Debra S. Bailey, Ph.D. , DAB CR5534 (2020)

DECISION

The Centers for Medicare & Medicaid Services (CMS), acting through its administrative contractor, National Government Services, Inc. (NGS), revoked the Medicare enrollment and billing privileges of Debra S. Bailey, Ph.D. (Petitioner or Dr. Bailey) pursuant to 42 C.F.R. § 424.535(a)(3) and (a)(9) because, within the preceding ten years, Dr. Bailey was convicted of a felony offense that CMS determined was detrimental to the best interests of the Medicare program and its beneficiaries and because she failed to report that felony conviction to NGS, contrary to the reporting requirement found at 42 C.F.R. § 424.516(d)(1)(ii).  Dr. Bailey does not deny that she was convicted of a felony but contends that her offense is not detrimental to the best interests of the Medicare program and its beneficiaries.  She also admits that she did not report her conviction to CMS but argues that her failure to report should be excused because, in her view, the conviction did not relate to her license to practice psychology.

For the reasons discussed below, I reject Petitioner’s arguments and conclude that CMS had a basis to revoke her Medicare enrollment and billing privileges.  Accordingly, I affirm the revocation.

Page 2

I.  Background

Petitioner is a licensed psychologist who resides in Connecticut and was enrolled as a supplier of Medicare services.  CMS Exhibit (Ex.) 2 at 1-2; Petitioner’s (P.) Ex. 1 at 1.  On February 9, 2016, Petitioner was found guilty, pursuant to a plea of nolo contendere, of violating Conn. Gen. Stat. §§ 14-227a (prohibiting operation of a motor vehicle while under the influence of intoxicating liquor or any drug or both or while having an elevated blood alcohol content) and 14-224(a) (prohibiting evasion of responsibility in operation of motor vehicles involving an accident that causes the death of any person).  CMS Ex. 3.  The court ultimately sentenced Petitioner to pay a $500 fine; to serve ten years in jail, suspended after time served; and to three years of probation.  Id.

By letter dated July 3, 2017, NGS notified Petitioner that it was revoking her Medicare enrollment and billing privileges, effective February 9, 2016, under 42 C.F.R. § 424.535(a)(3) (felony conviction) and 42 C.F.R. § 424.535(a)(9) (failure to report).  CMS Ex. 1 at 1.  NGS also imposed a three‑year re‑enrollment bar.  Id. at 2.

In a letter dated August 3, 2017, Petitioner requested reconsideration.  CMS Ex. 5.  By letter dated November 9, 2017, CMS, through its Provider Enrollment & Oversight Group,1 issued an unfavorable reconsidered determination.  CMS Ex. 6.  In the reconsidered determination, CMS expressly found that Dr. Bailey’s conviction was for an offense detrimental to the Medicare program and its beneficiaries:

Dr. Bailey admits to pleading guilty to one felony count of Evade – Death or Serious Injury in violation of Connecticut General Statutes § 14-224(a), in the State of Connecticut Superior Court on February 9, 2016. . . . Dr. Bailey pleaded nolo contendere to leaving the scene of an accident which involved the injury or death of another person. . . .

. . . CMS . . . finds that Dr. Bailey’s felony conviction is detrimental to the Medicare program and its beneficiaries. CMS finds Dr. Bailey’s plea of nolo contendere involves accepting responsibility for, at minimum, the reckless endangerment of the life of at least one person, as well as leaving the scene of an accident before the arrival of the authorities. This behavior raises concern that Medicare beneficiaries and Trust Funds may be at risk if Dr. Bailey is allowed to continue to practice in the Medicare program because being part of the Medicare program involves the supplier’s

Page 3

propensity for good judgment. . . .  It necessarily follows that placing Trust Funds at risk is also a detriment to the beneficiaries.

CMS Ex. 6 at 5.

Petitioner requested a hearing, and the case was assigned to me.  I issued an Acknowledgment and Pre-Hearing Order (Pre-Hearing Order) dated January 24, 2018, in which I directed each party to file a pre-hearing exchange consisting of a brief and any supporting documents and also set deadlines for those filings.  Pre-Hearing Order ¶¶ 4-5.  I also explained that the parties should submit written direct testimony for any witnesses in lieu of in-person direct testimony.  Pre-Hearing Order ¶ 8.  Finally, I explained that a hearing would only be necessary to cross-examine witnesses, if any.  Pre‑Hearing Order ¶ 10.  In response to the Pre-Hearing Order, CMS filed a pre-hearing brief with incorporated motion for summary judgment (CMS Br.) and six proposed exhibits (CMS Exs. 1-6).  Petitioner filed a brief (P. Br.), a supplemental brief opposing summary judgment (P. Supp. Br.), and five proposed exhibits (P. Exs. 1-5).  Petitioner did not object to CMS’s proposed exhibits, and CMS did not object to P. Exs. 1-4.  See Pre‑Hearing Order ¶ 7.  CMS did, however, object to P. Ex. 5 (CMS Obj. (Docket Entry #7 in DAB E-File)).

In the absence of objection, I admit into the record CMS Exs. 1-6 and P. Exs. 1-4.  CMS argues that P. Ex. 5 should be excluded because it is new evidence that was not previously presented to CMS or its contractor.  CMS Obj. at 1-2.  Pursuant to 42 C.F.R. § 498.56(e), an administrative law judge must examine “any new documentary evidence submitted to the [administrative law judge] by a provider or supplier to determine whether the provider or supplier has good cause for submitting the evidence for the first time at the [administrative law judge] level.”  If the administrative law judge does not find good cause for the failure to submit the evidence earlier, the evidence must be excluded and may not be considered in reaching a decision.  42 C.F.R. § 498.56(e)(2)(ii).  Petitioner did not identify P. Ex. 5 as new evidence, nor did she argue that she had good cause to submit the evidence for the first time before me,2 although my Pre-Hearing Order instructed Petitioner to do so.  Pre-Hearing Order ¶ 6.  Nor did Petitioner respond to CMS’s objection.  Thus, Petitioner has not disputed that P. Ex. 5 is new evidence, nor has she made any showing of good cause for submitting the evidence for the first time before me.  Absent any showing of good cause, I am required to exclude P. Ex. 5.

Page 4

42 C.F.R. § 498.56(e)(2)(ii).  Accordingly, I sustain CMS’s objection and exclude P. Ex. 5 from the record.3

My Pre‑Hearing Order advised the parties that they must submit written direct testimony for any proposed witness and that an in-person hearing would only be necessary if the opposing party requested an opportunity to cross-examine a witness.  Pre‑Hearing Order ¶¶ 8-10; Civil Remedies Division Procedures (CRDP) §§ 16(b), 19(b); Pacific Regency Arvin, DAB No. 1823 at 7-8 (2002) (holding that the use of written direct testimony for witnesses is permissible so long as the opposing party has the opportunity to cross‑examine those witnesses).  Neither party offered the written direct testimony of any witness.  Consequently, an in-person hearing is not required, and I issue this decision based on the written record, without regard to whether the standards for summary judgment are met.  Pre‑Hearing Order ¶¶ 8-11; CRDP § 19(d).  I deny CMS’s motion for summary judgment as moot.

II.  Issue

The issue in this case is whether CMS had a legal basis to revoke Petitioner’s Medicare enrollment and billing privileges.

III.  Jurisdiction

I have jurisdiction to decide this case.  42 C.F.R. §§ 498.3(b)(17), 498.5(l)(2); see also Social Security Act (Act) § 1866(j)(8) (codified at 42 U.S.C. § 1395cc(j)(8)).

IV.  Discussion

A.   Statutory and Regulatory Framework

As a licensed psychologist, Petitioner is a supplier of health care services for purposes of the Medicare program.  See Act § 1861(d) (42 U.S.C. § 1395x(d)); 42 C.F.R. §§ 400.202 (definition of supplier), 410.71.  In order to participate in the Medicare program as a supplier, an individual must meet certain criteria to enroll and receive billing privileges.  42 C.F.R §§ 424.505, 424.510.  CMS may revoke the enrollment and billing privileges of a supplier for any reason stated in 42 C.F.R. § 424.535.  When CMS revokes a supplier’s Medicare billing privileges, CMS establishes a reenrollment bar for a period ranging

Page 5

from one to three years.  42 C.F.R. § 424.535(c).4  Generally, a revocation becomes effective 30 days after CMS mails the initial determination revoking Medicare billing privileges, but if the revocation is based on a felony conviction, the revocation is effective with the date of the conviction.  42 C.F.R. § 424.535(g).

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

1.    CMS had a legal basis to revoke Dr. Bailey’s Medicare enrollment and billing privileges pursuant to 42 C.F.R. § 424.535(a)(3) because, within the ten years prior to revocation, Dr. Bailey was convicted of a felony offense that CMS reasonably determined to be detrimental to the best interests of the Medicare program and its beneficiaries.5

CMS may revoke a supplier’s enrollment in the Medicare program if, within the preceding ten years, the supplier was convicted of a felony offense that CMS “has determined to be detrimental to the best interests of the Medicare program and its beneficiaries.”  42 C.F.R. § 424.535(a)(3)(i); see also Act § 1842(h)(8) (42 U.S.C. § 1395u(h)(8)) (authorizing the Secretary of Health and Human Services (Secretary) to deny or terminate enrollment after ascertaining that a supplier has been convicted of a felony offense the Secretary has determined is “detrimental to the best interests of the program or program beneficiaries”).  Offenses for which billing privileges may be revoked include—but are not limited to—felony crimes against persons, such as murder, rape, assault, and similar crimes; financial crimes such as extortion,embezzlement, income tax evasion, insurance fraud, and similar crimes; felonies that place the Medicare program or its beneficiaries at immediate risk (such as convictions for criminal neglect or misconduct); and felonies that would result in mandatory exclusion under section 1128 of the Act.  42 C.F.R. § 424.535(a)(3)(ii)(A)-(D).

Page 6

a.    Petitioner was convicted of a felony offense within the 10 years prior to revocation.

Section 424.535(a)(3) defines a conviction for which enrollment may be revoked by cross‑referencing the definition at 42 C.F.R. § 1001.2.  In turn, section 1001.2 provides:

Convicted means that—

(a) A judgment of conviction has been entered against an individual or entity by a Federal, State or local court, regardless of whether:

(1) There is a post-trial motion or an appeal pending, or

(2) The judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;

(b) A Federal, State or local court has made a finding of guilt against an individual or entity;

(c) A Federal, State or local court has accepted a plea of guilty or nolo contendere by an individual or entity; or

(d) An individual or entity has entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld.

Petitioner concedes that she pleaded nolo contendere to the charge of evading responsibility.  P. Supp. Br. at 3; CMS Ex. 3.  Specifically, Petitioner entered a nolo contendere plea to the charge that she violated Conn. Gen. Stat. § 14-224(a).6

  CMS Ex. 3.  Any person found guilty of violating Conn. Gen. Stat. § 14-224(a) is subject to a sentence of at least two and no more than twenty years in prison.  Conn. Gen. Stat.

Page 7

§ 14‑224(f).  As such, violating Conn. Gen. Stat. § 14-224(a) is a felony under Connecticut law.  See Conn. Gen. Stat. § 53a-25(a) (“An offense for which a person may be sentenced to a term of imprisonment in excess of one year is a felony.”).  A Connecticut court accepted Petitioner’s plea and, on February 9, 2016, found her guilty.  CMS Ex. 3.  Accordingly, Petitioner was convicted of a felony offense, as defined by 42 C.F.R. § 1001.2.  NGS notified Petitioner that her Medicare billing privileges were revoked in a letter dated July 3, 2017.  CMS Ex. 1 at 1.  The date of Petitioner’s felony conviction was February 9, 2016, which is within 10 years of the revocation notice.

b.    CMS reasonably determined that the offense for which Petitioner was convicted is detrimental to the best interests of the Medicare program and its beneficiaries.

In its November 9, 2017 reconsidered determination, CMS, through its Provider Enrollment Oversight Group, concluded that Petitioner’s felony conviction was detrimental to the Medicare program and its beneficiaries under 42 C.F.R. § 424.535(a)(3).  CMS Ex. 6 at 5.  CMS concluded first that Petitioner’s felony conviction for evading responsibility, which involved the death of a person, was “akin to the enumerated felony crimes against persons in 42 C.F.R. § 424.535(a)(3)(ii)(A) [i.e., crimes against persons, such as murder and assault], which CMS has found to be per se detrimental to the Medicare program and its beneficiaries.”  Id.  In the alternative, CMS concluded that Dr. Bailey’s conviction was “detrimental to the Medicare program and its beneficiaries” based on its finding that her nolo contendere plea

involve[d] accepting responsibility for, at minimum, the reckless endangerment of the life of at least one person, as well as leaving the scene of an accident before the arrival of the authorities.  This behavior raises concern that Medicare beneficiaries and Trust Funds may be at risk if Dr. Bailey is allowed to continue to practice in the Medicare program because being part of the Medicare program involves the supplier’s propensity for good judgment.

Id.

Page 8

In promulgating 42 C.F.R. § 424.535(a)(3), CMS determined that the enumerated crimes are detrimental per se to Medicare.7  See Letantia Bussell, M.D., DAB No. 2196 at 9 (2008).  Accordingly, if Dr. Bailey’s conviction for evading responsibility is for a crime against persons similar to murder or assault, CMS is authorized to revoke her Medicare enrollment and billing privileges.  See Abdul Razzaque Ahmed, M.D., DAB No. 2261 at 13‑14 (2009), aff’d, Ahmed v. Sebelius, 710 F. Supp. 2d 167 (D. Mass 2010).  Moreover, even if Dr. Bailey’s conviction is for a crime not deemed similar to one enumerated in 42 C.F.R. § 424.535(a)(3), CMS is authorized to determine, on a case‑by‑case basis, that a particular felony conviction is detrimental to Medicare and its beneficiaries and therefore supports revocation.  See, e.g., Saeed A. Bajwa, M.D., DAB No. 2799 at 10-12 (2017) (holding that 42 C.F.R. § 424.535(a)(3)(i) authorizes CMS to determine what felony convictions are a basis for revocation and that CMS is not limited to the felonies enumerated as examples).

CMS relies solely on the definition of Petitioner’s felony offense to argue that the offense is a felony crime against persons deemed per se detrimental to the best interests of the Medicare program and its beneficiaries.  CMS Br. at 7-8.  As CMS accurately summarizes, “[t]he felony occurs when a person operating a motor vehicle is knowingly involved in an accident which causes serious physical injury or death and fails to stop and render assistance and/or report the necessary information to the person injured or to any officer or witness immediately thereafter.”  Id. at 8.  In CMS’s view, this offense is a felony against persons that is per se detrimental to Medicare because it “involves the failure to act following an accident which causes serious physical injury or death to another . . . .”  Id.

I am not satisfied that Petitioner’s felony conviction for evading responsibility, as defined, is for a crime against persons akin to murder or assault.  Although an element of the crime is that the operator of a motor vehicle be “knowingly involved in an accident which results in the death of any other person” (Conn. Gen. Stat. § 14-224(a)), there is no requirement that the operator be legally responsible for the accident (or the death) itself.  Thus, a motor vehicle operator who bore no legal responsibility for an accident that resulted in the death of another could still be convicted of evading responsibility in violation of Conn. Gen. Stat. § 14-224(a) if the operator left the accident scene without rendering assistance or providing necessary information to a witness or officer (or failed

Page 9

to report the accident immediately to the nearest police precinct or station).  Put another way, Conn. Gen. Stat. § 14-224(a) does not require that the motor vehicle operator intend to cause death or injury to the victim.  Based solely on the definition of the offense, then, I do not find the offense sufficiently similar to the crimes against persons enumerated in 42 C.F.R. § 424.535(a)(3)(ii)(A) (e.g., murder or assault, which include an element of intent) to be considered per se detrimental to Medicare.  Cf. Sunsites Pearce Fire Dist., DAB No. 2926 at 11 (2019) (concluding that the crime of “felony disorderly conduct,” which was defined “in a way which highlights its hostile impact on other persons in a manner endangering their safety,” was sufficiently analogous to felonies against persons, like assault, to be per se detrimental).8

Ultimately, though, it is of no consequence whether Petitioner’s offense is detrimental per se.  It is apparent in this case that CMS exercised its discretion, pursuant to 42 C.F.R. § 424.535(a)(3)(i), to determine that a felony conviction not listed in 42 C.F.R. § 424.535(a)(3)(ii) is detrimental to the Medicare program and its beneficiaries and, accordingly, warrants revocation.  See Bajwa, DAB No. 2799 at 8, 10-11.  If I am satisfied that CMS exercised its discretion under 42 C.F.R. § 424.535(a)(3)(i), I may not substitute my own determination as to whether a given felony is detrimental to the Medicare program and its beneficiaries for that of CMS.  See Brian K. Ellefsen, DO, DAB No. 2626 at 7 (2015).  The record before me amply demonstrates that CMS exercised its discretion.  CMS itself issued the reconsidered determination in which it expressly found that Petitioner’s conviction is detrimental to the Medicare program and its beneficiaries because the conviction calls into question whether Petitioner can be trusted to exercise good judgment and not put others at risk.  CMS Ex. 6 at 5.

Moreover, even if I could review CMS’s discretion to determine whether Petitioner’s felony offense is detrimental to Medicare and its beneficiaries, I would find CMS’s exercise of discretion proper.  Petitioner’s arguments in support of her position that her conviction is not detrimental to Medicare and its beneficiaries do not persuade me otherwise.

Petitioner argues first that, despite her convictions, she did not “operate a motor vehicle while under the influence of liquor or drugs or while having an elevated blood alcohol

Page 10

content,” P. Supp. Br. at 2, 3-4.  Petitioner’s argument that she is not, in fact, guilty of a crime for which she was convicted amounts to a collateral attack on her conviction, which I may not consider in determining whether to sustain the revocation of Petitioner’s Medicare billing privileges.9  See Gary J. Ordog, M.D., DAB CR4806 at 7 (2017) (and cases there cited).  As described above, in addition to being convicted of evading responsibility, Petitioner was also convicted, based on her nolo contendere plea, of operating a motor vehicle while under the influence of intoxicating liquor or with an elevated blood alcohol content, in violation of Conn. Gen. Stat. § 14‑227a.  CMS Ex. 3.  See also P. Supp. Br. at 3 (admission that Petitioner pleaded nolo contendere to “common law DUI”).  Because being under the influence of alcohol or having an elevated blood alcohol level are elements of the crime for which she was convicted, the fact of her conviction establishes as a matter of law that she was under the influence of alcohol or had an elevated blood alcohol content while operating a motor vehicle on the night of the accident.

Petitioner’s attempt to collaterally attack her convictions must fail for the reasons just described.  Petitioner’s other arguments are equally unavailing.  Petitioner recounts details of the circumstances underlying her conviction that, in her view, mitigate the seriousness of her crimes.  She asserts that she did not leave the scene of the accident until “after the police and an ambulance had been called” and that she did so “to take her medically compromised 87 [year old] mother home, less than a half a mile away.”  P. Br. at 1; P. Supp. Br. at 2.  She also denies responsibility for the accident and insinuates that the pedestrian who she struck with her car was responsible for the accident, stating that he was intoxicated, dressed in dark clothes, walking on the wrong side of the road, and “walked into the passenger side of the vehicle [she] was driving.”  P. Supp. Br. at 2 (bold font omitted).  She notes also that the State of Connecticut Licensing Board for her profession (Licensing Board) did not take action against her license to practice

Page 11

psychology, instead dismissing the licensing case and renewing her license “without interruption.”  P. Supp. Br. at 3.  Finally, she asserts that the “accident, while tragic, does not indicate any moral turpitude or personal quality that would prevent her from acting . . . in the best interests of Medicare and its beneficiaries.”  P. Supp. Br. at 4-5.

Even taking all of Petitioner’s assertions as true, they do not undermine the conclusion that her felony offense is detrimental to Medicare and its beneficiaries.  The fact that Petitioner did not leave the accident scene until after police had been called does not excuse her retreat from the scene before they arrived.  Her elderly mother’s presence does not mitigate the circumstances of her conviction either.  Rather, in my view, the fact that Petitioner apparently considered it appropriate to drive her 87-year-old, medically-compromised mother home (P. Br. at 1; P. Supp. Br. at 2) when Petitioner was either under the influence of alcohol or had an elevated blood alcohol level is yet another indication of a serious lapse in judgment.  Further, whether Petitioner caused the accident or not, she is still responsible for her decisions to operate a motor vehicle while under the influence of alcohol or with an elevated blood alcohol level and to leave the accident scene before police arrived.  Indeed, I find it more likely than not that being under the influence of alcohol or having an elevated blood alcohol content influenced Petitioner’s unlawful decision to leave the scene of the accident without rendering assistance or providing necessary information to a witness or officer (or reporting immediately to the nearest police precinct or station).  Furthermore, Petitioner was 60 years old at the time of the accident, an age at which she should have known far better than to conduct herself in such a manner.10  CMS Ex. 4.

Next, the Licensing Board’s decision to take no adverse action against Petitioner’s license to practice psychology may be evidence that her peers do not consider her offense significant enough to remove her from her practice, but neither CMS nor I am bound by that decision.  And, were I reviewing CMS’s exercise of discretion de novo, I would find that the Licensing Board’s decision not to take disciplinary action against Petitioner does not outweigh the seriousness of Petitioner’s felony offense.  Further, even if I were to accept that Petitioner’s felony offense does not indicate moral turpitude or a personal quality preventing her from acting in the best interests of Medicare and its beneficiaries, I would still conclude that her felony offense demonstrates a personal quality that adversely affects her ability to act in that manner.  In view of the foregoing analysis, I cannot agree with Petitioner that CMS committed error or acted unreasonably in determining that her felony offense is detrimental to the best interests of Medicare and its beneficiaries.  Rather, I agree with CMS that continued participation in Medicare relies on “the supplier’s propensity for good judgment.”  CMS Ex. 6 at 5.  Petitioner’s felony

Page 12

conviction and the conduct giving rise to it demonstrate that Petitioner’s judgment is, at best, unreliable.  Given these facts, I am satisfied that CMS acted reasonably in determining that Petitioner’s felony offense is detrimental to Medicare and its beneficiaries.

Finally, even if I were to find that CMS was not authorized to revoke Petitioner’s Medicare enrollment based on 42 C.F.R. § 424.535(a)(3), I would nevertheless conclude that CMS had a basis to revoke based on 42 C.F.R. § 424.535(a)(9).

2.    CMS had a legal basis to revoke Dr. Bailey’s Medicare enrollment and billing privileges pursuant to 42 C.F.R. § 424.535(a)(9) because Petitioner did not disclose her felony conviction to CMS or NGS within 30 days, contrary to the reporting requirement at 42 C.F.R. § 424.516(d)(1)(ii).

Having concluded that CMS had a legal basis to revoke Petitioner’s Medicare enrollment pursuant to 42 C.F.R. § 424.535(a)(3) based on her felony conviction for evading responsibility, it is not necessary to decide whether there is also a basis to revoke Petitioner’s enrollment under section 42 C.F.R. § 424.535(a)(9) for failing to report her convictions contrary to the reporting requirement at 42 C.F.R. § 424.516(d)(1)(ii).  See, e.g., Daniel Wiltz, M.D. & Family Healthcare Clinic, APMC, DAB No. 2864 at 12 (2018) (if one basis for sanction is established, CMS’s action would be sustained “regardless of any additional bases”).  However, while not required to do so, in this section, I explain why I conclude that there is a basis to revoke Petitioner’s Medicare enrollment pursuant to 42 C.F.R. § 424.535(a)(9).

Nonphysician practitioner suppliers, such as Petitioner, must report any adverse legal action to their Medicare contractor within 30 days.  42 C.F.R. § 424.516(d)(1)(ii).  “A conviction of a . . . State felony offense (as defined in [42 C.F.R.] § 424.535(a)(3)(i)) within the last 10 years preceding enrollment, revalidation, or re-enrollment” is a reportable final adverse action.  42 C.F.R. § 424.502.  As explained above, Petitioner’s felony conviction on February 9, 2016, satisfies this definition and, as a result, was a reportable adverse legal action.  Thus, she was obligated to report it to NGS, her Medicare contractor, within 30 days of February 9, 2016.

CMS may revoke a supplier’s enrollment and billing privileges if the supplier does not comply with the above-described reporting requirement.  42 C.F.R. § 424.535(a)(9).  Petitioner admits that she did not inform CMS of her felony conviction within 30 days.  P. Br. at 2; P. Supp. Br. at 4.  She does not dispute CMS’s assertion that she also failed to inform NGS of her felony conviction within 30 days of February 9, 2016.  CMS Br. at 11.  She states that she did not report her conviction to CMS “because it was not related to [her] license to practice,” as evidenced by the Licensing Board’s decision to take no action against her license.  P. Br. at 2.  She also notes that she timely reported the

Page 13

conviction to the National Uniform Provider Data-Source (CAQH ProView).”11  P. Br. at 2.  From this, she argues that her failure to report her conviction is understandable and, presumably, excusable.  P. Br. at 2; P. Supp. Br. at 4.

Petitioner is mistaken.  As a nonphysician practitioner enrolled in Medicare, she was obligated to report her conviction to NGS within 30 days, regardless of its relation to her license to practice and without regard to whether she reported it to a separate entity.  42 C.F.R. §§ 424.516(d)(1)(ii), 424.502.  Her failure to do so, whatever the reason, furnished an additional legal basis for CMS to revoke her Medicare enrollment and billing privileges.  42 C.F.R. § 424.535(a)(9).

3.    Petitioner’s arguments in equity are not a basis to reverse the revocation of her Medicare enrollment and billing privileges.

Petitioner argues that she “is entitled to equitable relief,” because of the “concern [she] demonstrated for her mother’s well-being,” “the history of [her] practice” (which she describes as “30 years of providing excellent patient care”), and her ability to “maintain[] an excellent reputation in her professional community with the continued respect of her peers.”  P. Supp. Br. at 4-5.  For support, she relies on her curriculum vitae and three letters signed by some of her colleagues in support of her continued participation in Medicare.  P. Exs. 1-4.

I am not persuaded that Petitioner, in driving while under the influence of alcohol or with an elevated blood alcohol level, with her mother in the car, demonstrated concern for her mother’s well-being.  And, even accepting that Petitioner has an excellent professional reputation among her peers and an otherwise-unblemished 30-year history of providing excellent patient care, I would not find that the balance of equities weighs in her favor.  The circumstances of her felony offense, as I described above, are simply too serious to warrant granting equitable relief.  But, even if I were personally sympathetic to Petitioner’s equitable arguments (which, as I have explained, is not the case), an administrative law judge may not overturn CMS’s discretionary act to revoke a provider or supplier based on equity or mitigating circumstances.  Bussell, DAB No. 2196 at 13.  Rather, “the right to review of CMS’s determination by an [administrative law judge] serves to determine whether CMS had the authority to revoke [the provider’s or supplier’s] Medicare billing privileges, not to substitute the [administrative law judge’s] discretion about whether to revoke.”  Id. (emphasis omitted).  Once CMS establishes a legal basis on which to proceed with a revocation, then the CMS determination to revoke becomes a permissible exercise of discretion, which I am not permitted to review.  See id. at 10; see also Ahmed, DAB No. 2261 at 19 (if CMS establishes the regulatory elements necessary for revocation, an administrative law judge may not substitute his or her

Page 14

“discretion for that of CMS in determining whether revocation is appropriate under all the circumstances”).

VI.  Conclusion

For the reasons stated, I affirm that CMS had a legal basis to revoke Petitioner’s Medicare enrollment and billing privileges.

• 1. The Provider Enrollment & Oversight Group is a component of CMS itself, not an administrative contractor.
• 2. It appears unlikely that Petitioner could make such a showing, given that P. Ex. 5 long pre-dates Petitioner’s reconsideration request (it is dated January 7, 2016, more than a year and a half before Petitioner’s August 3, 2017 reconsideration request) and the reconsidered determination does not list it as an exhibit CMS considered in conducting the reconsideration. See CMS Ex. 5 at 1, CMS Ex. 6 at 3, P. Ex. 5 at 1.
• 3. Although I do not base my decision in any way on the content of P. Ex. 5, I note that it includes a summary of the police investigation of the accident that led to Petitioner’s felony conviction. The investigating officer’s observations of Petitioner’s behavior, as reported in the exhibit, if anything, might have served to bolster CMS’s case.
• 4. CMS recently revised the regulation governing revocations. 84 Fed. Reg. 47,794 (Sept. 10, 2019). The revisions, which took effect November 4, 2019, authorize CMS to establish a reenrollment bar for a period ranging from one to ten years for a first-time revocation, and up to twenty years for a second revocation. Id. at 47,794, 47,855 (amending 42 C.F.R. § 424.535(c)). These revisions took effect well after the initial determination to revoke issued in this case. I apply the regulations in effect at the time of the initial determination. Linda Silva, P.A., DAB No. 2966 at 1 n.1 (2019).
• 5. My conclusions of law appear as headings in bold italic type. My findings of fact appear in the supporting text.
• 6. Conn. Gen. Stat. § 14-224(a) provides as follows:
  
  

  Each operator of a motor vehicle who is knowingly involved in an accident which results in the death of any other person shall at once stop and render such assistance as may be needed and shall give such operator’s name, address and operator’s license number and registration number to any officer or witness to the death of any person, and if such operator of the motor vehicle causing the death of any person is unable to give such operator’s name, address and operator’s license number and registration number to any witness or officer, for any reason or cause, such operator shall immediately report such death of any person to a police officer, a constable, a state police officer or an inspector of motor vehicles or at the nearest police precinct or station, and shall state in such report the location and circumstances of the accident causing the death of any person and such operator’s name, address, operator’s license number and registration number.

• 7. Effective February 3, 2015, CMS modified 42 C.F.R. § 424.535(a)(3). 79 Fed. Reg. 72,500, 72,532 (Dec. 5, 2014). In the prior version of the regulation, the enumerated felonies regarded as per se detrimental to Medicare appeared in subsection 424.535(a)(3)(i). However, the descriptions of the enumerated felonies are unchanged. Thus, prior decisions of Departmental Appeals Board (DAB) administrative law judges and appellate panels interpreting the former 42 C.F.R. § 424.535(a)(3)(i)(A)-(D) are relevant in interpreting the current provision at 42 C.F.R. § 424.535(a)(3)(ii)(A)-(D).
• 8. Decisions by appellate panels of the DAB make clear that CMS and administrative law judges may consider “the conduct and circumstances underlying” a felony conviction to determine whether it is akin to a crime listed in 42 C.F.R. § 424.535(a)(3)(ii). See, e.g., Ahmed, DAB No. 2261 at 11. However, both in the reconsidered determination upholding the revocation (CMS Ex. 6 at 5) and in briefing before me (CMS Br. at 7-8), CMS did not rely on the conduct and circumstances underlying Petitioner’s felony conviction in its attempt to analogize her felony conviction to the crimes listed in 42 C.F.R. § 424.535(a)(3)(ii).
• 9. Petitioner has offered no admissible evidence to support her claim of innocence; she relies entirely on P. Ex. 5 (which I have excluded) to support her position. However, even if P. Ex. 5 were admissible, it would not be a basis to disregard the state court’s judgment. As I have observed in the accompanying text, the regulations do not authorize me to consider collateral attacks on convictions. Additional support for this result is found in 28 U.S.C. § 1738. The statute provides that state judicial proceedings “shall have the same full faith and credit in every court within the United States . . . as they have by law or usage in the courts of such State.” See Kremer v. Chemical Const. Corp., 456 U.S. 461, 468 (2005) (“[A]n exception to [28 U.S.C.] § 1738 will not be recognized unless a later statute contains an express or implied partial repeal.”); cf. 42 C.F.R. § 498.70(a) (permitting an administrative law judge to “dismiss a hearing request . . . as to any stated issue” when “[t]here has been a previous determination . . . with respect to the rights of the same affected party on the same facts and law pertinent to the same issue or issues which has become final . . . by judicial affirmance”).
• 10. In addition to the fact that Petitioner was old enough to know better, I note with some sense of irony that Petitioner’s master’s thesis and doctoral dissertation focused on some of the ill effects of alcohol on human behavior. See P. Ex. 1 at 1.
• 11. She also refers to this entity as the “National Provider Database.” P. Supp. Br. at 4.