Ashley Nicole Cross, DAB CR6961 (2026)

Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division

Ashley Nicole Cross 
(OI File No. E-24-42136-9), 
Petitioner,

v.

The Inspector General.

Docket No. C-25-819
Decision No. CR6961

DECISION

I affirm the determination of the Inspector General (IG) of the United States Department of Health and Human Services to exclude Petitioner from participation in all federal health care programs for 23 years. 

I.  Background

In a June 30, 2025 notice, the IG excluded Petitioner from participation in all federal health care programs under section 1128(a)(1) of the Social Security Act (42 U.S.C. § 1320a-7(a)(1)) for a period of 23 years due to her conviction of a criminal offense related to the delivery of an item or service under Medicare or a state health care program in the U.S. District Court for the Western District of North Carolina (District Court).  IG Ex. 1. 

The notice stated that, based on the following aggravating circumstances, the exclusion would extend beyond the minimum five years required under the statute: 

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  1. The acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government agency or program or to one or more other entities of $50,000 or more.  (The entire amount of financial loss to such government agencies or programs or to other entities, including any amounts resulting from similar acts not adjudicated, will be considered regardless of whether full or partial restitution has been made.)  The court ordered [Petitioner] to pay approximately $481,400 in restitution.
  2. The acts that resulted in the conviction, or similar acts, were committed over a period of one year or more.  The acts occurred from about March 2016 to about January 2022.
  3. The sentence imposed by the court included incarceration.  The court sentenced [Petitioner] to 135 months of incarceration.
  4. The individual or entity has been the subject of any other adverse action by any Federal, State, or local government agency or board if the adverse action is based on the same set of circumstances that serves as the basis for the imposition of the exclusion.  The North Carolina Social Work Certification and Licensure Board suspended [Petitioner’s] license to practice as a licensed social worker.  The South Carolina Department of Health and Human Services excluded [Petitioner] from participating as a provider in the South Carolina Medicaid program. 

IG Ex. 1 at 1-2; see 42 C.F.R. § 1001.102(b)(1), (2), (5), (9). 

On July 11, 2025, Petitioner, acting pro se, filed a request for an administrative law judge hearing to dispute the 23-year length of exclusion.  Petitioner asserted that there was no basis for the exclusion because she had an appeal pending and that the length of the exclusion was unreasonable.  Hr’g Req. at 1-2. 

On August 1, 2025, the Civil Remedies Division (CRD) acknowledged Petitioner’s hearing request, informed the parties that I would hold a prehearing conference on September 10, 2025, and issued my Standing Prehearing Order (SPO). 

The prehearing conference was continued multiple times at Petitioner’s request.  On December 16, 2025, I held a telephonic prehearing conference, the substance of which is summarized in my December 16, 2025 Order Following Prehearing Conference and

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Setting Briefing Schedule. 

On January 13, 2026, the IG filed a prehearing brief (IG Br.) and seven proposed exhibits (IG Exs. 1-7).  Petitioner requested additional time to file a prehearing exchange.  On May 19, 2026, Petitioner retained counsel.  And, on July 21, 2026, Petitioner filed a prehearing brief (P. Br.) and one proposed exhibit.  (P. Ex. 1).  Petitioner’s prehearing exchange limited the issue before me to whether the 23-year exclusion period selected by the I.G. is unreasonable.  P. Br. at 1. 

II.  Admission of Evidence

I admit IG Exhibits 1 through 7 and Petitioner Exhibit 1 into the record, without objection.  See 42 C.F.R. § 1005.8(c). 

III.  Decision on the Written Record

I informed the parties that they needed to submit the written direct testimony for any witnesses that they wanted to testify in this case or, if they were unable to obtain the written direct testimony, to request a subpoena to be issued to the witness or witnesses.  SPO ¶ 11.  I also informed the parties that I would not conduct a hearing unless written direct testimony was submitted by a party and the opposing party requested to cross-examine one or more witnesses.  SPO ¶ 12. 

In the present case, the IG gave notice that it did not have any witnesses to present in this case and did not think an in-person hearing was necessary.  IG Br. at 10.  Petitioner neither provided any written direct testimony nor a witness list.  Therefore, there is no need for me to hold an in-person hearing and I issue this decision based on the written record.  CRDP §§ 16(a)-(b), 19(b), (d). 

IV.  Issue

Whether the length of the exclusion imposed by the IG is unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii). 

V.  Jurisdiction

I have jurisdiction to adjudicate this case.  42 U.S.C. § 1320a-7(f)(1); 42 C.F.R. § 1005.2. 

VI.  Findings of Fact

  1. Petitioner was the CEO of an outpatient behavioral health services provider in North Carolina.  IG Ex. 2 at 1.  Petitioner’s company was enrolled with the South

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Carolina Medicaid program to provide rehabilitative behavioral health services.  IG Ex. 2 at 1.

  1. On September 19, 2023, Petitioner was indicted in the U.S. District Court for the Western District of North Carolina with nine counts of health care fraud, one count of false writings related to a health care matter, one count of false statements related to a health care matter, two counts of promoting money laundering, one count of wire fraud, one count of wire fraud conspiracy, and one count of wire fraud affecting a financial institution.  IG Ex. 2.
  2. The criminal indictment alleged that Petitioner executed a scheme to defraud the South Carolina Medicaid Program.  IG Ex. 2 at 1.  The indictment further alleged that Petitioner purchased the names and personal identifying information of Medicaid beneficiaries to create fictious patient clinical notes to support claims for services that were not performed by Petitioner’s company.  Id.  The scheme allegedly took place from March 2016 through January 2022.  Id.; IG Ex. 3.
  3. One count of health care fraud was dismissed before Petitioner’s jury trial.  IG Ex. 4 at 1.
  4. On May 17, 2023, a jury found Petitioner guilty on all remaining counts for which Petitioner was indicted.  IG Ex. 3.
  5. On December 16, 2024, the District Court issued a Judgment in a Criminal Case, which indicated the following:
    1. Petitioner was found guilty on counts 1-3 and 5-16.  IG Ex. 4 at 1.
    2. The District Court sentenced Petitioner to imprisonment for 120 months and 135 months to run concurrently.  IG Ex. 4 at 3.
    3. The District Court sentenced Petitioner to supervised release for three years.  IG Ex. 4 at 4.
    4. The District Court ordered Petitioner to pay restitution in the amount of $481,436.08.  IG Ex. 4 at 6.  The restitution was divided as follows: $359,154.58 for healthcare fraud and $122,281.50 to the Small Business Association.  IG Ex. 5.
  6. On December 18, 2024, the North Carolina Social Work Certification and Licensure Board (Licensure Board) staff issued an order for summary suspension to summarily suspend Petitioner’s license.  On February 25, 2025, the Licensure Board upheld the summary suspension.  CMS Ex. 6. 

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  1. By letter dated January 17, 2025, Petitioner was notified that the South Carolina Department of Health and Human Services Petitioner from participating as a provider of services in the South Carolina Medicaid program.  IG Ex. 7. 

VII.  Conclusions of Law and Analysis

The Secretary of Health and Human Services (Secretary) must exclude an individual from participation in all federally funded health care programs when that individual “has been convicted of a criminal offense related to the delivery of an item or service under subchapter XVIII [of the Social Security Act] or under any State health care program.”  42 U.S.C. § 1320a-7(a)(1).  The Secretary has interpreted this statute to mean that an individual must be excluded when the individual “[h]as been convicted of a criminal offense related to the delivery of an item or service under Medicare or a State health care program, including the performance of management or administrative services relating to the delivery of items or services under any such program.”  42 C.F.R. § 1001.101(a).  Therefore, for the purposes of this case, the two essential elements to support a mandatory exclusion are:  (1) the excluded individual must have been convicted of an offense; and (2) the offense must be related to the delivery of a health care item or service under the Medicare or Medicaid programs. 

If an individual has been convicted of a crime that requires mandatory exclusion, then the Secretary must exclude the individual for at least five years.  42 U.S.C. § 1320a-7(c)(3)(B).  However, the Secretary established, by regulation, a list of aggravating and mitigating factors that are to be considered in each case to determine whether the length of a mandatory exclusion should exceed five years.  See 42 C.F.R. § 1001.102(b)-(c). 

The regulations state that the preponderance of the evidence standard of proof is employed in exclusion cases.  42 C.F.R. §§ 1001.2007(c), 1005.15(d).  The regulations provide administrative law judges with the discretion to allocate the burden of proof in most exclusion cases.  42 C.F.R. § 1005.15(c).  I gave notice at the beginning of these proceedings that the IG had the burden of proving the existence of all alleged aggravating factors and that Petitioner had the burden of proving all mitigating factors.  SPO ¶ 6. 

When reviewing the length of exclusion, an administrative law judge may only reduce the length of exclusion when the length imposed by the IG is “unreasonable.”  42 C.F.R. § 1001.2007(a)(1)(ii). 

1.  Petitioner is subject to a mandatory exclusion for at least five years under 42 U.S.C. § 1320a-7(a)(1). 

Petitioner does not dispute that the IG must exclude Petitioner for a minimum of five years under 42 U.S.C. § 1320a-7(a)(1).  P. Br. at 1 (seeking review only of the length of

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exclusion).  A review of the record indicates that there is no doubt that Petitioner is subject to a mandatory five-year exclusion.  In fact, Petitioner’s brief acknowledges that she is subject to an exclusion that is lengthier than the five-year exclusion.  P. Br. at 5, 7, 8.

2.  The IG appropriately considered as an aggravating factor that Petitioner’s criminal conspiracy resulted in a $481,436.08 loss to a government agency or program or to one or more other entities.  This amount is a significant factor that weighs heavily in favor of a lengthy exclusion. 

In the June 30, 2025 exclusion notice, the IG stated that the acts resulting in conviction, or similar acts, caused or were intended to cause, a financial loss to a government agency or program of $50,000 or more.  The IG specified that “[t]he court ordered [Petitioner] to pay approximately $481,400 in restitution.”  IG Ex. 1 at 1. 

As stated above, Petitioner was part of scheme to bill Medicare or a state health care program for healthcare services that were not provided.  The restitution order divided the payments as $359,154.58 to various healthcare related agencies and $122,281.50 to the Small Business Association, another government agency.  IG Ex. 5 at 1-2. 

Petitioner’s criminal conspiracy is responsible for a loss that is almost 10 times more than the minimum amount ($50,000) required for that loss to be considered an aggravating factor.  Therefore, this aggravating factor is sufficient to support a lengthy exclusion. 

Petitioner does not dispute that the $359,154.58 should be considered as part of the aggravating factors addressed in this case.  However, she instead argues that the weight given should be less because the $122,281.50 restitution ordered to be paid to the SBA is not related to healthcare losses.  P. Br. at 5-6.  However, the regulations provide the following as the language for this aggravating factor: 

The acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government agency or program or to one or more entities of $50,000 or more.  (The entire amount of financial loss to such government agencies or programs or to other entities, including any amounts resulting from similar acts not adjudicated, will be considered regardless of whether full or partial restitution has been made). 

42 C.F.R. § 1001.102(b)(1).  Petitioner does not argue that the loss to the SBA did not occur, only that it was not related to healthcare.  The regulation does not require such a connection, and the IG is permitted to consider losses to other government agencies,

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entities, or programs when considering this factor.  As a result, I find that the IG properly supported its inclusion of this aggravating factor. 

3.  The IG appropriately considered as an aggravating factor that Petitioner’s criminal conspiracy spanned almost six years.  This length of time is a significant factor that weighs heavily in favor of a lengthy exclusion. 

In the June 30, 2025 exclusion notice, the IG stated that Petitioner’s acts that resulted in the conviction, or similar acts, occurred from about March 2016 to June 2022.  IG Ex. 1 at 1.  Petitioner does not dispute the existence of this aggravating factor.  P. Br at 7.  Petitioner argues instead that this factor should be included in the increase in the length of the exclusion that resulted from the other aggravating factors and not considered as an automatic multiplier.  Id.  However, duration is listed as an independent aggravating factor.  42 C.F.R § 1001.102(b)(2). 

Additionally, Petitioner’s criminal conduct and conspiracy lasted almost six times longer than the minimum amount of time necessary for it to be considered an aggravating factor.  Such a lengthy period of time in which Petitioner committed fraud serves as an independent significant basis to impose a lengthy exclusion. 

4.  The IG appropriately considered as an aggravating factor that Petitioner was sentenced to incarceration for 120 months and 135 months concurrently.  This aggravating factor provides strong support for a lengthy exclusion. 

In the June 30, 2025 exclusion notice, the IG stated that the District Court’s sentence included 135 months of incarceration.  IG Ex. 1 at 1. 

As stated above, Petitioner was sentenced to incarceration for a total of 135 months. Petitioner did not dispute the existence of this aggravating factor.  P. Br. at 6.  Petitioner argues instead that the sentence was on the low end of the calculated guideline range.  P. Br. at 7. 

A prison sentence of as little as nine months is considered to be relatively substantial for exclusion purposes.  Jason Hollady, M.D., DAB No. 1855 at 12 (2002).  Petitioner’s 135-month sentence is fifteen times that amount and demonstrates the seriousness of Petitioner’s criminal offense.  This length of imprisonment strongly supports a lengthy exclusion. 

5.  The IG appropriately considered as an aggravating factor that Petitioner was the subject of an adverse action by both the States of North and South Carolina.  This aggravating factor provides strong support for a lengthy exclusion. 

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In the June 30, 2025 exclusion notice, the IG stated that Petitioner’s license to practice as a licensed clinical social worker was suspended by the North Carolina Social Work Certification and Licensure Board and the South Carolina Department of Health and Human Services excluded her from participating as a provider in the South Carolina Medicaid program.  IG Ex. 1 at 2. 

Petitioner does not dispute that she was the subject of an adverse action by both the states of North and South Carolina as a result of the criminal conviction that has formed the basis for this exclusion.  Rather, Petitioner argues that this factor should be afforded little weight in determining the reasonableness of the length of her exclusion because it is derivative of the same criminal conviction that formed the basis for the federal exclusion.  P. Br. at 8. 

However, the Board has held that an adverse action that is taken based on the same circumstances of a petitioner’s exclusion could be considered as additional evidence of the seriousness of the underlying conduct.  Narendra M. Patel, M.D., DAB No. 1736 at 29 (2000), aff’d, 319 F.3d 1317 (11th Cir. 2003), cert. denied, 539 U.S. 959 (2003) (stating that an adverse action beyond a criminal conviction is “additional evidence of the seriousness” of the conviction).  Petitioner’s license was indefinitely suspended by the North Carolina Social Work Certification and Licensure Board, and she was excluded from participation in South Carolina’s Medicaid program for a minimum of five years.  IG Exs. 6, 7.  The actions taken by the states of North and South Carolina further justify the 23-year exclusion period. 

6.  Petitioner does not argue that there are any mitigating factors present in this case. 

7.  The 23-year length of Petitioner’s exclusion is not unreasonable based on the aggravating factors in this case. 

When considering the length of exclusion, “[t]he evaluation does not rest on the specific number of aggravating or mitigating factors or any rigid formula for weighing those factors, but rather on a case-specific determination of the weight to be accorded each factor based on a qualitative assessment of the circumstances surrounding the factors in that case.”  Farzana Begum, M.D., DAB No. 2726 at 2 (2016).  Further, the general purpose of an exclusion under 42 U.S.C. § 1320a-7 is “to protect federal health care programs and the programs’ beneficiaries and recipients from untrustworthy providers.”  Susan Malady, R.N., DAB No. 1816 at 9 (2002).  Ultimately, I must decide whether the 23-year exclusion is unreasonable (i.e., is it within a reasonable range for the length of exclusion based on the relevant factors).  42 C.F.R. § 1001.2007(a)(1)(ii); 57 Fed. Reg. 3298, 3321 (Jan. 29, 1992). 

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Above, I performed the qualitative assessment of the aggravating factors.  Neither party argued that there were any mitigating factors to consider.  The loss amount is high, the length of time Petitioner engaged in criminal conduct is long, the length of Petitioner’s sentence of incarceration is long, and Petitioner was the subject of adverse actions by both the states of North and South Carolina.  These factors strongly support a lengthy exclusion. 

VIII.  Conclusion

I affirm the IG’s determination to exclude Petitioner for 23 years from participating in all federal health care programs. 

/s/

Kourtney LeBlanc Administrative Law Judge