Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
In the Case of: Henry T. Pimentel, M.D., Petitioner,
- v. -
The Inspector General.
DATE: October 16, 1992
Docket No. C-435
Decision No. CR235
DECISION
This case is governed by section 1128 of the Social Security Act (Act). By
letter dated June 7, 1991
(Notice), the Inspector General (I.G.) notified Petitioner that he was being
excluded from participation in
Medicare and all federally funded State health care programs for a period of
seven years. 1/ The I.G.
informed Petitioner that his exclusion resulted from his conviction of a criminal
offense related to the
delivery of an item or service under Medicaid, within the meaning of section
1128(a)(1) of the Act (42
U.S.C. 1320a-7).
Petitioner timely requested a hearing before an Administrative Law Judge (ALJ),
and the case was assigned
to ALJ Joseph K. Riotto. The case was reassigned to me on November 26, 1991.
On May 13, 1992, I held
an in-person evidentiary hearing in Chicago, Illinois. 2/ The parties submitted
posthearing briefs.
I have considered the evidence of record, the parties' arguments, and the applicable
law. I conclude that
the I.G. had authority to exclude Petitioner, and that the seven-year exclusion
imposed and directed by the
I.G. is appropriate and reasonable under the circumstances. Therefore, I sustain
the exclusion.
BACKGROUND
At the time of the criminal actions in question, Petitioner was a physician
licensed in the State of Illinois
and was a corporate officer of, and working at, the Reymar Clinic Health Care,
Inc. (Reymar Clinic) in
Chicago. Based upon an investigation by the Medicaid Fraud Control Unit for
the State of Illinois, it was
determined that from June 1985 until April 1988, Petitioner permitted Oscar
Hosenilla to work as a
"physician" at the Reymar Clinic seeing and treating patients, ordering
tests, and prescribing medications.
Petitioner was aware that, during this period, Mr. Hosenilla was not licensed
by the State of Illinois to
practice medicine. 3/ Petitioner submitted claims, under his own Medicaid provider
number, to the Illinois
Department of Public Aid (IDPA) for the medical services and items provided
by Mr. Hosenilla. An audit
identified approximately $40,000 in "false bills." The investigation
led to Petitioner's indictment, and he
subsequently pled guilty to the class one felony of vendor fraud. After the
conviction, Petitioner's license
to practice medicine in Illinois was suspended for a period of years, and the
I.G. determined to exclude
Petitioner for seven years. 4/
ADMISSIONS
Petitioner admits that he was "convicted" of a crime "related
to" the delivery of an item or service under the
Medicaid program, within the meaning of section 1128(a). Petitioner argues,
however, that he should be
excluded for only the minimum five -- not seven -- years. Tr. 4-6.
ISSUES
The remaining issues are:
1. Whether the regulations published on January 29, 1992, at 57 Fed. Reg. 3298
et seq., are
applicable to this case.
2. Whether the seven-year exclusion imposed and directed against Petitioner
by the I.G is
appropriate and reasonable.
FINDINGS OF FACT AND CONCLUSIONS OF LAW
Having considered the entire record, the arguments, and the submissions of
the parties, and being advised
fully, I make the following Findings of Fact and Conclusions of Law (FFCLs):
5/ 6/
1. I reaffirm each and every prehearing and hearing ruling regarding the admission
of testimony and
exhibits and the applicability of the relevant statutes and regulations.
2. This proceeding is governed by section 1128(a)(1) of the Act.
3. The regulations concerning mandatory exclusion proceedings brought under
section 1128(a)(1) of
the Act (to be codified at 42 C.F.R. Part 1001, promulgated at 57 Fed. Reg.
3298 et seq. (January 29,
1992)) were not intended to apply retroactively to proceedings which began before
the regulations were
promulgated.
4. Section 1128(c)(3)(B) of the Act authorizes the Secretary to impose a mandatory
five-year
exclusion against any person who is "convicted" of a criminal offense
"related to the delivery of a health
care item or service" within the meaning of section 1128(a)(1).
5. Petitioner, Henry T. Pimentel, M.D., was licensed by the State of Illinois
to practice medicine
between March 29, 1968, and April 15, 1991; between June 1985 and April 1988,
Petitioner practiced
medicine at Reymar Clinic. Stips. 1 and 7.
6. On May 11, 1990, Petitioner pled guilty in the Circuit Court of Cook County,
Illinois, to the
offense of vendor fraud, a class one felony, for willfully and fraudulently
obtaining Medicaid benefits for
the delivery of medical items and services purportedly delivered or ordered
by a licensed physician when,
in fact, those items and services had not been ordered or delivered by a licensed
physician. Stips. 5 and 6;
Tr. 31; I.G. Exs. 1 and 2/5-6.
7. Petitioner was sentenced to 24 months' probation and ordered to pay $40,000
restitution to IDPA
and to forfeit $20,000 to the Medicaid Fraud and Abuse Prevention Fund. Petitioner
still owes
approximately $15,000 of the $40,000. Stip. 6; Tr. 32-33; I.G. Exs. 4 and 5.
8. Petitioner admitted that he was convicted of a criminal offense within the
meaning of section
1128(a)(1) of the Act. Tr. 4-6.
9. The I.G. properly excluded Petitioner from participation in the Medicare
and Medicaid programs
for a period of at least five years, as required by the minimum mandatory exclusion
provision of sections
1128(a)(1) and 1128(c)(3)(B) of the Act.
10. The remedial purpose of section 1128 of the Act is to protect federally
funded health care
programs and their beneficiaries and recipients from providers who have demonstrated
by their conduct
that they cannot be trusted to handle program funds or treat beneficiaries and
recipients.
11. The serious nature of Petitioner's conviction is reflected in the fact
that the conviction was for a
class one felony which involved the defrauding of the Medicaid program for a
period of several years and
for many thousands of dollars.
12. Petitioner endangered the health and safety of his patients at the Reymar
Clinic by allowing an
unlicensed individual to treat them.
13. Petitioner has not demonstrated that he understands the seriousness of
his crime as it relates to the
health and safety of his patients and the integrity of the Medicaid program.
14. Petitioner's fraudulent acts are harmful to the Medicaid program and show
a high degree of
culpability.
15. Petitioner has not presented any mitigating circumstances which would establish
his
trustworthiness or temper the necessity for a seven-year exclusion.
16. A lengthy exclusion is needed in this case to satisfy the remedial purposes of the Act.
17. The seven-year exclusion imposed and directed by the I.G. is reasonable.
DISCUSSION
I. The I.G. Had The Authority To Exclude Petitioner Pursuant To Sections 1128(a)(1)
And
1128(c)(3)(B) Of The Act.
A. Petitioner Was "Convicted" Of A Criminal Offense "Related
To" The Medicaid Program.
Section 1128(a)(1) of the Act mandates the exclusion of individuals who have
been "convicted" of a
criminal offense "related to the delivery of an item or service" under
the Medicare or Medicaid programs.
Petitioner does not contest that he was convicted of a criminal offense within
the meaning of section
1128(a)(1). Tr. 5-6. He was indicted by a grand jury in Cook County, Illinois
for the criminal offenses of
vendor theft and fraud. Stip. 3; I.G. Ex. 1. On May 11, 1990, Petitioner pled
guilty to vendor fraud, a class
one felony. Stip. 4. Petitioner's crime involved the willful and fraudulent
obtaining of Medicaid benefits
and the taking of payments from the IDPA, between June 1985 and April 1988,
for the delivery of items or
services purportedly delivered or ordered by Petitioner, a licensed physician
when, in fact, those items and
services had been ordered or delivered by Mr. Hosenilla, an unlicensed individual.
7/
The Court sentenced Petitioner to 24 months' probation and ordered him to pay
$40,000 restitution to the
IDPA and to forfeit $20,000 to the Medicaid Fraud and Abuse Prevention Fund.
Tr. 32-33; I.G. Exs. 4-6.
As of May 13, 1992 (the date of the hearing), Petitioner still owed to IDAPA
approximately $15,000 of the
$40,000 restitution. Tr. 33.
Therefore, based on the evidence and Petitioner's admissions, I find that this
was a program-related
conviction under section 1128(a)(1) of the Act.
B. The I.G. Was Required To Exclude Petitioner For A Minimum Period Of Five
Years.
I have found that Petitioner was "convicted" of a criminal offense
related to the delivery of an item or
service under the Medicaid program, within the meaning of section 1128(a)(1)
of the Act. Thus, the I.G.
has authority to impose and direct an exclusion against Petitioner pursuant
to sections 1128(a)(1) and
1128(c)(3)(B) of the Act. Under these circumstances, the statute mandates that
the I.G. exclude Petitioner
for a minimum period of five years.
II. The Substantive Portions Of The Regulations Published On January 29, 1992,
Are Not Applicable
To This Case And Do Not Establish Criteria Which Govern My Decision On The Reasonableness
Of The
Length Of The Exclusion.
On January 29, 1992, the Secretary published new regulations which effect both
procedural and substantive
changes with respect to exclusion cases. 42 C.F.R. Parts 1001-1007; 57 Fed.
Reg. 3298 et seq. (new
regulations). Before the hearing, I permitted the parties to brief the issue
of whether the new regulations
should apply to this proceeding. The I.G. argued that the new regulations should
apply because they were
effective upon publication. Petitioner argued that the relevant regulations
on the length of the exclusion do
not limit an ALJ's authority to review cases, and it would be unfair to apply
the new regulations as the
Notice was filed before they were published.
At a prehearing conference on May 1, 1992, I ruled that the procedural aspects
of the new regulations and
the substantive aspects of the former regulations, 42 C.F.R. Part 1001 (1991),
would apply to this case.
The I.G. has renewed his objection to this ruling. I reaffirm the above ruling.
Also, I conclude that my
review of the reasonableness of the length of the exclusion is not governed
by the new regulations' criteria
for the I.G.'s determination of that matter. I find that 42 C.F.R. 1001.102
of the new regulations was not
intended by the Secretary to govern de novo hearings as to the reasonableness
of the I.G.'s exclusion
determinations. See Anthony W. Underhill, DAB CR231 at 12-13 (1992).
Even if the Part 1001 regulations were to govern these hearings, an appellate
panel of the Departmental
Appeals Board (DAB) recently found that they do not apply retroactively in cases
such as this one where
the exclusion determination was made prior to the regulations' publication date.
Behrooz Bassim, M.D.,
DAB 1333 at 5-9 (1992) (retroactive application would deprive petitioner of
due process). The I.G. relied
on the former regulations at 42 C.F.R. 1001.125(b) (1991) to determine the length
of Petitioner's
exclusion. I find that the application of the new regulations, and, in particular,
the application of 42 C.F.R.
1001.102, to this proceeding would materially alter Petitioner's substantive
rights.
III. A Seven-Year Exclusion Is Appropriate And Reasonable.
A. Several Factors Are Relevant To DeterminingTrustworthiness.
Since the parties agree that the minimum mandatory exclusion of five years
is applicable to Petitioner, the
issue before me is whether the I.G. is justified in excluding Petitioner for
seven years -- rather than the
minimum five years. Since this is a de novo hearing, I may consider whether
the I.G.'s exclusion period,
which is in excess of the five years' minimum, is reasonable and either increase
it or decrease if I find it to
be unreasonable. See Section 205(b)(11) of the Act.
The exclusion laws are civil statutes and designed to protect government financed
health care programs
from fraud and abuse by providers. Thus, resolution of the reasonableness of
Petitioner's seven-year
exclusion depends on an analysis of the evidence of record in light of the remedial
purposes of the Act.
Arthur V. Brown, M.D., DAB CR252 at 9 (1992). 8/
Also, the regulations at 42 C.F.R. 1001.125(b) (1991), set forth criteria which
the I.G. was required to
consider in setting the length of Petitioner's exclusion. As discussed in part
II of this decision, I may refer
to these criteria -- but am not required to do so -- in determining the reasonableness
of the length of the
exclusion. These factors include: 1) the number and nature of the program violations
and other related
offenses; 2) the nature and extent of any adverse impact the violations have
had on beneficiaries; 3) the
amount of the damages incurred by the Medicaid program; 4) whether there are
any mitigating
circumstances; 5) the length of the sentence imposed by the court; 6) any other
facts bearing on the nature
and seriousness of the program violations; and 7) the previous sanction record
of the excluded party under
the Medicare or Medicaid program. The I.G. must consider any mitigating circumstances
and balance
them against other factors bearing on the nature and seriousness of the program
violations. John Crawford,
Jr., M.D., DAB 1324 at 8 (1992). These factors may be used by me as general
guidance as to the type of
evidence that may be relevant to determining a person's trustworthiness to be
a health care provider. See,
e.g., Eric Kranz, M.D., DAB 1286 at 11 (1991); Chandor Kachoria, R.Ph., DAB
CR220 at 13 (1992).
Also, an appellate panel of the DAB, in adopting criteria previously outlined
by ALJs in section 1128
cases, has provided a listing of some of the factors which should be considered:
the nature of the offense committed by the provider, the circumstances surrounding
the offense,
whether and when the provider sought help to correct the behavior which led
to the offense, how far the
provider has come toward rehabilitation, and any other factors relating to the
provider's character and
trustworthiness.
Robert Matesic, R.Ph., d/b/a Northway Pharmacy, DAB 1327 at 12 (1992).
B. The Evidence Of Untrustworthiness In This CaseSupports The Seven-Year Exclusion.
I find Petitioner's violations to be serious. His fraudulent behavior lasted
almost three years, from June
1985 until April 1988. Tr. 41, 44-45, 51; I.G. Ex. 1/2. Mr. Hosenilla identified
approximately $40,000 in
Medicaid monies which were paid as a result of his practicing medicine in place
of Petitioner. 9/ Tr. 28-
29; I.G. Ex. 1/2. As a result of these actions, Petitioner was convicted of
a class one felony which requires
a showing of "willful" misconduct. Tr. 31; I.G. Exs. 1/2, 2/5-6. Petitioner
could have received a sentence
for this crime of four to fifteen years incarceration and a $10,000 fine. His
sentence of 24 months'
probation and payment of a total of $60,000.00 was substantial. The evidence
also establishes that
Petitioner's conduct was motivated by considerations of unlawful and personal
gain. 10/
I also find that Petitioner's violations had an adverse impact on program beneficiaries
and recipients.
Petitioner knowingly permitted Mr. Hosenilla, an unlicensed individual, to evaluate
and treat patients
without supervision. In addition, he permitted Mr. Hosenilla to order x-ray,
blood, and urine tests for
patients. Tr. 21-22; I.G. Exs. 13/2-3 and 15-16. Petitioner not only gave Mr.
Hosenilla presigned blank
lab request and prescription forms but later instructed him on how to sign Petitioner's
initials on
prescriptions, patient charts, and medical forms. 11/
Petitioner argues that, based on his proffered mitigating circumstances, I
should reduce the exclusion from
seven to five years. He states that there was no intent to defraud the Illinois
Medicaid program, and that
although Mr. Hosenilla is not licensed in Illinois, he is a real doctor. He
asserts that Mr. Hosenilla was
initially hired only as a technician for another clinic, and Medicaid was not
billed for those services. Tr.
39-41, 96. It is Petitioner's position that he allowed Mr. Hosenilla only later
to see patients because the
latter told him he wanted patient contact and clinical experience. Tr. 40, 98.
Petitioner further argues that
Mr. Hosenilla was permitted only to treat minor ailments such as headaches and
colds, and Mr. Hosenilla
only saw one to six patients a day, for which Medicaid paid about $20.50 per
patient visit. 12/ Tr. 41, 46,
98, 102, 114.
I find Petitioner's argument that there was no attempt to defraud Medicaid
to be specious and to undercut
his assertions that he is trustworthy. This argument demonstrates only Petitioner's
poor judgment. In an
analogous case, James D. Payne, D.O., DAB CR142 at 9 (1991), a ten-year exclusion
was found
reasonable, in part, because petitioner allowed untrained individuals to treat
patients. Petitioner was well
aware that he could not bill for the unsupervised services of an unlicensed
physician. Whether Mr.
Hosenilla is licensed in the Philippines or anywhere else is not the question.
He is not licensed in Illinois.
Tr. 20. Moreover, the only evidence of Mr. Hosenilla's medical background is
Petitioner's testimony that
he was told that Mr. Hosenilla was a doctor in the Philippines, had been a ship
doctor, and had passed the
FLEX test. 13/ Tr. 96.
Equally specious is Petitioner's argument regarding the extent of Mr. Hosenilla's
services. Again, were it
relevant, there is no evidence, other than Petitioner's testimony, to support
this. Further, there is no way to
determine whether a patient's ailment is minor before examining him or her.
As the I.G. notes, "colds" and
"headaches" may be symptoms of far more serious problems. The evidence
shows that Mr. Hosenilla
treated a special investigator once for an ear ache and once for pain in the
right hand. Also, Mr. Hosenilla
told investigators that when he wanted to hospitalize a patient, Petitioner
would arrange it without
examining the patient. I.G. Ex. 13/3. Finally, regardless of the amount paid
by Medicaid for each patient
($20.50 as claimed by Petitioner or $12.65 as noted by an I.G. witness), Petitioner's
documented "false"
billings totalled approximately $40,000. Tr. 28; I.G. Ex. 1/2.
Also, Petitioner offered as mitigating circumstances his acknowledgement of
his mistake, the benefit to the
community of an early reinstatement, and his knowledge and reputation as a physician.
Petitioner argues
that he did not have the motivation to defraud and feels remorse for his actions.
He contends that his clinic
provides medical services in an area in which the availability of other medical
services is extremely
limited. He states that the clinic is in a poor area with a high crime rate
and that approximately 90 percent
of the clients there are public aid patients. P. Br. at 8; Tr. 67, 94-95, 114.
Petitioner maintains that the
need for medical services is much greater than he can provide and that, because
of the area, it has been
difficult to hire additional doctors. Tr. 101-02, 114, 123. Without the services
of Mr. Hosenilla, Petitioner
claims that many of the patients of the clinic would have gone without medical
services at all. 14/ In
further support, Petitioner has introduced evidence of his credentials as a
surgeon, his attendance at
numerous medical workshops and continuing medical education courses, and the
testimony of Mr. James
E. Malone, an x-ray technologist, who worked at the clinic. (See P. Exs. 1-27
for Petitioner's credentials
and training and Tr. 75-91 for the testimony of Mr. Malone.)
Petitioner has introduced some evidence of the limited availability of medical
services in the area
surrounding his clinic. This is not a mitigating circumstance for fraud. Petitioner
may not have been able
to hire as many qualified doctors as needed, but this not an excuse for hiring
and encouraging an
unlicensed individual to treat and medicate Medicaid patients. Nor is it an
excuse for billing Medicaid for
those services and items. Medicaid patients are entitled to the care for which
federally funded health care
programs are designed.
I do not find Petitioner's extensive credentials and training to be mitigating
factors. Inasmuch as they are
neither related to the crime for which Petitioner was convicted nor to the services
or items provided by
someone else, they are not relevant. If anything, Petitioner's patients and
the Medicaid program would
have the right to expect more from a physician of Petitioner's training and
experience.
The testimony of Petitioner's former x-ray technologist is not mitigating.
Mr. Malone's statement that
Petitioner ordered fewer x-rays than other doctors at the clinics has no relevance
to this case. Further, Mr.
Malone's testimony regarding Petitioner's good reputation among his patients
is not probative of whether
Petitioner is trustworthy.
In summary, I find that the I.G. has demonstrated that Petitioner is culpable
and untrustworthy. Petitioner
actively participated in, and profited from, his systematic and fraudulent behavior
for almost three years.
He knowingly and intentionally allowed Mr. Hosenilla to treat and medicate Petitioner's
patients; he gave
Mr. Hosenilla presigned forms and taught him to sign Petitioner's name; and
he filed the Medicaid forms
using Petitioner's provider number for services and items provided by Mr. Hosenilla.
I find no probative evidence of remorse. In fact, the evidence shows that,
although Petitioner is currently
working as a surgeon for a Veteran's Administration hospital in Michigan, as
of the hearing he had not paid
$15,000 of the $40,000 restitution owed to IDPA. Tr. 32-33, 107, 126-27; P.
Ex. 2/1. Petitioner's unlawful
acts show that he is capable of engaging in fraudulent schemes for personal
gain and that he has a
propensity to commit offenses harmful to the financial integrity and operation
of federally-funded health
care programs. By using an unlicensed individual to act as a physician and billing
for those services and
items under Petitioner's name, Petitioner has undercut the public's perception
of the honesty and integrity
of federally financed health care program providers. A lengthy exclusion is
needed to provide Petitioner
with an opportunity to demonstrate that he can be trusted to be a program provider.
In light of the record
and the paucity of evidence minimizing the risk to the program, I am unable
to conclude that the seven-
year exclusion is extreme or excessive and should be reduced. I find the seven-year
exclusion to be
appropriate and reasonable.
CONCLUSION
Based on the law and the evidence, I conclude that the seven-year exclusion
from participating in the
Medicare and Medicaid programs which was imposed and directed against Petitioner
by the I.G. is
reasonable. I sustain the exclusion.
Charles E. Stratton
Administrative Law Judge
1. "State health care program" is defined by section 1128(h) of the
Act to include three types of federally
assisted programs, including State plans approved under Title XIX of the Act
(Medicaid). I use the term
"Medicaid" in this decision to represent all State health care programs
from which Petitioner was excluded.
2. By letter dated June 18, 1992, the I.G. noted several errors and omissions
in the hearing transcript. As
Petitioner has not objected, I shall consider the transcript record with the
I.G.'s proposed amendments.
3. The parties have argued extensively over whether to address Oscar Hosenilla
as "Dr." Petitioner argues
that he should be addressed as such because he holds a degree in medicine from
the Philippines. As
Petitioner has introduced no evidence to support this claim, I have no basis
to make a determination on Mr.
Hosenilla's status as a medical practitioner.
4. On April 15, 1991, the Illinois Department of Professional Regulations suspended
Petitioner's medical
license for a period of years. Stip. 8; Tr. 63. The I.G.'s Brief at 7 states
that the suspension period is two
years, but Stipulation 8 refers only to "a period of years."
5. The documentary record of this case will be cited as follows:
I.G.'s Exhibits I.G. Ex. (number/page)
Petitioner's Exhibits P. Ex. (number/page)
I.G.'s Posthearing Brief I.G. Br. at (page)
Petitioner's Posthearing P. Br. at (page)
Brief
Transcript Tr. (page)
Stipulations Stip.
6. Some of my statements in the sections preceding these formal findings and
conclusions are also FFCLs.
To the extent that they are not repeated here, they were not in controversy.
7. Petitioner, as corporate officer or registered agent, pled guilty on behalf
of several corporations that
also were indicted on the charge of vendor fraud: Reymar Clinic; Reymar Clinic
Pharmacy, Inc.; Reymar
Clinic X-Ray, Inc.; and Englewood Clinical Laboratory, Inc. The corporations
were convicted and
sentenced to a period of conditional discharge for 24 months. Tr. 29; I.G. Exs.
2/5-6, 8, 9, and 10. Mr.
Hosenilla was indicted for practicing medicine without a license and holding
himself out as a physician.
I.G. Ex. 1/4-7. Based on Mr. Hosenilla's cooperation in the investigation, he
was permitted to plead to the
class four felony of holding himself out as a physician, and the court sentenced
him to two years' probation.
I.G. Ex. 7.
8. Congress enacted the exclusion law to protect the integrity of federally
funded health care programs.
Among other things, the law is designed to protect program beneficiaries and
recipients from individuals
who have demonstrated by their behavior that they threaten the integrity of
the programs or that they can
not be entrusted with the well-being and safety of beneficiaries and recipients.
See S. Rep. No. 109, 100th
Cong., 1st Sess., reprinted in 1987 U.S.C.C.A.N. 682.
9. Mr. Donald G. Schweihs, special assistant attorney general for the Illinois
State Police Medicaid Fraud
Control Unit, testified that, based on handwriting on the records, he believed
that Mr. Hosenilla did not
identify every service date and patient that he, Mr. Hosenilla, saw. Therefore,
Mr. Schweihs thought that
the actual amount of false billings was greater. Tr. 42, 50.
10. In contrast to Petitioner receiving approximately $40,000.00 from Medicaid
for items and services
provided by Mr. Hosenilla, Mr. Hosenilla stated that he worked about 34 hours
a week and was paid a net
amount of $397.00 every two weeks. I.G. Ex. 13/2-3.
11. The evidence indicates that Petitioner permitted Mr. Hosenilla to use Petitioner's
DEA number (a
number assigned to physicians for their individual use in prescribing controlled
substances). Tr. 60-61.
12. Mr. Hosenilla told investigators that he treated 10-20 Medicaid patients
per day. I.G. Ex. 13/2-3. The
I.G. witness noted that Medicaid paid about $12.65 per patient visit during
the period at issue. Tr. 54.
13. "FLEX" is the Federation Licensing Examination which is one of
the prerequisites for obtaining a
medical license in Illinois. I.G. Br. at 9.
14. Petitioner introduced some testimony regarding the closing of several hospitals
and the limited
remaining medical services in the area of the Reymar Clinic. Tr. 68, 78-80,
94, 99, 105.