Stanley Librach, DAB CR6965 (2026)

DECISION

I affirm the 20-year exclusion of Petitioner, Stanley Librach, from participation in all federal health care programs.

I. Background and Procedural History

In a December 31, 2025 notice, the Inspector General (IG) of the United States Department of Health and Human Services excluded Petitioner from participation in all federal health care programs under section 1128(a)(1) and (4) of the Social Security Act (42 U.S.C. § 1320a-7(a)(1), (4)) for 20 years due to his conviction in the United States District Court for the Eastern District of Missouri (District Court) of a criminal offense related to the delivery of an item or service under Medicare or a state health care program, and due to his conviction of a felony offense related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.  IG Ex. 1 at 1.  The notice alleged that the following four aggravating factors provided a basis to lengthen the exclusion from the statutorily required minimum 5 years to 20 years:

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• The District Court ordered Petitioner to pay approximately $2,874,200 in restitution.
• The acts that resulted in the conviction, or similar acts, occurred from about October 2013 to about April 2018.
• The District Court sentenced Petitioner to 60 months of incarceration.
• The Missouri Board of Registration for the Healing Arts revoked Petitioner’s medical license based on the same set of circumstances the IG used to impose the exclusion.

IG Ex. 1 at 1-2; see 42 C.F.R. § 1001.102(b).  Finally, the notice stated that the exclusion would take effect 20 days after the date on the notice.  IG Ex. 1 at 1.

Petitioner timely requested a hearing to dispute the imposition and length of the exclusion.  On March 23, 2026, the Civil Remedies Division acknowledged receipt of the hearing request, gave notice of a telephonic prehearing conference, and issued my Standing Order and the Civil Remedies Division Procedures (CRDP).  On May 6, 2026, I held a telephonic prehearing conference with the parties, the substance of which is summarized in my May 7, 2026 Order Following Prehearing Conference.  At the conference, the parties agreed on a prehearing exchange schedule.

On June 1, 2026, the IG submitted a prehearing exchange consisting of a brief (IG Br.) and five proposed exhibits (IG Exs. 1-5).  Petitioner did not submit a prehearing exchange.

II. Admission of Exhibits

In the absence of an objection, I admit IG Exhibits 1 through 5 into the record.  Standing Order ¶ 13; see 42 C.F.R. § 1005.8(c).  Petitioner did not offer any marked exhibits.

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III. Decision on the Written Record

I directed the parties to submit written direct testimony from all witnesses that the parties wanted to present and advised that the opposing party could request to cross-examine the witnesses.  Standing Order ¶¶ 11-12; see also 42 C.F.R. § 1005.16(b).  I also stated:

I will not conduct a hearing in this case unless a party files admissible, written direct testimony, and the opposing party asks to cross-examine one or more witnesses.  If I do not conduct a hearing, then I will issue a decision based on the written record.

Standing Order ¶ 12.

All deadlines for submitting prehearing exchanges have passed and neither party filed written direct testimony.  The IG affirmatively stated that witness testimony and an in-person hearing are not necessary.  IG Br. at 10.  Therefore, I do not need to hold an in-person hearing and may issue a decision based on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 12 (2022); EI Med., Inc., DAB No. 3117 at 15 (2023).

IV. Issues

1) Whether the IG had a legitimate basis to exclude Petitioner from participation in all federal health care programs under 42 U.S.C. § 1320a-7(a)(1) and/or (a)(4).

2) Whether a 20-year length of exclusion is unreasonable.

V. Jurisdiction

I have jurisdiction to adjudicate this case.  42 U.S.C. § 1320a-7(f)(1); 42 C.F.R. §§ 1001.2007, 1005.2.

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

1. Petitioner pleaded guilty to federal felony offenses involving a conspiracy against the United States, illegal prescribing of controlled substances, illegal kickback referrals, and a health care fraud scheme.  The District Court adjudged Petitioner guilty of those crimes, sentenced him to 60 months imprisonment, and ordered him to pay more than $2.8 million dollars in restitution to the Medicare and Medicaid programs.  Based on the criminal conviction, the state of Missouri revoked Petitioner’s medical license.

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On April 27, 2022, a grand jury empaneled by the District Court returned a 44-count Superseding Indictment against Petitioner and three co-conspirators.  IG Ex. 2.  In July 2024, Petitioner entered into a Guilty Plea Agreement with the United States in which Petitioner agreed to plead guilty to Counts 1, 5, 30, and 39 of the Superseding Indictment.  IG Ex. 3.  In doing so, Petitioner pleaded guilty to the following crimes:  Conspiracy (42 U.S.C. § 371), Illegally Prescribing Controlled Substances (21 U.S.C. § 841(a)(1); 18 U.S.C. § 2); Illegal Kickbacks for Referrals (42 U.S.C. § 1320a-7b(b)(1)(B); 18 U.S.C. § 2); and Health Care Fraud Scheme (18 U.S.C. §§ 2, 1347).  IG Ex. 2 at 10, 23, 27, 31-32; IG Ex. 3 at 1-4.

In the Guilty Plea Agreement, Petitioner admitted specific facts related to the charges he pleaded guilty to committing.  Petitioner was a physician licensed to practice medicine in Missouri.  Petitioner owned, operated, or served as the medical director for multiple health care entities.  Petitioner’s criminal acts involved other health care providers who also owned, operated, or served as the medical director for health care entities.  IG Ex. 3 at 5-6.

Petitioner admitted that he and his co-conspirators referred urine specimens to a laboratory owned or operated by one of Petitioner’s co-conspirators in exchange for payments to business entities owned by Petitioner’s co-conspirators.  Further, Petitioner knew that the co-conspirator who owned the laboratory billed the Medicare and Medicaid programs for tests performed as the result of illegal kickbacks.  IG Ex. 3 at 6.

Petitioner also admitted that he and other co-conspirators “created and caused to be issued prescriptions outside the usual course of professional conduct with no legitimate medical purpose.  [Petitioner] admits that he and [a co-conspirator] had not examined or determined that the patients whose names appeared on the prescriptions had a medical need for the controlled substance medications.  [Petitioner] further admits that he knew pharmacies would submit reimbursement claims to Medicare and Medicaid for the medications obtained through the use of these prescriptions.”  IG Ex. 3 at 6.

On June 20, 2025, the District Court issued a Judgment in a Criminal Case in which Petitioner was “adjudged guilty” of:

• 18 U.S.C. § 371 Conspiracy to Commit Offenses Against the United States;
• 42 U.S.C. § 1320a-7b(b)(1)(B) Illegal Kickbacks for Referrals;
• 18 U.S.C. § 1347(a)(2) Health Care Fraud; and
• 21 U.S.C. § 841(a)(1) and 18 U.S.C. § 2 Illegally Prescribing Controlled Substances.

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IG Ex. 4 at 1.  The District Court sentenced Petitioner to 60 months of imprisonment for each of the four crimes he committed, to be served concurrently.  IG Ex. 4 at 2.  Finally, the District Court ordered Petitioner to pay $2,874,207.29 in restitution to the Centers for Medicare & Medicaid Services.  IG Ex. 4 at 6.

On September 5, 2025, the Missouri State Board of Registration for the Healing Arts (Missouri Board) revoked Petitioner’s medical license.  IG Ex. 5.  The charges of misconduct leading to revocation were based on Petitioner’s guilty plea to four criminal charges before the District Court because “said charges are felonies, involve fraud and dishonesty and are reasonably related to the qualifications, functions or duties of . . . the [Petitioner’s] profession.”  IG Ex. 5 at 2.  The Missouri Board reviewed the details of the Superseding Indictment and Guilty Plea Agreement.  IG Ex. 5 at 3-7.  The Missouri Board concluded that it “must revoke [Petitioner’s] physician and surgeon’s license” under Missouri law.  IG Ex. 5 at 8.

2. Petitioner was convicted of a criminal offense related to the delivery of an item or service under the Medicare and Medicaid programs; therefore, exclusion is required under 42 U.S.C. § 1320a-7(a)(1).

The IG must exclude an individual from participation in all federal health care programs if that individual was convicted under federal or state law of a criminal offense related to the delivery of an item or service under Medicare or a state health care program, such as Medicaid.1   42 U.S.C. § 1320a-7(a)(1).

There is no doubt that Petitioner was convicted of criminal offenses because he pleaded guilty to four counts of the Superseding Indictment, the District Court accepted that plea, and the District Court issued a judgment of conviction.  42 U.S.C. § 1320a-7(i)(1), (3); IG Exs. 3-4.

There is also no doubt that Petitioner’s criminal offenses related to the delivery of an item or service under the Medicare and Medicaid Programs.  In the Guilty Plea Agreement, Petitioner admitted that his conspiracy to commit health care fraud and kickback scheme resulted in payment of over $2.8 million in fraudulent claims by the Medicare program, the Missouri Medicaid Program, and Tricare.  IG Ex. 3 at 17.  Further, Petitioner’s conspiracy also included the submission of Medicare and Medicaid claims related to controlled substantives based on improper prescribing practices.  IG Ex. 3 at 17.

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Petitioner’s criminal offense is related to the delivery of an item or service under the Medicare and Medicaid programs.  For purposes of exclusion, the term “related to” simply means that there must be a nexus or common-sense connection.  See Quayum v. U.S. Dep’t of Health & Hum. Servs., 34 F. Supp. 2d 141, 143 (E.D.N.Y. 1998); see also Baxter v. Kennedy, 136 F.4th 70, 86 (4th Cir. 2025) (holding that mandatory exclusion under § 1320a-7(a)(1) means that the conviction must “merely . . . be related to . . . a delivery [of an item or service].  So there was no need to prove that [the excluded individual’s company] shipped an item to an identified [Medicaid participant].  The causal chain that [the excluded individual] pleaded to–misbranding as an attempt to get [Medicaid] to cover [a new medication]–is more than enough.”); Friedman v. Sebelius, 686 F.3d 813, 820 (D.C. Cir. 2012) (describing the phrase “relating to” in another part of section 1320a-7 as “deliberately expansive words,” “the ordinary meaning of [which] is a broad one,” and one that is not subject to “crabbed and formalistic interpretation”) (internal quotation marks omitted).

A conviction involving false claims submitted to the Medicare and/or Medicaid programs is “related to” the delivery of an item or service under those programs.  See Travers v. Shalala, 20 F.3d 993, 998 (9th Cir. 1994) (conviction for filing false claims with the Medicaid program is “a program-related offense” and “such financial misconduct is exactly what Congress sought to discourage” through imposing exclusions.); Kahn v. Inspector Gen. of the U.S. Dep’t of Health & Hum. Servs., 848 F. Supp. 432, 434, 436 (S.D.N.Y. 1994) (concluding that a podiatrist’s conviction for attempted grand larceny was program-related for purposes of an exclusion because it was related to the filing of false Medicaid claims); Greene v. Sullivan, 731 F. Supp. 835, 838 (E.D. Tenn. 1990) (“There is no question that Mr. Greene’s crime [of filing false claims] resulted in a Medicaid overpayment and was a program-related crime triggering the mandatory exclusion under Section 1320a-7(a).”).

Because Petitioner was convicted of criminal offenses directly related to fraudulent and improper claims made to the Medicare and Medicaid programs, Petitioner is subject to a mandatory exclusion under 42 U.S.C. § 1320a-7(a)(1).

3. Petitioner was convicted of a felony related to the unlawful distribution, prescription, or dispensing of a controlled substance; therefore, exclusion is required under 42 U.S.C. § 1320a-7(a)(4).

The IG must exclude an individual from participation in any federal health care program if that individual:

[H]as been convicted for an offense which occurred after August 21, 1996, under Federal or State law, of a criminal offense consisting of a felony relating to the unlawful

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manufacture, distribution, prescription, or dispensing of a controlled substance.

42 U.S.C. § 1320a-7(a)(4).  This exclusion provision applies to, among others, health care practitioners.  42 C.F.R. § 1001.101(d)(1).

In the present case, the record supports the conclusion that the elements for a mandatory exclusion are met.  Petitioner was a health care practitioner because he was licensed as a physician in Missouri in 1994.  IG Ex. 5 at 3.  Further, Petitioner admitted in the Guilty Plea Agreement that he was guilty of Illegally Prescribing Controlled Substances in violation of 21 U.S.C. § 841(a)(1).  IG Ex. 2 at 24-25, 27; IG Ex. 3 at 13-14.  Specifically, Petitioner admitted that he and another co-conspirator would pre-sign controlled substance prescriptions for patients without examining or evaluating the patients to whom the prescriptions would be given.  IG Ex. 3 at 13.  Petitioner admitted that this conduct was outside the usual course of professional practice.  IG Ex. 3 at 14.  Further, Petitioner admitted that, despite the fact that patients would repeatedly test negative for the controlled substances Petitioner was prescribing, but would test positive for controlled substances not prescribed by Petitioner, he failed to address “the obvious diversion of the prescribed controlled substances by [Petitioner’s and his co-conspirator’s] patients.”  IG Ex. 3 at 14.  Because Petitioner was convicted of a felony directly related to the unlawful prescribing of controlled substances, Petitioner is subject to a mandatory exclusion under 42 U.S.C. § 1320a-7(a)(4).

4. Petitioner must be excluded for a minimum of five years.

Because I have concluded that a basis exists to exclude Petitioner under 42 U.S.C. § 1320a-7(a)(1) and (a)(4), Petitioner must be excluded for a minimum of five years.  42 U.S.C. § 1320a-7(c)(3)(B).

5. The IG has proven that four aggravating factors exist in this case to extend the length of exclusion beyond the minimum five-year requirement.

Although individuals excluded under 42 U.S.C. § 1320a-7(a)(1) and/or (a)(4) must be excluded for a minimum of five years, the statute does not preclude a longer term of exclusion.  The applicable regulations provide a list of aggravating factors that may serve as the basis for extending an exclusion beyond five years.  42 C.F.R. § 1001.102(b).  As explained below, the IG proved the existence of four aggravating factors listed in the regulations.  Further, Petitioner does not dispute that the aggravating factors identified by the IG exist in this case.  See H’rg Req.

1. Petitioner agreed to pay over $2.8 million in restitution for the loss caused to victims by his crimes, and the District Court ordered

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1. Petitioner to pay that amount of restitution to the Centers for Medicare & Medicaid Services.

The regulations provide the following as an 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 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).

42 C.F.R. § 1001.102(b)(1).

In the Guilty Plea Agreement, Petitioner agreed to the following:  “Regardless of the Count of conviction, the amount of mandatory restitution imposed shall include all amounts allowed by section 3663A(b) and the amount of loss agreed to by the parties, including all relevant conduct loss.  [Petitioner] agrees to provide full restitution to all victims of all charges in the indictment, and the parties stipulate that the amount of restitution as to the [Petitioner] is $2,874,207.29.”  IG Ex. 3 at 25-26.  The District Court ordered Petitioner to pay $2,874,207.29 in restitution to the Centers for Medicare & Medicaid Services.  IG Ex. 5 at 6.  It is well-established that an amount ordered as restitution constitutes proof of the amount of financial loss to a government program.  See, e.g., Juan de Leon, Jr., DAB No. 2533 at 5 (2013); Jason Hollady, M.D., DAB No. 1855 (2002).  Therefore, I conclude the IG proved this aggravating factor.

2. The District Court sentenced Petitioner to 60 months of imprisonment.

The regulations provide the following as an aggravating factor:  “The sentence imposed by the court included incarceration.”  42 C.F.R. § 1001.102(b)(5).  The District Court sentenced Petitioner to 60 months of imprisonment.  IG Ex. 5 at 2.  Therefore, I conclude that the IG proved this aggravating factor.

3. Petitioner’s acts that resulted in conviction, or similar acts, were committed for more than one year.

The regulations provide the following as an aggravating factor:  “The acts that resulted in conviction, or similar acts, were committed over a period of one year or more.”  42 C.F.R. § 1001.102(b)(2).  Petitioner admitted that his conspiracy against the United States began in or about October 2013 and ended in or about April 2018.  IG Ex. 3 at 16.

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Petitioner admitted that his other crimes took place in 2016 and 2017.  IG Ex. 3 at 17-19.  Therefore, I conclude that the IG proved this aggravating factor.

4. Petitioner was subject to an adverse action by a state board based on the same set of circumstances that served as the basis for the exclusion.

The regulations provide the following as an aggravating factor:  “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.”  42 C.F.R. § 1001.102(b)(9).  The Missouri Board revoked Petitioner’s medical license based on Petitioner’s criminal conviction in the District Court.  IG Ex. 5 at 5-6.  This conviction serves as the basis for the IG’s exclusion.  IG Ex. 1 at 1.  Therefore, I conclude that the IG proved this aggravating factor.

6. Petitioner did not prove the existence of any mitigating factors listed in the regulations to reduce the length of exclusion imposed by the IG.

If there are aggravating factors that justify increasing the length of exclusion to exceed five years, then the length of exclusion can be reduced if certain mitigating factors listed in the regulations are present in a case.  42 C.F.R. § 1001.102(c).  In mitigation, Petitioner asserts that he is currently serving his debt to society in prison and that “it is in the best interest of the public for me to resume helping the underserved, underprivileged, and debilitated patients that I treat.”  Hr’g Req.  However, this is not a mitigating factor listed in the regulations; therefore, I cannot consider it to reduce the length of exclusion.  Baldwin Ihenacho, DAB No. 2667 at 8 (2015).

7. The 20-year length of Petitioner’s exclusion is not unreasonable based on a qualitative analysis of 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).  However, an excluded individual’s age, financial condition, and employment prospects are not considered.  Jeremy Robinson, DAB No. 1905 (2004); Zahid Imran, M.D., DAB No. 2680 at 14 (2016).  Ultimately, I must decide whether the 20-year length of exclusion is unreasonable, i.e., whether it is within a reasonable range 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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When conducting this analysis, it is important to note that health care providers do not have a fundamental right to participate in federal health care programs; therefore, an exclusion only needs to be rationally related to a legitimate government interest, such as patient health or protecting federal health care programs from fraud and abuse.  Parrino v. Price, 869 F.3d 392 (6th Cir. 2017).  For exclusions, the trustworthiness of the excluded individual is a key question.  See Morgan v. Sebelius, 694 F.3d at 538 (4th Cir. 2012) (“[T]he legislative history to § 1320-7(a)(3) as it was originally enacted indicates that it was specifically intended to protect federal programs from untrustworthy individuals . . . .”); see also Susan Malady, R.N., DAB No. 1816 at 9 (2002).  Because the purpose of an exclusion is to protect federal health care programs from fraud and abuse, it is remedial and not punitive.  Manocchio v. Kusserow, 961 F.2d 1539, 1541-42 (11th Cir. 1992).

Turning to the aggravating factors in this case, Petitioner caused more than $2.8 million in loss to the Medicare and Medicaid programs.  This is 57 times the minimum $50,000 amount in loss to make the loss an aggravating factor.  This factor requires the imposition of a lengthy exclusion.

Further, Petitioner engaged in conspiracy to commit health care fraud that lasted four and a half years.  This multi-year length of criminal conduct involving fraud weighs heavily against a finding of Petitioner’s trustworthiness to participate in federal programs.  See Janice Cassandra Wrenn, DAB No. 3118 at 17 (2023).  Further, such lengthy misconduct shows that Petitioner is a significant threat to federal health care programs.

Petitioner was also sentenced to 60 months in prison.  A prison sentence of as little as nine months is relatively substantial for exclusion purposes.  Hollady, DAB No. 1855 at 12.  Petitioner’s sentence is more than six times longer than the nine months in Hollady and constitutes a significant basis to increase the length of exclusion.

Petitioner’s medical license was also revoked by the Missouri Board.  The Missouri Board, after reviewing Petitioner’s crimes and conviction in detail, determined that Petitioner’s medical license must be revoked.  IG Ex. 5 at 8.  Further, the Missouri Board ordered that Petitioner could not seek reinstatement of his medical license for seven years, which is the longest period of time that the Missouri Board could impose.  IG Ex. 5 at 9.  This is significant and further supports a long exclusion.

Petitioner believes that “[t]he argum[e]nts for a 20-year exclusion are substantively weak.”  Hr’g Req.  I disagree.  Petitioner worked in combination with other health care providers for years committing health care fraud on the Medicare and Medicaid programs, resulting in nearly $3 million in losses.  Further, Petitioner was convicted of multiple crimes and, as a result, met two separate provisions that mandate exclusion.  Petitioner is a significant threat to federal health care programs.  Therefore, I conclude

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that the 20-year length of exclusion for Petitioner is reasonable and necessary to serve the remedial purpose of protecting federal health care programs from fraud.

VII. Conclusion

I affirm the IG’s determination to exclude Petitioner for 20 years from participating in all federal health care programs under 42 U.S.C. § 1320a-7(a)(1) and (a)(4).