial determination.”  Petitioner’s Witness List at 2.

CMS argues that the testimony and declaration are irrelevant because administrative law judges (ALJs) review de novo CMS’s determinations.

Petitioner responds that the “ALJ hearing process is hardly de novo,” because an ALJ “is bound to apply all applicable regulations even if they are not authorized by Congress and thus invalid and even if they are applied in a manner that deprives due process of law.”  Petitioner also complains that the ALJ defers to CMS’s “allegedly discretionary decision making.”  P. Response to CMS’s Objections to Proposed Witnesses (e-file # 17).

Petitioner misunderstands the administrative process and the ALJ’s role in that process.  As I explained in an earlier ruling:

Petitioner’s complaint that the reconsidered determination was “not performed by a disinterested CMS reviewer” is irrelevant.  Hearings held pursuant to section 205(b) of the Act have long been considered de novo.  Heckler v. Campbell, 461 U.S. 458, 463 n.6 (1983); see also Matthews v.

Page 6

Eldridge, 424 U.S. 319, 339 n.21 (1976).  The ALJ reviews “the legality of the challenged determination based on the evidence presented in [the ALJ] proceeding.”  Fady Fayad, M.D., DAB No. 2266 at 10-11, aff’d, Fady Fayad v. Sebellius, 803 F. Supp. 699 (E.D. Mich. 2011).  Thus, if bias or other irregularity tainted the prior determination, the ALJ review is designed to correct the resulting errors, if any.

ALJ Ruling 2026-18 at 6 n.2; Lake Worth Nursing Home, DAB No. 3194 at 18 (2025) (explaining that the “ALJ’s proper role is not to decide how CMS exercised its discretion . . . but rather ‘to take evidence on any contested issue relating to the [relevant] factors.’”); Edwin L. Fuentes, DAB No. 2988 at 9 (2020).

Further, Petitioner’s attacks on the contractor’s employee, the CMS hearing officer, and the administrative review process itself are misplaced.  In Schweiker v. McClure, 456 U.S. 188 (1982), the plaintiffs – claimants for Medicare Part B benefits – argued that the review procedures for Medicare Part B claims denied them due process.  At that time, the review process for Part B claims was limited (certainly more limited than the process afforded Petitioner in this case):  if the Medicare contractor (then referred to as a “carrier”) refused to pay a claim, the claimant was entitled to a “review determination” made by a contractor employee other than the initial decisionmaker.  The reviewer reviewed the written record, de novo, and affirmed or adjusted the original determination.  If the amount in dispute was $100 or more, a dissatisfied claimant had the right to an oral hearing.  The contractor selected a hearing officer – who had not been involved prior to the hearing stage – to preside at the hearing.  Neither the statute nor the regulations allowed for further review.  Id. at 191.  The claimant was not entitled to an ALJ hearing.3

The Court noted that contractor hearing officers “serve in a quasi-judicial capacity, similar in many respects to that of administrative law judges.”  Due process demands impartiality from those who function in judicial or quasi-judicial capacities.  “But the burden of establishing a disqualifying interest rests on the party making the assertion.”  Id. at 196.  Generalized assumptions of possible interest are insufficient to meet this burden.  “[I]n the absence of proof of financial interest on the part of the carriers, there is no basis for assuming a derivative bias among their hearing officers.”  Id. at 197.

Nothing in this record suggests that either the contractor’s employee or the CMS hearing officer had any disqualifying interest.  Nor may Petitioner compel the witnesses’ testimony in the hope of discovering a disqualifying interest.  A hearing officer’s deliberations, like those of other administrative decision-makers and, for that matter, judges, have long been protected.  U.S. v. Morgan, 313 U.S. 409, 422 (1941) (holding that “it was not the function of the court to probe the mental processes of the Secretary

Page 7

[of Agriculture] . . . .  Just as a judge cannot be subjected to such scrutiny . . . so the integrity of the administrative process must equally be respected.”).  A hearing officer cannot be compelled to testify.

I therefore sustain CMS’s objections to the testimonies of Hearing Officer Nmagu and Contractor Representative Courtwright, and I deny Petitioner’s requests to subpoena these individuals.  See 42 C.F.R. 498.58 (requiring that subpoenas “be reasonably necessary for the full presentation of a case.”).

For the same reasons, I decline to admit P. Ex. 1.

CMS’s objections to remaining exhibits.  CMS also objects to my admitting P. Exs. 2-7:

• P. Ex. 2 – Transcript of the District Court arguments of counsel in Lee v. Kennedy.
  
  I am authorized to receive into evidence testimony and documents that are “relevant and material.”  42 C.F.R. § 498.60(b)(1).  CMS argues that the transcript – which consists of the arguments of counsel to the District Court – are irrelevant to the issues before me.  I agree.  These legal arguments of counsel are neither relevant nor material.  Petitioner claims, without further explanation, that the transcript is “relevant to due process issues that should be reserved for judicial review.”  This is puzzling; the arguments centered around the statutory requirement that Petitioner exhaust his administrative remedies, which, presumably, would not be an issue after those remedies have been exhausted.  In any event, even if due process requires the Court’s revisiting those arguments, they are based on the Constitution, the Medicare statute, and the regulations and need not be repeated during the administrative review process for Petitioner to raise them on appeal.
  
  I therefore decline to admit P. Ex. 2.
• P. Ex. 3 – Email from Petitioner to the California Department of Public Health, advising that, effective March 31, 2025, he resigned from his position as medical director at Passion and Love Hospice.
  
  CMS objects to my admitting P. Ex. 3, citing 42 C.F.R. § 498.56(e).  Section 498.56(e)(1) directs the ALJ to examine any new documentary evidence to determine whether the supplier has good cause for submitting the evidence, for the first time, at the ALJ level.  If the ALJ finds no good cause, she must exclude the evidence from the proceeding and may not consider it in reaching a decision.  42 C.F.R. § 498.56(e)(2).

Page 8

The revocation notice was unequivocal:  “[I]f you have additional information that you would like a Hearing Officer to consider during the reconsideration or, if necessary, an [ALJ] to consider during a hearing, you must submit that information during the administrative appeals process unless an ALJ allows additional information to be submitted.”  CMS Ex. 3 at 3.

Petitioner concedes that he did not submit the document at the reconsideration level but argues that the document “did not become necessary” until the hearing officer questioned his credibility on the issue of when he resigned as the hospice’s medical director.  First, inasmuch as this case is based on Petitioner’s relationship with the hospice, I find Petitioner’s claim not credible.

Second, even if Petitioner’s purported ignorance could be considered good cause for his failing to submit the document when required, I find his after-the-fact resignation irrelevant.  His participation was revoked because of his affiliation with Passion and Love Hospice, based on unacceptable billing practices that occurred from March 1, 2024, through April 30, 2024, and from October 27, 2024, through December 31, 2024, well before the March 31, 2025 date he identifies as the date he resigned.

For these reasons, I decline to admit P. Ex. 3.

• P. Ex. 4 – Professional Services agreement between Petitioner and Passion and Love Hospice, dated January 8, 2024.
  
  CMS objects to my admitting P. Ex. 4 because Petitioner did not submit the document at the reconsideration level and because the document is unsigned.  Petitioner responds that the document is necessary to refute the hearing officer’s characterization of him as a hospice employee.  With respect to the lack of signature, he asserts that he would, at an in-person hearing, verify that P. Ex. 4 “was the controlling contract during the period at issue.” 4

Again, as Petitioner was well aware at the time of the reconsideration, this case turns on his relationship with the hospice.  His professed surprise that the hearing officer made a finding with regard to that relationship is not credible.

Page 9

Because Petitioner did not submit the proposed exhibit at the reconsideration level and has not shown good cause for failing to do so, I must exclude it from the proceeding and may not consider it in reaching a decision.  42 C.F.R. § 498.56(e)(2).5

• P. Ex. 5 – National Practitioner Data Bank Report, indicating that Petitioner’s Medicare Program participation terminated on April 1, 2026;
• P. Ex. 6 – Letter from San Antonio Regional Hospital to Petitioner, suspending Petitioner’s staff privileges, effective April 15, 2026, based on his Medicare termination;
• P. Ex. 7 – Notice, dated April 23, 2026, from the California Department of Health Care Services to Petitioner advising Petitioner that he was suspended from the Medi-Cal program; and
• P. Ex. 8 – Petitioner does not identify P. Ex. 8 in its exhibit list but it appears to be a database result showing that Petitioner was, in fact, suspended from the Medi-Cal program.

CMS objects to P. Exs. 5-8, citing 42 C.F.R. § 498.60(b)(1) and arguing that the documents are irrelevant.  Petitioner responds, without further explanation, that they are “relevant to the due process issue [that] will be decided by a court on judicial review even if the due process issues are not addressed by the ALJ.”

I agree with CMS.  The documents are irrelevant.  They may establish the predictable results of a supplier’s revocation, but they are irrelevant to the issues before me:  whether CMS had the authority to revoke Petitioner’s Medicare enrollment and

Page 10

include him on the Preclusion List.6  I therefore decline to admit P. Exs. 5-8.  42 C.F.R. § 498.60(b)(1).

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); 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.  I have denied Petitioner’s requests to call the CMS hearing officer and the contractor’s provider enrollment representative.  CMS has not asked to cross-examine Petitioner’s remaining witness, Petitioner himself.  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.7

Issues

The sole questions before me are:

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).

Page 11

Discussion

1. CMS properly revoked Petitioner Lee’s Medicare enrollment under 42 C.F.R. § 424.535(a)(19) because his affiliation with the provider, Passion and Love Hospice, Inc., poses an undue risk of fraud, waste or abuse.8

Revocation of enrollment:  disclosure requirements.  Petitioner complains that I am required to follow CMS regulations (which I am) “whether or not the regulations and the resulting imposition of sanctions are authorized by the controlling Medicare statute . . . .”  P. Br. at 2.  In fact, Congress has repeatedly expressed – through legislation – its legitimate concerns about fraud, waste, and abuse in the Medicare program.  To protect program integrity, it has directed the Secretary of Health and Human Services (and, thus, CMS) to hold accountable those individuals responsible for ensuring that the Medicare rules are followed.  This includes a provider’s medical director.  With this goal in mind, Congress expanded CMS’s authority to revoke the enrollment of those affiliated with entities that have had their billing privileges denied or revoked.

Section 1866(j)(5) of the Act (42 U.S.C. § 1395cc(j)(5)) 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 he 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).

Page 12

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 he 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:

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)) (Emphasis added).

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,

Page 13

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 (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:

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) If applicable, the reason for the termination of the affiliation.
5) Regarding the disclosable event (section 424.519(b)), CMS considers:  i) the type of disclosable event; ii) when the disclosable event occurred or was imposed; iii) whether the affiliation existed when the disclosable event occurred or was imposed . . . v) if a denial, revocation, termination, exclusion, or payment suspension is involved, the reason for the disclosable event.
6) Any other evidence that CMS deems relevant to its determination.

42 C.F.R. § 424.419(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).

Revocation of Passion and Love Hospice’s Medicare billing privileges.  Passion and Love Hospice, Inc., was a California hospice that participated in the Medicare program as a provider of services.

In an effort to combat fraud, waste, and abuse, CMS subjects new or newly-acquired hospice providers to a period of “enhanced oversight,” such as prepayment review.  Act § 1866(j)(3) (42 U.S.C. § 1395cc(j)(3)); 42 C.F.R. § 424.527.  Passion and Love apparently changed ownership on January 1, 2024, and was subject to a “Provisional Period of Enhanced Oversight” review of the hospice services for which it billed the Medicare Program.  CMS Ex. 7 at 4-7.

Page 14

Pursuant to this enhanced oversight, the contractor reviewed ten claims that the hospice submitted from March 1, 2024, through April 30, 2024.  Ultimately, four of those claims were denied because they did not meet Medicare program requirements, either:

• the documentation did not support a terminal prognosis of six months or less; or
• the documentation did not establish that the required face-to-face encounter had occurred;

CMS Ex. 1 at 1-2; CMS Ex. 12 at 8.

The contractor advised the hospice of its findings and offered the hospice one-on-one training so that it would learn how to correct its billing practices.  CMS Ex. 1 at 2.

From October 27, 2024, through December 31, 2024, the contractor reviewed an additional ten claims.  Ultimately, seven of the ten were denied for the following reasons:

• the documentation did not support a terminal prognosis of six months or less;
• the records no longer supported a trajectory of decline;
• the documentation did not establish that the required face-to-face encounter had occurred; or
• the claim was untimely (one case).

CMS Ex. 2 at 2; CMS Ex. 12 at 8.

In a letter dated March 25, 2025, the contractor advised the hospice that, pursuant to 42 C.F.R. § 424.535(a)(8)(ii), its Medicare billing privileges were revoked and its provider agreement terminated, effective April 24, 2025, because the hospice had “a pattern or practice of submitting claims that fail to meet Medicare requirements.”  CMS Ex. 3 at 1-2.  CMS imposed a ten-year reenrollment bar and placed the hospice on the preclusion list.  CMS Ex. 3 at 2.

The hospice sought reconsideration.  In a reconsidered determination, dated February 23, 2026, the Medicare hearing officer upheld the revocation.  CMS Ex. 17.  The hospice did not seek further review, so the reconsidered determination is final and binding.  42 C.F.R. § 498.25(b).

The revocation of Passion and Love’s Medicare billing privileges was a disclosable event that prompted CMS to review Petitioner Lee’s affiliation with the hospice and to

Page 15

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 Passion and Love Hospice, Inc.  In its Medicare enrollment documents, the hospice listed Petitioner Lee as a managing employee and medical director.  CMS Ex. 7 at 6.  Petitioner concedes that he was the hospice’s medical director on January 1, 2024, (when it changed ownership), through March 31, 2025.9  P. Br. at 5, 8.

Citing 42 C.F.R. § 424.535(e), Petitioner argues that, because he terminated his relationship with the hospice before its billing privileges were revoked, he is not subject to exclusion.  Petitioner misreads the regulation.  The regulation provides:

If the revocation was due to adverse activity (sanction, exclusion, or felony) against a provider’s or supplier’s owner, managing employee, managing organization, officer, director, authorized or delegated official, medical director, supervising physician, or other health care or administrative or management services personnel furnishing services payable by a Federal health care program, the revocation may be reversed if the provider or supplier terminates and submits proof that it has terminated its business relationship with that party within 15 days of the revocation notice.

42 C.F.R. § 424.535(e) (Emphasis added).  Thus, if a provider or supplier faces revocation because one of its employees (or other listed individuals) has been sanctioned (see, e.g., 42 C.F.R. § 424.535(a)(2)), it may avoid revocation by terminating its business relationship with the sanctioned individual.  The inverse is not true; the regulation does not allow an individual (such as a medical director) to avoid sanction by separating himself from his revoked employer.  See Diagnostic Imaging Network Medical Group, DAB No. 3100 at 12 (2023) (explaining that section 424.535(e) applies when the previously sanctioned individual is still employed by, or in a business relationship with the provider/suppler at the time CMS issues a revocation notice, and the provider/supplier timely terminates that relationship).  The Departmental Appeals Board also noted that the decision to reverse a revocation pursuant to section 424.535(e) is wholly within CMS’s discretion; it is not mandatory.

Petitioner’s affiliation with Passion and Love.  Although he concedes, as he must, that he was the hospice’s medical director, Petitioner argues that he did not have an

Page 16

“affiliation” with Passion and Love Hospice because he worked part-time and his relationship with the hospice was so tangential that it should not be considered an affiliation.

In fact, because he was the hospice’s medical director, Petitioner 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.”).  Petitioner’s efforts to distance himself from the hospice cannot change the nature of that affiliation.  As medical director, he was responsible for the “medical component of the hospice’s patient care program.”  42 C.F.R. § 418.102(d).  His 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).

Petitioner does not seem to understand what is required of a medical director.  The medical director plays an integral role and, like other provider officers and managers (as listed in the statute and regulation), must protect against fraud, waste, and abuse.  His efforts to distance himself from Passion and Love and his disregard for the hospice’s mismanagement establish that he was not fulfilling his obligations as set forth in 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 and the requirements for face-to-face encounters were not met – are attributable to the medical director’s lack of involvement.  He was responsible for the medical component of the hospice’s patient care program.  42 C.F.R. § 418.102(d).  He was supposed to have reviewed the clinical information and provided written certification regarding the patient’s anticipated life expectancy.  42 C.F.R. § 418.102(b).  Those were his responsibilities.  That he purportedly did not know that the hospice was improperly billing for those services just means that he was not paying proper attention and was allowing fraud, waste, and abuse to happen on his watch.  See Adel A. Kallini, M.D., DAB No. 3021 at 20 (2020) (in a related context, finding that a physician’s responsibility to ensure proper billing for the services he provides is “so core” to his role as a physician in the Medicare program “that it is hard to see how any physician oblivious to them . . . could be trusted to participate in the program.”)

In deciding to exclude Petitioner, CMS considered the factors, set forth in 42 C.F.R. § 424.519(f).  Although Petitioner considers the duration of his affiliation with Passion and Love inconsequential, a 15-month affiliation is, in fact, significant, particularly considering that the improper billing occurred at that time.  See, e.g., Ritu Khanna, M.D., DAB CR6854 (2026) (upholding revocation based, in part, on a one-year affiliation); Edmond Petrossian and Sterling Physicians Medical Group, DAB CR6758 (2025)

Page 17

(seven-month affiliation); Fernando D. Palacios, Fernando Palacios, M.D., DAB CR6754 (2025) (two-month affiliation).

Further, as discussed above, by law, the degree and extent of the affiliation between a hospice and its medical director are significant.  That Petitioner did not appreciate his critical role only underscores the risk he poses.

During his 15-month affiliation with the hospice (January 1, 2024, through March 31, 2025), Petitioner failed to perform the medical director’s duties to guard against fraud, waste, and abuse.  CMS reasonably found a risk that he 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.  Thus, his affiliation with Passion and Love poses 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, he 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 circumstance that don’t apply here), depending on the severity of the underlying offense.  42 C.F.R. § 424.535(c)(1).  Here, CMS imposed a ten-year reenrollment bar.  Because the length of a reenrollment bar is not listed as an appealable determination, I have no authority to review it.  42 C.F.R. § 498.3(b); Linda Silva, P.A., DAB No. 2966 at 11 (2019); Vijendra Dave, M.D., DAB No. 2672 at 9-12 (2016); accord, William Garner, 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 his Medicare privileges were revoked for conduct detrimental to the best interests of the Medicare program, and he is under a reenrollment bar.  I have no authority to review CMS’s determination as to the length of time he 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.10  Pursuant to 42 C.F.R. § 422.2 (Part

Page 18

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. 16,642-16643 (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, he had been affiliated with the hospice, Passion and Love Hospice, Inc., whose Medicare billing privileges were revoked because it had abused its billing privileges.  Although he did not personally submit the bills, as the provider’s medical director, Petitioner should have ensured that the hospice was providing the medical services required, and he should have paid some attention to whether the hospice was submitting bills for medical services that were not properly provided.

CMS reasonably determined that, based on his affiliation with Passion and Love, Petitioner poses an “undue risk of fraud, waste, or abuse” to the Medicare program and revoked his 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 his enrollment was revoked for conduct deemed detrimental to the best interests of the Medicare program and its beneficiaries and because he is under a reenrollment bar, CMS is authorized to add him 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).

Page 19

Having determined that CMS properly added Petitioner to the preclusion list, I have no authority to review CMS’s determination as to how long he 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 Lee’s Medicare enrollment and imposed a reenrollment bar because, based on his affiliation with Passion and Love Hospice, Inc., his enrollment poses an undue risk of fraud, waste, and abuse to the Medicare program.  42 C.F.R. § 424.535(a)(19).

CMS was authorized to include Petitioner on the preclusion list because his Medicare enrollment was revoked for conduct detrimental to the best interests of the Medicare program, and because he 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.