Amable R. Aguiluz, Jr., M.D.; Amable Delos Reyes Aguiluz, Jr. M.D., Inc.: Oxnard Medical Group, Inc., DAB CR6964 (2026)

DECISION

Petitioner, Amable R. Aguiluz, Jr., M.D., is a California physician, who participated in the Medicare program as a supplier of services.  He was the sole owner and managing employee of two medical practices:  Petitioners, Amable Delos Reyes Aguiluz, Jr., M.D. Inc. (Aguiluz Practice), and Oxnard Medical Group, Inc. 

Finding that Dr. Aguiluz 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 and his practices’ Medicare enrollments, imposed a ten-year re-enrollment bar, and added their names to the Medicare preclusion list.  42 C.F.R. § 424.535(a)(19); see 42 C.F.R. § 424.519. 

Petitioners appealed. 

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I affirm CMS’s determinations.  I find that CMS is authorized to revoke Petitioners’ Medicare enrollments, 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 Dr. Aguiluz’s affiliation with the provider, Forever in Peace Hospice Care, Inc., their enrollments in the Medicare program pose an undue risk of fraud, waste, and abuse.  For the same reason, CMS may add Petitioners’ names to the Medicare preclusion list. 

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

Background

Statutory and regulatory background.  The Medicare program, Title XVIII of the 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. 

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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, M.D., DAB No. 3227 at 9 (2026); Devine Sols. Grp., LLC, DAB No. 3159 at 12 (2024); Thomas Falls, M.D., DAB No. 3056 at 8 (2022); William Garner, M.D., DAB No. 3026 at 16 (2020); 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); 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.  I may not substitute my discretion for that of CMS in determining whether a legally-sound revocation is appropriate.  Johnson, DAB No. 2779 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, in letters dated November 15, 2024, the Medicare contractor, Noridian Healthcare Solutions, advised Dr. Aguiluz, the Aguiluz Practice, and the Oxnard Medical Group that their Medicare privileges were revoked, effective December 15, 2024.  The letters explained that the contractor revoked Petitioners’ Medicare privileges because Dr. Aguiluz had an affiliation with Forever in Peace Hospice Care, Inc., an entity previously enrolled in the Medicare program.  Forever in Peace’s Medicare billing privileges were revoked pursuant to 42 C.F.R. § 424.535(a)(8) – abuse of billing privileges.  The contractor determined that Dr. Aguiluz’s affiliation – as “an individual with managerial control” of Forever in Peace – 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).  CMS Exs. 8, 9, 10, 19. 

The contractor imposed ten-year reenrollment bars, effective 30 days after the postmark date of the notices, pursuant to 42 C.F.R. § 424.535(c).  CMS Exs. 9, 10, 19. 

The letters also advised Petitioners that the contractor added them 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 Petitioners requested reconsideration, this action would become effective on the date the reconsidered determination was issued.  CMS Exs. 9, 10, 19. 

Petitioners requested reconsideration.  CMS Ex. 4, 6, 17; see CMS Exs. 2, 3. 

In a reconsidered determination, dated February 20, 2026, a CMS hearing officer upheld the revocations under sections 424.519 and 424.535(a)(19).  Citing section 424.519, she found that Petitioner Aguiluz’s affiliation with Forever in Peace Hospice posed an undue risk of fraud, waste, or abuse to the Medicare program.  CMS Ex. 1 at 15. 

The hearing officer also upheld the ten-year reenrollment bars and the determination to include Petitioners’ names on CMS’s preclusion list.  Id. 

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Decision based on the written record.  CMS moves for summary judgment, which Petitioners oppose. 

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 CRDP ¶ 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.  Prehearing Order at 5, 6 (¶¶ 9, 10).  CMS lists no witnesses.  Petitioners list one witness, Dr. Aguiluz, and proffer his written declaration, although, contrary to my order, they do not mark it as an exhibit.  CMS has not asked to cross-examine Dr. Aguiluz.  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 CRDP ¶ 19b.2 

Exhibits.  CMS submitted its motion and brief (CMS Br.) with 32 exhibits (CMS Exs. 1-32).  In the absence of any objections, I admit into evidence CMS Exs. 1-32. 

Petitioners submitted their own brief and opposition to summary judgment (P. Br.) with Dr. Aguiluz’s written declaration, which I mark P. Ex. 1.  In the absence of any objection, I admit into evidence P. Ex. 1. 

Issues

The sole questions before me are: 

1.  Did CMS have the authority to revoke Petitioners’ Medicare enrollments pursuant to 42 C.F.R. § 424.535(a)(19)? 

2.  Did CMS have the authority to include Petitioners 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 bars.  Brian O’Connor, DAB No. 3140 at 17-18 (2024). 

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Discussion

1.  CMS properly revoked Petitioners’ Medicare enrollments under 42 C.F.R. § 424.535(a)(19) because Dr. Aguiluz’s affiliation with the provider, Forever in Peace Hospice Care, Inc., poses an undue risk of fraud, waste, or abuse.3

Revocation of enrollment: disclosure requirements.  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). 

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

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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 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, either 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, 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: 

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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; 

iv) If the disclosable event is uncollected debt: 

A) The amount of debt. 

B) Whether the affiliated provider is repaying the debt. 

C) To whom the debt is owed. 

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. § 424.519(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 Forever in Peace Hospice Care Inc.’s Medicare billing privileges.  Forever in Peace Hospice Care, Inc., was a California hospice that participated in the Medicare program as a provider of services. 

The Medicare contractor, National Government Services, reviewed six claims that the hospice submitted from March 30 through September 30, 2023.  Ultimately, three of those claims were denied because they did not meet Medicare program requirements because the required physician narrative statement was missing and because the documentation did not support a terminal prognosis of six months or less.  CMS Ex. 8 at 1, 5.  By letter, dated February 13, 2024, the contractor “educated” the hospice regarding its submission of the noncompliant claims.  Id. at 1. 

Thereafter, the contractor reviewed an additional ten claims, submitted from April 1 through 30, 2024.  Eight of the ten claims were denied.  Seven were denied because the documentation did not support a terminal prognosis of six months or less; one was denied because the documentation submitted did not support the services billed.  CMS Ex. 8 at 1, 6.  In a letter dated July 19, 2024, the contractor again “educated” the hospice regarding its submission of noncompliant claims.  Id. at 1. 

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In a letter dated July 29, 2024, the Medicare 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 August 28, 2024, because the hospice had “a pattern or practice of submitting claims that fail to meet Medicare requirements.”  CMS Ex. 8 at 1-2.  CMS imposed a ten-year reenrollment bar and placed the hospice on the preclusion list.  CMS Ex. 8 at 2. 

The hospice did not seek reconsideration, so the contractor’s initial determination is final and binding.  CMS Ex. 1 at 4; 42 C.F.R. § 498.20(b). 

The revocation of Forever in Peace’s Medicare billing privileges was a disclosable event that prompted CMS to review Dr. Aguiluz’s affiliation with the hospice and to determine whether that affiliation poses an undue risk of fraud, waste, or abuse to the Medicare program.  42 C.F.R. §§ 424.502, 424.519, 424.535(a)(19). 

Petitioner’s affiliation with Forever in Peace Hospice Care, Inc.  In its Medicare enrollment documents, the hospice listed Dr. Aguiluz as its medical director and a managing employee, effective August 1, 2022.  CMS Ex. 14 at 21, 23. 

At reconsideration, Dr. Aguiluz did not dispute this.  In a letter, dated December 12, 2024, and submitted to the hearing officer, Dr. Aguiluz conceded that he served as the hospice’s medical director but denied “having any managerial control.” 

My main duty as Medical Director is to examine patients and prescribe the care that they need and supervise the care provided them. 

CMS Ex. 3 at 2; see CMS Ex. 1 at 2, 5. 

Although he still does not explicitly deny that he was the hospice’s medical director, Dr. Aguiluz now insists that he “never authorized anyone” to list him as the hospice’s medical director or managing employee.  P. Ex. 1 at 4, 10 (Aguiluz Decl. ¶¶ 20, 58).  According to Dr. Aguiluz, the hospice “unilaterally” designated him as “medical director,” without his knowledge or authorization.  Id. at 10 (Aguiluz Decl. ¶ 58).  Inasmuch as he earlier described himself as the medical director, I don’t find this credible. 

Dr. Aguiluz seems to recognize the inconsistency because he also characterizes the title as “honorary or descriptive,” which would be irrelevant if he didn’t hold that title.  Id. 

Dr. Aguiluz also asserts that his relationship with the hospice did not begin until “May 2023, approximately nine months after the purported effective date.”  P. Ex. 1 at 4, 5 (Aguiluz Decl. ¶¶ 21, 23).  Dr. Aguiluz minimizes his relationship with Forever in Peace by claiming that it

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lasted only four to six months, from May 2023 through October 2023.  Id. at 6 (Aguiluz Decl. ¶ 33). 

Ultimately, Dr. Aguiluz concedes (as he must) that he was affiliated with Forever in Peace but insists that he did not review patient records at the hospice location, did not have an office or workspace there, and did not “conduct any work” on the premises or “within [its] operational systems.”  P. Ex. 1 at 10 (Aguiluz Decl. ¶ 64).  He claims that he did not participate in the hospice’s “intake process, referral screening, or patient selection proceedings.”  P. Ex. 1 at 11 (Aguiluz Decl. ¶ 65).  Instead, he provided “limited consulting services,” reviewing patient medical records and providing “a preliminary assessment of whether patients’ conditions appeared to potentially qualify for hospice care eligibility.”  Id. at 5, 6 (Aguiluz Decl. ¶¶ 28, 29).  He no longer admits that he prescribed and supervised the care provided – which further erodes his credibility. 

In any event, the type of assessment he admits he performed falls squarely within the duties of a medical director.  42 C.F.R. § 418.102(b). 

Dr. Aguiluz’s professed ignorance regarding the denied claims (which resulted in revocation of the hospice’s billing privileges) is belied by the sheer volume of documentary evidence indicating that he was the hospice’s medical director and actively participated in patient selection processes.  Patient orders and other records repeatedly list him as the hospice’s medical director and, significantly, include his distinctive signature.  For example: 

Patient GT.  A claim submitted for Patient GT was one of the three claims, with dates of service from March 30 through September 30, 2023, that the contractor disallowed and that helped form the basis for revoking the hospice’s billing privileges.  CMS Ex. 8 at 5 (first claim listed). 

Dr. Aguiluz claims that he “never saw, treated, evaluated, or approved” the patient.  P. Ex. 1 at 11 (Aguiluz Decl. ¶ 67).  The patient’s medical records say otherwise: 

• Intake forms, dated March 30, 2023 – two months before the month he claims he began his affiliation with Forever in Peace – and September 26 to November 24, 2023, list Dr. Aguiluz as the patient’s primary physician and the hospice’s medical director.  The forms list Dr. Aguiluz’s National Provider Identifier (NPI), which must be included on claims submitted to Medicare.  CMS Ex. 22 at 4, 103. 
  
  If, as Petitioners claim, Dr. Aguiluz was not affiliated with Forever in Peace until May 2023, how did the hospice have his name and NPI as early as March 30, 2023?  His affiliation must have started in or earlier than March 2023.
• Dr. Aguiluz signed the patient’s “Certification of Terminal Illness” as “hospice physician.”  Id. at 21, 120.

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• Dr. Aguiluz signed the patient’s plans of care.  Id. at 87, 93, 99, 186, 192.
• Dr. Aguiluz also signed the patient’s medication orders, dated March 30, April 8, and April 13, 2023.  Id. at 23, 26, 122, 125, 198. 

Patient RD.  A claim submitted for this patient was one of the three claims, with dates of service from March 30 through September 30, 2023, that the contractor disallowed and that helped form the basis for revocation of the hospice’s billing privileges.  CMS Ex. 8 at 5 (second claim listed). 

Again, Dr. Aguiluz claims that he “never saw, treated, evaluated or approved” Patient RD.  P. Ex. 1 at 11 (Aguiluz Decl. ¶ 68).  He denies referring the patient for hospice care, signing off on any hospice care referral or prescription for the patient, or authorizing anyone to refer the patient to Forever in Peace in his name or the name of the Oxnard Medical Group.  Id. (Aguiluz Decl. ¶ 70).  Yet, again, the patient’s medical records say otherwise.  Dr. Aguiluz’s name and signature appear throughout.  Significantly, his medical practice, the Oxnard Medical Group, also appears: 

• An intake form, dated April 12, 2023, lists Dr. Aguiluz as the patient’s primary physician, referring physician, and the hospice’s medical director.  CMS Ex. 23 at 1, 245.
• Dr. Aguiluz is listed as the patient’s physician on her “Informed Consent and Treatment Authorizations.”  Id. at 6, 7, 250, 251.
• Dr. Aguiluz is listed as the attending physician on the patient’s “Bereavement Care Plan,” which he signed and dated April 15, 2023.  Id. at 84, 308.
• Dr. Aguiluz is listed as the patient’s physician on the emergency notification form.  Id. at 21, 265.
• Dr. Aguiluz signed an assessment and progress note, dated April 11, 2023.  Id. at 262.
• Dr. Aguiluz signed the “Physician Orders for Life Sustaining Treatment,” dated April 12, 2023.  Id. at 19, 263.    Dr. Aguiluz also signed the medication orders forms, dated April 12, 2023.  Id. at 22, 27, 28, 266, 271, 272.
• Dr. Aguiluz signed the “Certification of Terminal Illness” as “hospice physician.”  Id. at 29, 273.  He signed a physician order for hospice care.  Id. at 30, 274.
• Dr. Aguiluz signed separate admissions orders for the patient’s hospice care.  Id. at 32, 33.  The order, dated April 11, 2023, is written on his prescription form from the Oxnard

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• Medical Group, so there can be no mistake that this was his order from his medical group.  Id. at 33, 277.  Dr. Aguiluz acknowledges, as he must, that the order exists and that it was written on an Oxnard prescription form.  He alleges, however, that the document “was prepared without my personal involvement, knowledge, or authorization.”  P. Ex. 1 at 12 (Aguiluz Decl. ¶ 72). 

Petitioners concede that “certain signatures” throughout CMS Ex. 23 “bear some resemblance” to Dr. Aguiluz’s actual signature, but they allege that all of the signatures in that exhibit that purport to be his are forged and were made “without his knowledge, authorization, or consent” by hospice personnel or others.  P. Ex. 1 at 14 (Aguiluz Decl. ¶¶ 86-90). 

I find this not credible.  First, the doctor’s signatures, found throughout the patient medical records and on the documents that are part of this appeal, are so strikingly similar that, absent any convincing evidence to the contrary, I find that they were signed by the same hand.  See, e.g., P. Ex. 1 at 43; CMS Ex. 2 at 2; CMS Ex. 3 at 4; CMS Ex. 5 at 7, 9. 

Moreover, is Dr. Aguiluz suggesting that someone (presumably affiliated with Forever in Peace) pilfered an Oxnard prescription pad (or at least a prescription form) and used it without his knowledge or consent?  Stealing a prescription form or pad, with the physician’s Drug Enforcement Administration (DEA) certification number on it, is a serious offense, which the physician should have detected when the disappearance occurred.  A DEA certification number is an identifier that allows the possessor to write prescriptions for controlled substances.  Because prescription pads contain the physician’s unique DEA registration number, their loss is handled with the same immediate severity as a direct physical theft of controlled substances.  Within one business day, the physician is required to report the loss, in writing, to his local DEA Diversion Field Division Office.  See 21 C.F.R. §§ 1301.76(b), 1311.102(b).  Dr. Aguiluz does not suggest that he ever reported the loss and provides no evidence of such reporting. 

If I accepted that someone affiliated with Forever in Peace regularly and illegally forged Dr. Aguiluz’s signature, without his knowledge or consent (which I do not), I would have to conclude that the hospice was not merely noncompliant but was engaged in criminal activity.  According to Dr. Aguiluz’s own testimony, he passively affiliated himself with this rogue enterprise, giving it access to his NPI and DEA certification number.  Even without his active involvement, such an affiliation poses an undue risk of fraud, waste, or abuse to the Medicare program.  See 42 C.F.R. §§ 424.80(a), 424.535(a)(7) (authorizing revocation when a supplier allows another individual or entity to use its billing number unless there has been a valid reassignment of benefits); Kermit E. White, M.D., DAB No. 2765 at 2, 6 (2017) (finding that revocation is authorized whenever a supplier permits another to use its billing number for any purpose, unless an exception applies). 

Patient DS.  A claim submitted for Patient DS was one of the three claims, with dates of service from March 30 through September 30, 2023, that the contractor disallowed and that helped form the basis for revoking the hospice’s billing privileges.  CMS Ex. 8 at 5 (third claim listed). 

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Again. Dr. Aguiluz claims that he “never saw, treated, evaluated, or approved” the patient.  P. Ex. 1 at 11 (Aguiluz Decl. ¶ 69).  Again, the documentation says otherwise: 

• An intake form, dated September 8, 2023, lists Dr. Aguiluz as the patient’s primary physician and the hospice’s medical director.  It includes Dr. Aguiluz’s NPI.  CMS Ex. 24 at 1, 77.
• Dr. Aguiluz is listed as the hospice physician on the patient’s “Certificate of Terminal Illness.”  Id. at 32, 33.
• Dr. Aguiluz is listed as the patient’s attending physician on the “Informed Consent and Treatment Authorization.”  CMS Ex. 24 at 82.
• Dr. Aguiluz is listed on the patient’s “Emergency Contact Form” as an attending physician.  CMS Ex. 24 at 16, 92.
• Dr. Aguiluz signed a physician order for Life-Sustaining Treatment, dated September 3, 2023.  CMS Ex. 24 at 17, 93.
• Dr. Aguiluz signed medication orders, dated September 8, 2023 through December 6, 2023, which identify him as the “hospice physician.”  CMS Ex. 24 at 19-25, 29, 31, 32.
• Dr. Aguiluz signed a review of the patient’s medication profile.  CMS Ex. 24 at 58.
• Dr. Aguiluz signed the “Bereavement Care Plan” on September 11, 2023.  CMS Ex. 24 at 69. 

Patient LW.  A claim submitted for Patient LW was one of the eight claims, with dates of service from April 1 through 30, 2024, that the contractor disallowed and that helped form the basis for revoking the hospice’s billing privileges.  CMS Ex. 8 at 6 (first claim listed). 

• The patient’s intake form, dated March 7, 2024, lists Dr. Aguiluz as the hospice’s medical director and includes his NPI.  CMS Ex. 25 at 1, 87.
• On its face, the patient’s “Physician Certification for Hospice Benefit,” also dated March 7, 2024, lists Dr. Aguiluz as the hospice’s medical director and indicates that the document was “reviewed and electronically signed” by him.4  The document includes the physician’s NPI.  CMS Ex. 25 at 5, 91.

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• March 7 progress notes are electronically signed by Dr. Aguiluz.  CMS Ex. 25 at 8-9, 94-95.
• A patient’s plan of care is electronically signed by Dr. Aguiluz on March 7, 2024.  CMS Ex. 25 at 24.
• A progress note is electronically signed by Dr. Aguiluz on April 18, 2024.  CMS Ex. 25 at 12.
• The patient’s plan of care is electronically signed by Dr. Aguiluz on April 4, 2024.  CMS Ex. 25 at 18. 

Patients MC (CMS Ex. 26); HL (CMS Exs. 27); TM (CMS Ex. 28); BA (CMS Ex. 29); WG (CMS Ex. 30); RS (CMS Ex. 31); and GT (CMS Ex. 32).  Claims submitted for these patients were among the eight claims, with dates of service from April 1 through 30, 2024, that the contractor disallowed and that helped form the basis for revoking the hospice’s billing privileges.  CMS Ex. 8 at 6 (claims two through eight). 

As with the patient medical records examined in more detail above, each of these patients’ records is replete with references to Dr. Aguiluz, identifying him as the hospice medical director, and each includes multiple examples of his electronic signature.  See, e.g., CMS Ex. 26 at 2, 6, 8-9, 21, 29; CMS Ex. 27 at 3, 6, 9-10, 15, 19, 25; CMS Ex. 28 at 5, 8-10, 12, 16, 22, 28, 79-81; CMS Ex. 29 at 3, 6, 811-14, 17, 21, 27, 33; CMS Ex. 30 at 3, 8, 10-13, 16, 19, 25; CMS Ex. 31 at 3, 5, 7, 9-12, 16, 23, 30; CMS Ex. 32 at 3, 6-24, 27, 30, 34, 37, 40. 

Thus, the overwhelming documentary evidence establishes that Dr. Aguiluz served as the medical director for Forever in Peace Hospice Care, Inc. 

Because he was the hospice’s medical director, Dr. Aguiluz 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.”). 

Petitioners’ efforts to distance themselves from the hospice cannot change the nature of that affiliation.  As medical director, Dr. Aguiluz 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). 

Petitioners do 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

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statute and regulation), must protect against fraud, waste and abuse.  Petitioners’ efforts to distance Dr. Aguiluz from Forever in Peace and the physician’s disregard for the hospice’s mismanagement, including any purported criminal activities, establish that Dr. Aguiluz was not fulfilling his obligations as set forth in the hospice regulations. 

I don’t doubt Petitioners’ claims that Dr. Aguiluz passively affiliated himself with the hospice, accepting monthly remuneration but providing minimal services.  But no physician affiliated with a provider and no physician who accepts the title of medical director, even if he considers it “honorary or descriptive,” can ignore that provider’s billing practices. 

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. 

In deciding to exclude Petitioner, CMS considered the factors, set forth in 42 C.F.R. § 424.519(f).  CMS Ex. 1 at 9-13.  Although Petitioners consider the duration of his affiliation with Forever in Peace inconsequential, the documentary evidence establishes that it lasted more than a year – from March 2023 (CMS Ex. 22 at 4) through April 2024.  CMS Ex. 25 at 98; CMS Ex. 28 at 16; CMS Ex. 30 at 19.  A 13-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 & Sterling Physicians Med. Grp., DAB CR6758) (seven-month affiliation); Fernando D. Palacios, Fernando Palacios MD Inc., 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 Petitioners do not appreciate the physician’s critical role only underscores the risk they pose. 

During his affiliation with the hospice, Dr. Aguiluz failed to perform the medical director’s duties to guard against fraud, waste, and abuse.  CMS reasonably found a risk that he and his practices 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, based on Dr. Aguiluz’s affiliation with Forever in Peace, Petitioners pose an undue risk of fraud, waste, or abuse to the Medicare program.  42 C.F.R. § 424.519(f). 

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Because CMS has grounds for revoking Petitioners’ Medicare enrollments 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, it 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, 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 Petitioners to its preclusion list because their Medicare privileges were revoked for conduct detrimental to the best interests of the Medicare program, and they are under a reenrollment bar.  I have no authority to review CMS’s determination as to the length of time they remain 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.5  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; 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. 

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Review of Petitioners’ inclusion on the preclusion list.  My review here is limited to whether CMS had the authority to include Petitioners on the preclusion list.  42 C.F.R. § 498.3(b)(20); see 83 Fed. Reg. 16,642-16,643 (Apr. 16, 2018) (explaining that appeals are limited to the individual’s inclusion on the preclusion list). 

As discussed above, CMS revoked Petitioners’ Medicare enrollments because it correctly determined that Dr. Aguiluz had been affiliated with the hospice, Forever in Peace Hospice Care, Inc., whose Medicare billing privileges were revoked because it had abused its billing privileges.  Although Dr. Aguiluz did not personally submit the bills, and may have been oblivious to them, as the provider’s medical director, he 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 Dr. Aguiluz’s affiliation with Forever in Peace, Petitioners pose an “undue risk of fraud, waste, or abuse” to the Medicare program and revoked their enrollments.  Posing an “undue risk of fraud, waste, or abuse” is necessarily detrimental to the best interests of the Medicare program and its beneficiaries.  Because their enrollments were revoked for conduct deemed detrimental to the best interests of the Medicare program and its beneficiaries and because they are under a reenrollment bar, CMS is authorized to add Petitioners 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)). 

Having determined that CMS properly added Petitioners to the preclusion list, I have no authority to review CMS’s determination as to how long they remain 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 listed in section 498.3(b)). 

Conclusion

I affirm CMS’s determinations. 

CMS justifiably revoked Petitioners’ Medicare enrollments and imposed reenrollment bars because, based on Dr. Aguiluz’s affiliation with Forever in Peace Hospice Care, Inc., their enrollments pose 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 Petitioners on the preclusion list because their Medicare enrollments were revoked for conduct detrimental to the best interests of the Medicare program, and because they are under a reenrollment bar. 

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I have no authority to review the lengths of the reenrollment bars nor Petitioners’ time on the preclusion list.