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United States Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
In the Case of:
)
)
)
)
)
)
)
)
)
)
Date:
Petitioner,
- v. -
The Inspector General.
INFORMAL BRIEF OF PETITIONER
The Inspector General (I.G.) argues that he is authorized to exclude you from
participating in Medicare, Medicaid, and other federally-funded health care
programs, because your license to provide health care was revoked, suspended, or
otherwise lost for a reason described at section 1128(b)(4) of the Social Security
Act. The length of the exclusion is for a period of time that is not less than the
period when your license is revoked, suspended, or otherwise lost plus at least
_____ additional years.
The issues in this case are whether:
1. The I.G. is authorized to exclude you; and
2. The length of the exclusion that the I.G. determined to impose is
reasonable.
I. Was your license revoked, suspended, or otherwise lost, or did you
surrender your license, under the circumstances that are described at section
1128(b)(4)?
Yes
Docket No. C-
-
No
XXX
XX
A. Do you agree that your license to provide health care was revoked,
suspended, or otherwise lost as a consequence of action taken by a State
licensing authority?
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
B. Do you agree that your license to provide health care was revoked,
suspended, or otherwise lost for reasons bearing on your professional
competence, professional performance, or financial integrity?
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
C. (Answer the following question only if your license to provide
health care was lost, suspended, or otherwise revoked based on an
agreement reached between you and a State licensing authority). Do
you agree that you surrendered your license to provide health care while a
State formal disciplinary proceeding was pending against you and the
proceeding concerned your professional competence, professional
performance, or financial integrity?
No
Yes
No
Yes
No
Yes
If you disagree, explain why you disagree. State which exhibits support
your argument and explain why they do.
II. Is the length of your exclusion unreasonable? The I.G. argues that the
length of the exclusion that he determined to impose is reasonable. He argues that
there is evidence relating to certain aggravating factors that he says supports the
length of the exclusion.
A. Do you disagree with the I.G.’s identification of aggravating factors
in your case?
If you disagree, state which of the aggravating factors cited by the I.G. you
believe are not present. Explain why you disagree. State which exhibits
support your argument(s) and explain why they do.
B. If you agree that there is/are an aggravating factor or factors
present in your case but believe that the exclusion is nonetheless not
justified by the presence of that factor or factors, explain your reasons
for your argument. State which exhibits support your arguments and
explain why they do.
No
Yes
C. Do you believe that a mitigating factor or factors exist(s) that
support(s) reducing the length of your exclusion (before answering this
question, read the list of potentially mitigating factors that is set forth
at 42 C.F.R. § 1001.501(b)(3))?
If you believe that a mitigating factor or factors exist(s), state what it is/they
are and explain why the presence of the factor or factors should support
reducing the length of your exclusion. State which exhibits support your
argument(s) and explain why they do.
III. Do you believe that an in-person hearing is necessary to decide your
case?
Do you have any testimony that you wish to offer at an in-person hearing?
If you have testimony that you wish to offer, provide the following:
1. The name of each witness whose testimony you want to offer.
2. A description of each witness’ proposed testimony and an explanation of
why you believe that the testimony relates to any of the arguments you
want to offer in connection with items I and II.
No
Yes
No
Yes
No
Yes
3. An explanation of why the proposed testimony does not duplicate
something that is already stated in an exhibit.
IV. Do you have any other arguments you wish to make? If so, please state
them here. State which exhibits support your argument(s) and explain why they
do.
Petitioner or Petitioner’s Representative
Date:
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Completed 23 February 2020

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