Vrajesh Patel, DAB CR6963 (2026)

DECISION

The Centers for Medicare & Medicaid Services (CMS) has revoked Petitioner’s Medicare enrollment pursuant to 42 C.F.R. §§ 424.535(a)(3); 424.535(a)(9); and 424.535(a)(12).  He appealed the revocation, and the appeal has been assigned to me.

Petitioner, Vrajesh Patel, is a physician, who practiced in Washington and participated in the Medicare program as a supplier of services.  Petitioner was found guilty of three felony counts of Assault in the Second Degree and two felony counts of Harassment.  Based on his conviction, the Washington Medical Commission suspended his medical license and the Washington Medicaid program terminated his participation.  Petitioner did not report either adverse action – the felony conviction or the license suspension – to the Medicare contractor.

Based on his felony conviction, suspension of his license and termination from state Medicaid, and his failure to report the adverse legal actions, the Medicare contractor, National Government Services, Inc. (NGS), acting on behalf of CMS, revoked Petitioner’s Medicare billing privileges, imposed a ten-year reenrollment bar, and added his name to the Medicare preclusion list.

Page 2

Petitioner appealed.

I affirm CMS’s determination.  I find that CMS is authorized to revoke Petitioner’s Medicare billing privileges and to add his name to the Medicare preclusion list because:  1) within the ten years preceding this action, Petitioner was convicted of a felony that CMS reasonably determined is detrimental to the best interests of the Medicare program and its beneficiaries; 2) Petitioner failed to report the conviction to the Medicare contractor; and 3) the subsequent suspension of his medical license and termination from the Washington Medicaid program to the Medicare contractor.  42 C.F.R. §§ 424.535(a)(3), 424.535(a)(9), and 424.535(a)(12).

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

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 services, 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, 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.

Page 3

Section 424.535(a) authorizes CMS to revoke a supplier’s Medicare enrollment and billing privileges on one or more of the grounds set forth under that subsection.  So long as CMS shows that one of the regulatory bases exists, I must uphold the revocation.  Eva Orticio Villamor-Goubeaux, DAB No. 2997 at 13 (2020); Wassim Younes, M.D. & 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)).

Procedural Background.  Here, by letter dated August 19, 2021, the Medicare contractor advised Petitioner that his Medicare privileges were revoked, effective March 8, 2019.  CMS Ex. 1.  The letter explained that the contractor revoked Petitioner’s Medicare privileges for three reasons:

1) pursuant to 42 C.F.R. § 424.535(a)(3), because Petitioner was convicted of multiple felonies, as defined in 42 C.F.R. § 1001.2, for harassment in violation of the Revised Washington Code § 9A.46.020(2)(b) and assault in the second degree in violation of the Revised Washington Code § 9A.36.021(1)(g);

2) pursuant to 42 C.F.R. § 424.535(a)(9), because Petitioner did not notify CMS within 30 days of the felony convictions; and

3) pursuant to 42 C.F.R. § 424.535(a)(12), because Petitioner was terminated from the Washington Medicaid program.

CMS Ex. 1.  The contractor imposed a ten-year reenrollment bar  pursuant to 42 C.F.R. § 424.535(c).  CMS Ex. 11 at 3.

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, 423.100, and 423.120(c)(6).  It explained that, if Petitioner requested reconsideration, this action would become effective on the date the reconsidered determination was issued.  CMS Ex. 1 at 2.

Petitioner requested reconsideration.  CMS Ex. 5.  In a reconsidered determination, dated May 5, 2026, a CMS hearing officer upheld the revocation under sections 424.535(a)(3), 424.535(a)(9), and 424.535(a)(12).  Specifically, the hearing officer found that:

• Petitioner had been convicted of a felony detrimental to the best interests of the Medicare program and its beneficiaries under section 424.535(a)(3);
• Petitioner did not notify CMS within 30 days of the felony convictions under section 424.535(a)(9); and

Page 4

• Petitioner was terminated from participation in a State Medicaid program (Petitioner was terminated from the Washington State Medicaid program effective December 4, 2020) under section 424.535(a)(12).

CMS Ex. 11. 

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

Decision based on the written record.  Because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Standing Order at 9 (May 6, 2025).  The matter may therefore be decided based on the written record, without considering whether the standards for summary judgment are satisfied.

Exhibits.  CMS submits its brief (CMS Br.) with 11 exhibits (CMS Exs. 1-11).  Petitioner submits his own brief (P. Br.) with no exhibits.1

In the absence of any objections, I admit into evidence CMS Exs. 1-11.

Discussion

1. CMS properly revoked Petitioner’s Medicare enrollment under 42 C.F.R. §§ 424.535(a)(3), 424.535(a)(9), and 424.535(a)(12) because, within ten years preceding the revocation, he was convicted of a felony that CMS reasonably finds detrimental to the best interests of the Medicare program; because he failed to report, to the Medicare Contractor, his conviction; and because Petitioner was also terminated from the Washington Medicaid program.2

Revocation of enrollment.  CMS may revoke a supplier’s Medicare enrollment and billing privileges if, within the preceding ten years, the supplier was convicted of a “felony offense that CMS determines is detrimental to the best interests of the Medicare

Page 5

program and its beneficiaries.”  42 C.F.R. § 424.535(a)(3)(i); see also Act §§ 1842(h)(8), 1866(b)(2)(D).  Offenses for which billing privileges may be terminated include – but are not limited to – felony crimes against persons, such as murder, rape, assault, and other similar crimes.  42 C.F.R. § 424.535(a)(3)(ii)(A).

CMS may also revoke Medicare privileges if a supplier does not comply with the reporting requirements specified in section 424.516(d).  42 C.F.R. § 424.535(a)(9).  Under section 424.516(d), physicians must report to their Medicare Contractor, within 30 days, “[a]ny adverse legal action.”

CMS may also revoke Medicare privileges if a supplier is also terminated from other programs.  42 C.F.R. § 424.535(a)(12). 

Petitioner’s conviction, license suspension, and termination from state Medicaid.  Petitioner was charged with Assault in the Second Degree and Harassment in October, 2017.  CMS Ex. 1; CMS Ex. 2; CMS Ex. 11.  Petitioner entered into a one year stipulated order of continuance that required Petitioner to comply with the terms and complete recommended treatment.  Prosecutors alleged that Petitioner was not compliant with the stipulated order and on March 8, 2019, Petitioner was found guilty by the court of Assault in the Second Degree and Harassment.  CMS Exs. 2, 11.  The court sentenced Petitioner to sixty months in prison.  Id.

On October 2, 2020, the Washington Medical Commission indefinitely suspended Petitioner’s medical license by agreed order.  CMS Ex. 2.  The Washington Medicaid program terminated Petitioner’s participation effective December 4, 2020.  CMS Ex. 3.

Petitioner did not report his conviction nor his license suspension to the Medicare Contractor.

Legal basis for revocation.  The Departmental Appeals Board has consistently held that an administrative law judge’s review of CMS’s determination to revoke a supplier’s Medicare enrollment is limited to deciding whether CMS has established one or more of the grounds specified in section 424.535(a).  William Garner, M.D., DAB No. 3026 at 16 (2020); Norman Johnson, M.D., DAB No. 2779 at 11 (2017), and cases cited therein.  Although CMS itself has the discretion to consider “unique or mitigating circumstances in deciding whether, or how, to exercise its revocation authority,” I do not.  Norman Johnson, DAB No. 2779 at 11 (citing Care Pro Home Health, Inc., DAB No. 2723 at 9 n.8 (2016)).  I may not substitute my discretion for that of CMS in determining whether the revocation is appropriate.  Id. (quoting Abdul Razzaque Ahmed, M.D., DAB No. 2261 at 19 (2009), aff’d., Ahmed v. Sebelius, 710 F. Supp. 2d 167 (D. Mass. 2010)).

Page 6

Here, because CMS has grounds for revoking Petitioner’s Medicare enrollment under either section 424.535(a)(3), section 424.535(a)(9) or section 424.535(a)(12), I must sustain the revocation.

Petitioner does not dispute that he was convicted of felonies that are detrimental to the Medicare program.  He similarly does not dispute that he failed to report the convictions to the contractor or CMS.  Petitioner also does not dispute that his medical license was suspended or that he was terminated from a state Medicaid program.  Instead, Petitioner argues that the reenrollment bar and his placement on the preclusion list are the equivalent of “a professional execution.”  P. Br. at 1.  Petitioner points out that his license has been reinstated and he has been removed from the exclusion list.  Id.  Petitioner asserts that he has attained sobriety and has lots to offer his community.  Id.

While Petitioner’s efforts to turn his life around should not be disregarded, I am without authority to reverse or alter CMS’s determinations on equitable grounds.  Petitioner’s arguments are a request for equitable relief, which I am unable to grant.  US Ultrasound, DAB No. 2302 at 8 (2010)( “Neither the ALJ nor the [DAB] is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”).  If CMS’s action is legally authorized, as found here, then it must be upheld.  Wendell Foo, M.D., DAB No. 2904 at 25 (2018) (The Board “has repeatedly confirmed that neither it nor the ALJs have authority to overturn a legally valid agency action on equitable grounds or otherwise grant equitable relief.”).

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 its reenrollment bar, which must be for a minimum of one year but no more than ten years (except under circumstances that don’t apply here), depending on the severity of the underlying offense.  42 C.F.R. § 424.535(c)(1).  Here, CMS imposed a ten-year reenrollment bar.  Because the length of a reenrollment bar is not listed as an appealable determination, I have no authority to review it.  42 C.F.R. § 498.3(b); Linda Silva, P.A., DAB No. 2966 at 11 (2019); Vijendra Dave, M.D., DAB No. 2672 at 9-12 (2016); accord, William Garner, M.D., DAB No. 3026 at 16 (2020), Lilia Gorovits, M.D., P.C., DAB No. 2985 at 15-16 (2020).

3. CMS acted within its authority when it added Petitioner to its preclusion list because his Medicare billing 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.

Page 7

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.3  Pursuant to 42 C.F.R. § 422.2 (Part C) and 42 C.F.R. § 423.100 (Part D), CMS’s “preclusion list” includes individuals and entities that:

• are currently revoked from Medicare enrollment, are under an active reenrollment bar, and CMS determines that the underlying conduct leading to the revocation is detrimental to the best interests of the Medicare program;
• 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; or
• have been convicted of a felony within the previous ten years that CMS deems 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. 16,440, 16,642-43 (Apr. 16, 2018) (explaining that appeals are limited to the individual’s inclusion on the preclusion list).

As discussed above, Petitioner was convicted of a crime that is detrimental to the best interests of the Medicare program and its beneficiaries.  His Medicare enrollment has been revoked and he is currently under a reenrollment bar.  CMS was therefore 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); Wassim Younes, M.D., P.L.C., DAB No. 2861 at 8 (2018) (citing Patrick Brueggeman, D.P.M., DAB No. 2725 at 15 (2016)).

Having determined that CMS properly added Petitioner to the preclusion list, I have no authority to review CMS’s determination as to how long he remains there.

Page 8

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

CMS justifiably determined that Petitioner was convicted of felonies detrimental to the best interests of the Medicare program and its beneficiaries; it may therefore revoke his Medicare enrollment and billing privileges and impose a reenrollment bar.  In the alternative, CMS may revoke Petitioner’s Medicare enrollment because he did not timely report adverse legal actions to the Medicare contractor and he was terminated from a state Medicaid program.

CMS was also authorized to include Petitioner on the preclusion list.  I have no authority to review the lengths of the reenrollment bar nor his time on the preclusion list.

For these reasons, I affirm CMS’s determinations.