Marianna Zadov, DAB CR7008 (2026)

DECISION

The Inspector General (IG) of the United States Department of Health and Human Services excluded Petitioner, Dr. Marianna Zadov, from participation in Medicare, Medicaid, and all other federal health care programs for a minimum period of 10 years pursuant to section 1128(a)(1) of the Social Security Act (Act) (42 U.S.C. § 1320a-7(a)(1)).  For the reasons discussed below, it is determined that the IG had a basis to exclude Petitioner from program participation, and a mandatory exclusion must be imposed.  Based on the facts and evidence presented in this case, I find that a 10-year exclusion is not unreasonable based on the presence of three aggravating factors and no mitigating factors. 

I.  Background and Procedural History

By notice letter dated December 31, 2025, the IG informed Petitioner that she was being excluded from participation in Medicare, Medicaid, and all federal health care programs for a minimum period of 11 years pursuant to section 1128(a)(1) of the Act.  The exclusion was imposed due to Petitioner’s conviction, in the Fifteenth Judicial Circuit Court in and for Palm Beach County, Florida, “of a criminal offense related to the delivery of an item or service under the Medicare or a State health care program, including the performance of management or administrative services relating to the

Page 2

delivery of items or services under such program.”  IG Exhibit (Ex.) 1.  The IG identified two aggravating factors to support extending the exclusion beyond the five-year mandatory minimum.  Id. 

The Civil Remedies Division (CRD) received Petitioner’s request for a hearing on February 26, 2026.  On March 26, 2026, at my direction, the CRD issued my Standing Pre-Hearing Order (Standing Order) and a letter, acknowledging receipt of Petitioner’s hearing request and notifying the parties that a telephone prehearing conference was scheduled for April 15, 2026 at 12:30 p.m. EST.  Petitioner requested an extension of the prehearing conference to seek counsel.  Petitioner’s request was granted, and the prehearing conference was rescheduled for June 9, 2026 at 11:00 a.m. EST.  On that date, both parties appeared for the prehearing conference and agreed to a briefing schedule.  An Order Following Prehearing Conference and Setting Briefing Schedule was issued on June 24, 2026.  (June 24, 2026 Order). 

On July 21, 2026, the IG filed a brief (IG Br.) along with five exhibits (IG Exs. 1-5).  On August 31, 2026, Petitioner filed a brief (P. Br.), along with six exhibits (P. Exs. 1-6).  On September 10, 2026, the IG filed a reply brief (IG Reply Br.) along with an amended exhibit list and two additional exhibits (IG Exs. 6-7).  It is important to note that IG Ex. 6 is an amended notice of exclusion that reduced Petitioner’s proposed exclusion to a minimum of 10 years and amended the aggravating factors. 

Petitioner filed a Motion for Leave to File Sur-Reply on September 11, 2026.  Petitioner’s request was granted, and she filed a reply (P. Reply Br.) on September 18, 2026. 

II.  Admission of Exhibits and Decision on the Written Record

At the prehearing conference, both parties indicated that an in-person hearing was not necessary to resolve this case.  The IG again indicated that an in-person hearing is not necessary to resolve this matter in its brief.  IG Br. at 5. 

As stated in the June 24, 2026 Order, a hearing will be held only if a party asks to cross-examine a witness for whom the opposing party has provided written direct testimony and the witness’ proposed testimony is found to be relevant and non-cumulative.  June 24, 2026 Order at 4-5; Civil Remedies Division Procedures § 19(d).  There are no proposed witnesses in this matter.  Therefore, a hearing is not necessary, and this matter will be decided on the written record. 

Absent objection, IG Exs. 1-7 are admitted into evidence.  The IG objected to P. Exs. 1-5, arguing that the exhibits are irrelevant and immaterial.  IG Reply Br. at 5.  The evidence submitted by Petitioner regarding billing and coverage of dental services is not relevant or material to the issues to be decided in this case.  Therefore, the IG’s objections to

Page 3

P. Exs. 1-5 are sustained.  P. Ex. 6 is admitted into evidence.  All evidence will be given the proper weight and consideration. 

III.  Issues

The issues to be decided are: 

1.  Whether the IG had a basis to exclude Petitioner from participation in Medicare, Medicaid, and all other federal health care programs under section 1128(a)(1) of the Act.  42 C.F.R. § 1001.2007(a)(1)(i). 

2.  Whether the 10-year exclusion imposed by the IG is unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii). 

IV.  Jurisdiction

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

V.  Findings of Fact

1.  Petitioner is a dentist licensed to practice in the State of Florida.  P. Br. at 1.  Petitioner, and her husband, owned and operated several dental clinics in multiple Florida counties including, “Happy Smiles”, Elite Dental, Polo Dental, and Royal Dental.  IG Ex. 4 at 2; IG Ex. 7 at 1-2. 

2.  On February 19, 2025,  a Criminal Information (Information) was filed in the Circuit Court accusing Petitioner of engaging in fraudulent billing practices with Medicaid recipients.  IG Ex. 4. 

3.  According to Count 1 of the Information, Petitioner directed employees and staff to lie and inform Medicare recipients that their dental work was not completely covered by Medicaid to collect additional fees.  Id.  Petitioner also used false billing codes, not covered under Medicaid, to conceal their scheme to defraud Medicaid recipients.  Petitioner threatened to deny treatment to Medicaid recipients who would not pay the additional fraudulent co-pays and fees.  Lastly, Petitioner submitted claims to Medicaid for services that were never provided to Medicaid recipients.  Id. 

4.  Count 2 of the Information accused Petitioner and her husband of engaging in a conspiracy while obtaining monies from customers through the collection of unlawful dental fees.  Id at 16. 

Page 4

5.  Petitioner entered into a plea agreement in which she admitted guilt to Counts 1 and 2 of the Information, both felonies.  IG Ex. 2. 

6.  On May 15, 2025, the Circuit Court accepted Petitioner’s guilty plea and adjudicated her guilty on Counts 1 and 2 of the Information.  Petitioner was found guilty of one count of Racketeering Influenced and Corrupt Organizations Act (RICO) and one count of Conspiracy, both first-degree felonies.  IG Ex. 3 at 1, 6.  Petitioner was sentenced to two years of community control (house arrest), placed on eight years of probation, and ordered to pay $1,470,912.98 in restitution.  Id. at 3, 6. 

VI.  Legal Authorities

The Secretary of the United States Department of Health and Human Services (Secretary) shall exclude an individual from participation in Medicare, Medicaid, and all other federal health care programs if that individual has been convicted of a criminal offense related to the delivery of an item or service under Medicare or any state health care program.  42 U.S.C. § 1320a-7(a)(1).  The Act requires a minimum exclusion period of five years when the exclusion is mandated under section 1320a-7(a).  42 U.S.C. § 1320a-7(c)(3)(B). 

In exclusion cases, the IG has the burden of proving the basis for the exclusion and the existence of any aggravating factors.  42 C.F.R. § 1005.15(c); Standing Order ¶ 6.  Petitioner has the burden of proving any affirmative defenses or factors to mitigate the length of the exclusion if aggravating factors have been established.  42 C.F.R. § 1001.102(c); Standing Order ¶ 6.  The standard of proof is a preponderance of the evidence, which means a fact is proven if the evidence shows that it is more likely true than not true.  42 C.F.R. §§ 1001.2007(c), 1005.15(d).  In this case, the IG must prove that Petitioner was convicted of an offense related to the delivery of an item or service under Medicare or a state health care program. 

An excluded individual may request a hearing before an administrative law judge (ALJ), but only on the issues of whether the IG had a basis for the exclusion and whether an exclusion longer than the required minimum period is unreasonable in light of any applicable aggravating and mitigating factors.  42 C.F.R. §§ 1001.2007(a), 1005.2(a). 

VII.  Analysis and Conclusions of Law

1.  Petitioner was convicted of a criminal offense related to the delivery of an item or service under the Medicare program, which subjects her to a mandatory exclusion from all federal health care programs for a minimum of five years. 

Page 5

To prevail, the IG must prove that Petitioner was convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program.  42 U.S.C. § 1320a-7(a)(1); 42 C.F.R. § 1001.101(a).  Under the Act, an individual is considered to have been convicted of a criminal offense when “a plea of guilty or nolo contendere by the individual or entity has been accepted by a Federal, State, or local court . . .”  Act § 1128(i)(3), (4) (42 U.S.C. § 1320a-7(i)(3), (4)); see also 42 C.F.R. § 1001.2 (paragraphs (a), (c), and (d) under the definition of “Convicted”).  It is undisputed that the Circuit Court accepted Petitioner’s guilty plea and adjudicated her guilty on May 15, 2025. IG Ex. 3.  Petitioner does not dispute that she was convicted of two felony offenses.  P. Br. at 1. 

Next, to prove that Petitioner’s conviction was related to the delivery of an item or service under Medicare, the IG must show a nexus between the offense and the delivery of an item or service under Medicare.  The Departmental Appeals Board (Board) has repeatedly held that the phrase “related to” within the context of section 1128(a)(1) requires only that a common-sense nexus exist between the offense and the delivery of an item or service under Medicare.  Summit S. Shah, M.D., DAB No. 2836 at 6 (2017) (citing cases).  The Departmental Appeals Board (Board) has also ruled that “when determining whether a requisite nexus exists, an ALJ may consider evidence as to the nature of the offense, including the facts upon which the conviction was predicated.”  Janice Cassandra Wrenn, DAB No. 3118 (2023).  In this case, Petitioner is a dentist who owned and operated several dental clinics and was convicted of two felony offenses for fraudulently billing Medicaid recipients and submitting claims to Medicaid for services that were never actually rendered. IG Exs. 2, 5.  The evidence shows that Petitioner’s conviction is related to the delivery of an item or service under Medicare. Therefore, the IG has a legal basis to impose an exclusion against Petitioner. 

2.  The IG identified three aggravating factors that support an exclusion beyond the five-year minimum. 

Exclusions imposed under section 1128(a)(1) carry a five-year mandatory minimum exclusion period.  Act § 1128(c)(3)(B) (42 U.S.C. § 1320a-7(c)(3)(B)); 42 C.F.R. § 1001.102(a).  The IG may extend the five-year exclusion period based on the application of the aggravating factors listed in 42 C.F.R. § 1001.102(b).  If any of the aggravating factors set forth in 42 C.F.R. § 1001.102(b) justifies an exclusion longer than five years, mitigating factors listed at 42 C.F.R. § 1001.102(c) may be considered as a basis for reducing the period of exclusion to no less than five years.  In this case, the IG has proposed a 10-year exclusion based on three aggravating factors and no mitigating factors.  Petitioner is requesting that the exclusion be reduced to the five-year mandatory minimum.  P. Br. at 1. 

The IG identified the following aggravating factors as a basis for imposing a 10-year exclusion against Petitioner:  loss to a government program or other entities as a result of

Page 6

Petitioner’s criminal conduct was greater than $50,000 and the acts that resulted in the conviction, or similar acts, were committed over a period of one year or more, and the acts that resulted in conviction, or similar acts, had significant adverse physical, mental, or financial impact on one or more program beneficiaries or other individuals.  IG Ex. 6; 42 C.F.R. § 1001.102(b)(1)-(2).  Each factor is discussed below. 

A.  The acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government program, or one or more other entities, of $50,000 or more. 

The first aggravating factor identified by the IG is “the acts that resulted in Petitioner’s conviction caused or were intended to cause a financial loss of $50,000 or more to a government program or one or more other entities”.  IG Ex. 6. The Circuit Court ordered Petitioner, and another defendant, to pay $1,470,912.98 in restitution stating, “[a]ll available [r]estitution will be distributed to victims including but not limited to Medicaid Recipients, The Agency for Health Care Administration, The Office of Statewide Prosecution for the Costs of Prosecution, Fines and any administrative costs.”  IG Ex. 3 at 3. 

The initial Notice of Exclusion identified the restitution amount as $1,470,900.  IG Ex. 1.  However, in the amended Notice of Exclusion the IG notes that the District Court ordered Petitioner to pay $62,400 in restitution to the Medicaid program and $1,408,400 in restitution to Medicaid beneficiaries who were the victims of Petitioner’s crimes.  IG Reply Br. at 2.  The attorney general’s office offered the following loss calculations regarding Petitioner’s case:  the loss attributed to Medicaid fraud services not rendered and unusable dentures was $62,411.38, the loss for charging a Medicaid recipient a few for a covered or inclusive service was $963,351.60, and the loss for theft that involved orthodontics was determined to be $445,150.  IG Ex. 7 at 5.  Petitioner argues that the $62,400 is less than the initial figure cited by the IG and that this should be reflected in the length of her exclusion.  P. Reply Br. at 3. 

It is well-established that an amount ordered as restitution constitutes proof of the amount of financial loss to a government program or entity.  Yolanda Hamilton, M.D., DAB No. 3061 at 12-14 (2022).  It is undisputed that the Circuit Court ordered Petitioner to pay $1,470,912.98 to Medicaid recipients and several entities.  Even using the $62,411.38 amount, which is directly attributed to Medicaid fraud, the $50,000 threshold is met.  Therefore, the IG has established that the restitution amount may be used as an aggravating factor. 

B.  The acts that resulted in Petitioner’s conviction, or similar acts, were committed over a period of one year or more.

Page 7

The second aggravating factor identified by the IG is, “the acts that resulted in the conviction, or similar acts, were committed over a period of one year or more”.  “[T]he purpose of this aggravating factor ‘is to distinguish between petitioners whose lapse in integrity is short-lived from those who evidence a lack of such integrity over a longer period . . . .’”  Vinod Chandrashekhar Patwardhan, M.D., DAB No. 2454 at 7 (2012) (quoting Donald A. Burstein, Ph.D., DAB No. 1865 at 8 (2003)).  It is undisputed that the acts that resulted in Petitioner’s conviction occurred from approximately November 2018 to January 2022.  IG Ex. 3.  Defrauding Medicaid recipients and submitting fraudulent claims to the Medicaid program for over three years is indicative of deliberate participation and is not merely a temporary lapse in judgment.  The IG has proven the existence of a second aggravating factor, which is significant, and supports an enhancement to the mandatory minimum five-year exclusion. 

C.  The acts resulting in conviction, or similar acts, had a significant adverse physical, mental, or financial impact on one or more program beneficiaries or other individuals. 

The regulations provide that an aggravating factor is present if, “acts that resulted in the conviction, or similar acts, had a significant adverse physical, mental or financial impact on one or more program beneficiaries or other individuals.” 42 C.F.R. § 1001.102(b)(3).  Here, the IG argues, and the evidence shows that Petitioner’s actions had a significant adverse financial impact on several Medicaid recipients. 

In the final rule promulgating 42 C.F.R. § 1001.102(b)(3), the Secretary stated in response to public comments that “[t]o be an aggravating factor, we agree that the impact must be more than minimal, that is, it must have been significant.” 57 Fed. Reg. 3298, 3315 (Jan. 29, 1992).  In this case, the victims of Petitioner’s scheme were Medicaid recipients.  Medicaid is a program that provides free or low-cost health coverage for some people with limited income and resources, this includes low-income adults, pregnant women, the elderly , and people with disabilities1.  The Affidavit in Support of Arrest Warrants, shows that between November 3, 2018 and January 31, 2022, Petitioner received payments totaling $13,580 from Medicaid recipients for procedures covered or considered inclusive to a procedure covered under Medicaid. IG Ex. 5 at 6. During the same period, Petitioner received $1,300 from 10 Medicaid recipients for cleanings which were covered or considered inclusive to a procedure covered under Medicaid. Similarly, nine Medicaid recipients were charged $1,495 in fees for fillings, again procedures that were covered or considered inclusive to a procedure covered under Medicaid.  Id.  This is just a small example of the extra fees that Petitioner collected.  The warrant lists numerous Medicaid recipients who were impacted by Petitioner’s fraudulent scheme and the amounts that they paid ranging from $200 to $1440.  IG Ex. 5 at 7-14.  Regardless of the amount of loss incurred by each victim,  I find that fraudulent and unnecessary fees

Page 8

charged to Medicaid recipients for dental care resulted in significant adverse financial impact. 

Based on information provided by the State of Florida Office of the Attorney General Medicaid Fraud Unit, the IG argues that $1,408,400 in restitution is due to Medicaid recipients who were victims of Petitioner’s crimes.  IG Reply Br. at 2.  Petitioner correctly argues that the Circuit Court did not make the allocation but admits that it is anticipated that the State would later file an accounting of how the restitution funds should be distributed.  P. Reply Br. at 4.  I have no reason to doubt that the Attorney General’s allocation is accurate.  As stated, the Circuit Court’s order includes victims in the $1,400,912.98 restitution order.  The evidence presented by the IG shows that the acts that resulted in Petitioner’s conviction resulted in significant adverse impact to Medicaid recipients.  Therefore, the IG has proven the existence of a third aggravating factor. 

3.  The parties have not identified any mitigating factors that may be considered to reduce the length of Petitioner’s exclusion. 

The regulations provide three mitigating factors that may be considered to reduce an exclusion to no less than five years if aggravating factors are present:  (1) a petitioner was convicted of three or fewer misdemeanor offenses and the resulting financial loss to the program was less than $5,000; (2) the record in the criminal proceedings demonstrates that the court determined that a petitioner had a mental, physical, or emotional condition before or after the commission of the offense that reduced their culpability; and (3) a petitioner’s cooperation with federal or state officials resulted in others being convicted or excluded, additional cases being investigated, or a civil money penalty being imposed.  42 C.F.R. § 1001.102(c). 

Petitioner provides an in-depth argument concerning “inclusive” and non-covered Medicaid services and argues that there is a difference between administrative billing practices and clinical decision making.  P. Br. at 3.  Petitioner states that management guidance concerning fees or coding should not be equated with proof that she caused for the fabrication of clinical services that were not rendered.  Id.  However, these are not issues to be addressed in this forum.  Petitioner’s arguments amount to collateral attacks on her underlying conviction.  Collateral attacks of the convictions that provide the basis of the exclusion are prohibited by the regulations.  42 C.F.R. § 1001.2007(d). 

Petitioner also notes that the Florida Department of Health may refuse to renew the license of a health professional when the applicant is listed on the IG’s List of Excluded Individuals and Entities.  P. Br. at 8.  This is particularly concerning for Petitioner because she has reached a tentative disciplinary resolution with the Florida Department of Health to return to practice in two years, which makes a 10-year exclusion even more impactful.  P. Br. at 8.  However, this is not a factor that I may consider when

Page 9

determining whether the length of the exclusion is unreasonable, as it is not one of the mitigating factors defined by the regulations. 

The parties have not identified any mitigating facts that may be considered to reduce the length of Petitioner’s exclusion. 

4.  Based on the three aggravating factors and no mitigating factors, I find that the 10-year exclusion imposed by the IG is not unreasonable. 

In determining whether the length of exclusion is unreasonable, I must determine whether the length of the exclusion falls into a “reasonable range” based on the evidence submitted.  The regulations provide that the IG’s proposed exclusion must be upheld as long as the length of exclusion is not unreasonable.  42 C.F.R. § 1001.2007(a)(1)(ii).  It is important to note that it is the quality of the aggravating (or mitigating) factors that is most important when considering the length of exclusion and not the sheer number of aggravating factors that are present in a given case.  The Secretary stated in the preamble to the final rule establishing the exclusion regulations that: 

We do not intend for the aggravating and mitigating factors to have specific values; rather, these factors must be evaluated based on the circumstances of a particular case.  For example, in one case many aggravating factors may exist, but the subject’s cooperation with the OIG may be so significant that it is appropriate to give that one mitigating factor more weight than all of the aggravating.  Similarly, many mitigating factors may exist in a case, but the acts could have had such a significant physical impact on program beneficiaries that the existence of that one aggravating factor must be given more weight than all of the mitigating.  The weight accorded to each mitigating and aggravating factor cannot be established according to a rigid formula, but must be determined in the context of the particular case at issue. 

57 Fed. Reg. 3298, 3314-15 (Jan. 29, 1992). 

Petitioner states that the record supports the mandatory minimum exclusion.  P. Br. at 11.  I disagree.  Petitioner not only directed employees and staff to lie to Medicaid recipients collect additional fees, but she also threatened to deny dental treatment to those who would not pay the fraudulent co-pays and fees.  IG Ex. 4 at 2.  I find Petitioner’s actions to be quite alarming.  Here, the aggravating factors are significant and carry much weight.  For over three years, Petitioner knowingly and willingly imposed fraudulent fees on Medicaid recipients for her own personal gain.  Again, this was not a short-lived scheme that showed a temporary lapse of judgment, it was deliberate behavior that shows

Page 10

Petitioner’s lack of integrity and trustworthiness.  This is the exact behavior that should be excluded from federal healthcare programs.  The significant adverse financial impact on the victims cannot be ignored.  The amount of restitution, and the length of the fraudulent scheme are significant aggravating factors which justify an exclusion substantially longer than the mandatory minimum.  Based on the facts of this case, I find that the IG was very gratuitous in imposing a 10-year exclusion and that the length of the exclusion is not unreasonable. 

VIII.  Conclusion

For the foregoing reasons, I find that the IG has proven, by a preponderance of the evidence, that Petitioner was convicted of an offense that requires exclusion under section 1128(a)(1) of the Act.  I find that a 10-year exclusion is not unreasonable based on three aggravating factors and no mitigating factors.