Health Law Daily Wrap Up, ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—DAB DECISIONS: Length of participation in scheme, amount of loss to government, were aggravating factors justifying 12-year program exclusion, (Jun 12, 2026)

By Jeffrey H. Brochin, J.D.

Physician’s willing participation in billing scheme for approximately 5 years called into question his integrity and trustworthiness, and that duration coupled with being sentenced to incarceration, and losing his medical license, rendered extended program exclusion reasonable.

The HHS Departmental Appeals Board (DAB or Board) Civil Remedies Division has affirmed the 12-year program exclusionary period imposed on an Illinois-licensed Missouri physician following his guilty plea involving a Medicare and Medicaid billing scheme. The Board found that four aggravating factors were present in the case to justify the extension of exclusion from the mandatory 5 years to 12 years, and his claim that the restitution amount ordered was “a negotiated figure, not a judicial finding of actual loss,” was without merit because the amount ordered as restitution constitutes proof of the amount of financial loss to a government program (Sonny Sagar, DAB No. CR 6885, Doc. No. C-26-39 (April 24, 2026)).

Conviction of criminal offense. The physician practiced as a medical doctor for 27 years and was licensed to practice in the state of Missouri where he operated several healthcare businesses. On July 26, 2023, Petitioner was indicted by Grand Jury for one count of Conspiracy in violation of 18 U.S.C. §371; and eight counts of Making False Statements Related to Health Care Matters in violation of 18 U.S.C.§1035. Specifically, it was alleged that physician conspired to bill Medicare and Medicaid for un-reimbursable services performed by assistant physicians, but billed as if the services were performed by the physician.

The physician entered into a plea agreement in which he voluntarily pled guilty to the one count of Conspiracy, admitting that: (1) two or more persons reached an agreement or came to an understanding to make false statements relating to health care matters, (2) that he voluntarily and intentionally joined in the agreement or understanding, either at the time it was first reached or at some later time; (3) he knew the purpose of the agreement or understanding; (4) and knowingly did one or more overt acts for the purpose of carrying out or carrying forward the agreement or understanding.

Sentencing and restitution. The physician was sentenced to 35 months of incarceration and three years of supervised release upon release of imprisonment, and also ordered to pay $642,942.70 to the Medicare program and $99,585.37 to the Missouri Medicaid program. In addition, the State of Illinois Department of Financial and Professional Regulation Division of Professional Regulation issued an order indefinitely suspending the physician and surgical licenses, without a hearing, based on his conviction in District Court.

By notice letter dated September 30, 2025, the IG informed the physician that he was being excluded from participating in Medicare, Medicaid, and all federal health care programs for a minimum period of 12 years. The exclusion was imposed due to the physician’s conviction “of a criminal offense related to the delivery of an item or service under Medicare or a State health care program, including the performance of management or administrative services relating to the delivery of items or services under any such program.”

Aggravating factors. The aggravating factors cited by the IG in support of extending the exclusionary period from the mandatory 5 years to 12 years included: (1) the acts resulting in the conviction, or similar acts, caused, or were intended to cause, a financial loss to a government agency or program of $50,000 or more; (2) the acts that resulted in the conviction, or similar acts, were committed over a period of one year or more; (3) the sentence imposed by the court included incarceration; and, (4) the individual or entity had been the subject of any other adverse action by any federal, state, or local government agency or board.

Petitioner’s arguments. It was undisputed that the District Court accepted the physician’s guilty plea and entered judgment on February 19, 2025; and the physician did not dispute that he was convicted of a criminal offense. However, he disputed the aggravating factors applied by the IG to extend the exclusionary period. As to the amount of loss to a government program, he argued that the restitution was a “negotiated figure, not a judicial finding of actual loss” and that there was no stipulation that Medicare’s actual loss exceeded $50,000. However, the Board found that it is well-established that the amount ordered as restitution constitutes proof of the amount of financial loss to a government program.

He next argued that the duration of the scheme over five years had not been established because he was unaware that the improper billing was occurring., and, that duration alone could not be used to imply knowledge, since he did not design, implement, or personally execute the billing practices at issue. However, the Board noted that in his plea agreement, the physician accepted responsibility for claims being submitted for services rendered by assistant physician—but billed under his name—from July 10, 2018 through July 2023, and that this aggravating factor did not require that the physician design, implement, or personally execute the scheme for over one year, only that the acts be committed for over a period of one year or more.

No valid mitigating factors. Although the physician contended that various mitigating factors existed that should serve in his favor, the Board rejected all of them because the regulations are clear that only three mitigating factors are recognized and none of his fit those factors.

Based on the foregoing, the Board upheld the imposition of the exclusion as mandated by law, and the long exclusionary extension as not unreasonable based on the aggravating factors.

AdministrativeDecisions: DABDecisions CMSNews CoPNews FraudNews ProgramIntegrityNews ProviderNews