Health Law Daily Wrap Up, PROGRAM INTEGRITY—DAB DECISIONS: CMS revocation upheld after medical license suspension, misconduct findings, (Mar 5, 2026)
By WK Editorial Staff
The ALJ concluded that the reconsidered determination provided sufficient reasoning for placing the physician’s name on the CMS Preclusion List.
A recent administrative decision by an administrative law judge (ALJ) for the HHS Departmental Appeals Board affirmed CMS’s determination to revoke a physician’s Medicare enrollment and place the practitioner on the CMS Preclusion List. The ALJ concluded that CMS had a legitimate basis to include the provider on the Preclusion List (Stevens v. CMS, DAB No. CR6576, Doc. No. C-24-510 (Nov. 19, 2024)).
Suspension of license. CMS relied on the regulatory principle that a Medicare supplier must maintain all applicable state licensure. The physician’s sole license to practice medicine was suspended in Ohio for several months, making the practitioner noncompliant with Medicare enrollment requirements. The ALJ concluded that this lapse alone provided a legitimate basis for revocation under 42 C.F.R. § 424.535(a)(1).
The suspension stemmed from a consent agreement with the state medical board following admissions of factual allegations related to improper prescribing practices and failure to cooperate with the board’s investigation. The physician agreed to an indefinite suspension of at least 180 days and acknowledged violations described in two disciplinary letters.
Although the license was eventually reinstated with probationary terms, the period of suspension satisfied CMS’s threshold for revocation because the supplier was not legally authorized to practice medicine during that time.
Preclusion List placement. Beyond revocation, CMS also placed the physician on the CMS Preclusion List. The ALJ affirmed this determination by focusing on the underlying conduct that prompted state disciplinary action and the agency’s assessment of risk to program integrity. Under CMS regulations, preclusion requires three elements: a revocation, an active reenrollment bar, and a finding that the conduct leading to revocation is detrimental to the Medicare program. CMS determined that all three criteria were met.
In its analysis, CMS emphasized the seriousness of the practitioner’s conduct during the state board’s investigation. According to CMS, the practitioner knowingly provided incomplete patient records in response to a subpoena and instructed staff to certify those records as complete. CMS viewed this as an obstruction of an official investigation and a failure to meet basic standards of honesty and compliance. The agency described the conduct as “extremely serious” because it raised concerns about trustworthiness and respect for regulatory requirements.
CMS also found that the misconduct had direct implications for the integrity of the Medicare program. A practitioner who demonstrates dishonesty with state authorities, CMS reasoned, poses an undue risk to federal health care programs and beneficiaries. CMS concluded that similar behavior could recur and could undermine the reliability of information essential for Medicare oversight.
Finally, CMS considered the practitioner’s pattern of noncompliance, including the conduct detailed in the disciplinary history. The agency concluded that this history further supported a finding that the underlying behavior was detrimental to Medicare.
ALJ’s determination. The ALJ agreed that CMS acted within its authority in both revoking enrollment and imposing a preclusion. The decision found no dispute regarding the license suspension period and emphasized that CMS may revoke enrollment whenever a supplier fails to meet essential requirements such as maintaining licensure. The ALJ also accepted CMS’s analysis of the seriousness of the conduct and its impact on program integrity, concluding that CMS had a legitimate basis for determining that the practitioner’s behavior threatened the best interests of Medicare.
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