Court Opinion

ID: 4430274
Source: CourtListenerOpinion
Date Created: 2019-08-20 19:38:39.863973+00
Date Added: 2024-06-11T14:50:59.089166
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE
                           APPROVAL OF THE APPELLATE DIVISION
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 internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.

                                                     SUPERIOR COURT OF NEW JERSEY
                                                     APPELLATE DIVISION
                                                     DOCKET NO. A-3308-15T3

IN THE MATTER OF THE SUSPENSION
OR REVOCATION OF THE LICENSE OF

AMGAD HESSEIN, M.D.
LICENSE NO.: 25MA067650

TO PRACTICE MEDICINE AND SURGERY
IN THE STATE OF NEW JERSEY.
______________________________________

                Argued October 9, 2018 – Decided October 18, 2018

                Before Judges Sabatino, Haas and Sumners.

                On appeal from the State Board of Medical Examiners,
                Division of Consumer Affairs, Department of Law and
                Public Safety.

                Joseph M. Gorrell argued the cause for appellant
                Amgad A. Hessein (Brach Eichler, LLC, attorneys;
                Joseph M. Gorrell, on the briefs).

                Doreen A. Hafner, Deputy Attorney General, argued
                the cause for respondent State Board of Medical
                Examiners (Gurbir S. Grewal, Attorney General,
                attorney; Melissa H. Raksa, Assistant Attorney
                General, of counsel; Jillian G. Sauchelli, Deputy
                Attorney General, on the brief).
PER CURIAM

      Appellant Amgad Hessein, M.D., appeals from the March 28, 2016 final

agency decision of the Board of Medical Examiners revoking his medical license

and ordering him to pay $130,000 in penalties and $308,749.53 in costs for,

among other things, fraudulent billing practices, multiple acts of gross and

repeated negligence related to patient care, and the creation of false and

fictitious patient records. We affirm.

                                         I.

      The Administrative Law Judge (ALJ) conducted a seventeen-day hearing,

and issued a comprehensive eighty-six page initial decision. The history of this

litigation and the facts relevant to this appeal are set forth at length in that

decision, and in the Board's equally thorough twenty-six page final decision.

Therefore, we need only summarize the most salient facts here.

      Prior to the Board's revocation of his license, appellant was a Board-

certified anesthesiologist specializing in interventional pain management.

Appellant was the sole practitioner in Advanced Pain Management Specialists

(APMS), which had offices in Newark, Union, Roseland, Belleville, and South

Orange. These offices were staffed by various personnel, including appellant's

brother, Ashraf Sami, who served as the APMS office manager.

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                                         2
      In June 2009, Detective David Nechamkin of the Union County

Prosecutor's Office initiated an investigation of appellant and his practice after

receiving a complaint from a member of appellant's staff about the theft of

insurance payments.     The detective testified that he arranged for one of

appellant's patients, J.C., to wear a recording device during her August 6, 2009

appointment with appellant.      During that visit, appellant administered an

injection to address J.C.'s complaints of pain only two minutes and twelve

seconds after the examination began. According to appellant's own medical

expert, Dr. Alexander Weingarten, appellant should have thoroughly questioned

J.C., and performed a comprehensive physical examination, a process that

should have taken approximately forty-five minutes, before injecting her. In

addition to this breach of medical protocol, appellant prepared a fictitious

progress note for J.C. indicating that the required examination had been

performed. Detective Nechamkin also learned that appellant charged J.C.'s

insurance company for six office visits in April 2009 even though she only

visited his office twice that month.

      Detective Nechamkin took statements from several other patients,

including B.Z., D.C., and E.M. These patients stated they never saw appellant

on consecutive days or on Sundays or Mondays when his office was closed.

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                                        3
They were required to sign in when they arrived at the office, and almost always

signed a consent form prior to receiving their treatment. Three other patients,

J.R., T.A., and A.G. provided similar testimony at the hearing. The ALJ found

the testimony by the patients who appeared at the hearing to be credible, and

corroborative of the written statements provided by the other patients.

      After a year-long investigation, Detective Nechamkin obtained arrest and

search warrants that the prosecutor's office executed at approximately 9:00 a.m.

on November 17, 2010. Detective Nechamkin arrested appellant at his home. 1

Even though appellant had yet been at work, the detective later found a stack of

completed bills on the office manager's desk for interventional pain procedures

that had allegedly been administered at appellant's Belleville office on that date.

1
  On August 3, 2011, a Union County grand jury charged appellant in thirty-
eight counts of a seventy-four count indictment with second-degree conspiracy
to commit health care fraud, N.J.S.A. 2C:5-2(a)(1); second-degree theft by
deception, N.J.S.A. 2C:20-4(a); and thirty-six counts of second-degree health
care fraud by a practitioner, N.J.S.A. 2C:21-4.3(a). Appellant's brother was
charged in the remaining thirty-six counts. On September 14, 2016, appellant
pled guilty pursuant to a plea agreement to one count of second-degree theft by
deception and one count of second-degree health care fraud by a practitioner.
After denying appellant's motion to withdraw his plea, the judge sentenced
appellant to concurrent eight-year terms on the two charges. The judge also
ordered appellant to pay restitution in the amount of $235,093.75 and to forfeit
$2 million. We recently affirmed appellant's conviction and sentence. State v.
Hussein, Docket No. A-1693-16 (App. Div. Oct. 1, 2018).
                                                                           A-3308-15T3
                                        4
The ALJ found that appellant "did not perform those services on November 17"

and, instead, prepared the bills "in advance of any scheduled office visits."

      Two investigators assigned to the Enforcement Bureau of the Division of

Consumer    Affairs,   Gina   Galloni   and   Marianne     Nucci,   accompanied

representatives of the prosecutor's office during the search of the Belleville

location. While there, they observed and inventoried approximately 110 packs,

bottles, vials, and sheets of expired medications in drawers, cabinets, and a

refrigerator commingled with unexpired medicine. The ALJ found that their

testimony on this point, which was supported by photographs of the "prodigious

number" of outdated medications they discovered, was "irrefutable."

      The prosecutor's office copied all of the patient records seized from

appellant and gave them to Galloni and Nucci. Galloni reviewed appellant's

billing and treatment records for a representative sample of six patients, D.C.,

B.Z., A.G., J.R., T.A., and J.C. She looked to see if the patients, Medicare,

Medicaid, or a private insurance provider had been billed for services where the

patient's name did not appear in the scheduler maintained by appellant and his

office staff, on consecutive dates, on Sundays or Mondays when the offices were

closed, or where the patient had not signed the required consent form. Out of

348 total visits recorded by appellant for these six patients, Galloni found that

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                                        5
175 of those visits were billed when the patient was not on the schedule.

Another twenty-eight visits allegedly occurred when the office was closed, and

eighty-two more were on consecutive days, which the patients stated did not

occur.

      After hearing and observing Galloni as she testified, the ALJ concluded

that the investigator's "detailed recitation of the methodology she used to review,

compare, and organize the data presented to her, reflect[ed] a professional,

methodical, thorough[,] and credible process."        The ALJ also found that

appellant failed to present any "persuasive arguments to question the accuracy

of the data assembled by Galloni from patient records, patients statements," and

information she received from appellant's billing company.

      In so ruling, the ALJ considered, but rejected, the testimony of appellant's

witnesses, including Malana Green, who worked as a medical assistant and

office manager. Green testified that she signed patients in when they arrived at

the office, and usually had them sign a consent form. Sometimes, however, she

did not have time to get the consent forms signed, and she did not always stay

at the office until the end of the day. Another officer worker, Haitham Sami,

who was appellant's nephew, alleged the office was not closed on Sundays and

Mondays, even though Galloni testified there was a sign on the door saying that

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                                        6
it was. Two patients, L.F. and K.M., claimed that appellant always explained

the procedures he would perform during a visit, even if a consent form was not

signed.

      Appellant did not testify at the hearing, but argued that because he

produced "progress notes" for a number of the visits, this meant they actually

occurred. The ALJ rejected this claim, finding that any such notes had been

fabricated by appellant in an attempt to hide the fact that he was billing for

services he never performed.

      For the most part, the ALJ concluded that the testimony of these witnesses

was not credible. In addition, he found that even if "some bona fide aberrational

visits found their way into Galloni's analysis[,]" such as a case where a patient

received a service even though they were not on the schedule and did not sign a

consent form, the sheer number "of unsupported billings coupled with witness

statements and testimony withstands challenge."

      Thus, the ALJ found that appellant "billed patients or their insurance

compan[ies] for medical services provided on days when the patients were not

in the office." The ALJ explained:

            The breadth of the fictitious patient visits and the
            consequent billing, as well as the patterns, dispel any
            notion that such billing was inadvertent, accidental or
            attributable to clerical errors. This is particularly so

                                                                         A-3308-15T3
                                       7
            when the Progress Notes in question were prepared by
            [appellant] rather than fabricated by an employee
            seeking personal gain. The shamelessness of this
            conduct is evidenced by the discovery of [bills]
            prepared in advance of the day of [appellant's] arrest for
            patient visits that had not occurred and would not occur
            that day.

      Turning to issues of medical care, Dolores Gilmore, an office worker

responsible for medical billing, testified that appellant had patients sign consent

forms before they received treatment, but no one explained anything on the form

to the patients. She admitted that appellant directed her to perform physical

therapy procedures on patients even though she had none of the required

certifications or licenses. Another unlicensed employee, Samirah McDaniel,

confirmed Gilmore's account concerning the improper handling of consent

forms. She also stated that appellant had her perform unlicensed physical

therapy on patients when Gilmore was absent. The ALJ found that Gilmore's

and McDaniel's testimony was credible.

      The ALJ also found that appellant billed his patients for alcohol and

substance abuse counseling that was not provided. Patients with an alcohol or

substance abuse issue, who are receiving pain medication, must receive "thirty

minutes of face-to-face discussion between the physician and the patient

regarding treatment involvement;" and "a physician is also required to document

                                                                           A-3308-15T3
                                        8
the history taken from the patient and the time spent with the patient; and to

justify" the billing. According to T.A.'s and D.C.'s records, appellant charged

each patient twenty-eight times for such counseling. Appellant billed A.G.

twice. However, they never received this required treatment.

      The parties' medical experts, Dr. Jennifer Yanow for the State, and Dr.

Weingarten for appellant, reviewed the patient files for five patients. After

reviewing their testimony, the ALJ accepted Dr. Yanow's conclusion that

appellant continued to give injections to patients even though they were not

working to alleviate the patients' complaints of pain.                Under these

circumstances, the ALJ concluded that appellant "improperly subjected patients

. . . to repeated injections as the treatments he administered were clearly not

working.    When the injections were not working, [appellant] should have

referred those patients to a surgeon to explore other options."

      The ALJ also credited Dr. Yanow's testimony that appellant performed

procedures on some of the patients without preparing a procedure note or an

operative report. Dr. Yanow "stressed that an accurate history and physical

examination, including labs or imaging when indicated[,] is mandatory for

correct diagnosis and subsequent treatment as well as for uncovering potentially

dangerous    pathology."      The   ALJ     determined   that     these   violations

                                                                            A-3308-15T3
                                        9
"demonstrate[d] a disturbing pattern, rather than isolated occurrences, of shoddy

and potentially dangerous recordkeeping."

      The ALJ also found that appellant's failure to explain the consent form to

patients prior to performing a procedure was "grossly deficient" and a "gross

deviation from the standard of care." In addition, the patient records revealed

that appellant "performed procedures where the patient was under conscious

sedation without recording vital signs," which the ALJ ruled was "a major

deviation" from the standard of care. Just as troubling, appellant did not have

an appropriately-licensed staff person record the vital signs or monitor the

sedated patient.

      The ALJ did accept Dr. Weingarten's opinion that appellant did not violate

the standard of care by administering Kenalog, a long-acting steroid, to patients

during epidural injections or facet blocks. Dr. Yanow had opined that this

medication should not be repeatedly administered to a patient, because it is not

"very water-soluble and therefore has a long duration of action." As a result,

she believed that Kenalog should not be administered more than once in six

weeks. On the other hand, Dr. Weingarten asserted there is no agreement among

anesthesiologists as to the ideal timing between, or total number of, epidural

injections, and he believed Dr. Yanow was "under-medicating her patients and

                                                                         A-3308-15T3
                                      10
not offering sufficient long-term pain relief" to them. Based on this conflicting

testimony, the ALJ concluded that there was "no standard of care that appellant

violated with regard to the type and dosage, or frequency and total numb er of

[Kenalog] injections given to patients reviewed" by Dr. Yanow and Dr.

Weingarten.

      Based upon the foregoing, the ALJ determined that appellant's medical

license should be revoked.       With regard to the billing and record-keeping

violations discussed above, the ALJ explained:

              The overwhelming evidence extracted from the medical
              records of various patients as well as the credited
              testimony of patients T.A., A.G., and J.R., the
              statement of J.C. and the corroborating statements of
              B.Z. and D.C.[ ] supports the findings that [appellant]
              engaged in a flagrant, extensive, repetitive, systematic,
              and long-standing pattern and practice of creating
              fictitious medical records and consequent billings for
              visits that did not occur such as on consecutive days or
              on days when there was no signed patient Consent
              Forms or scheduled appointments.             There was
              consistent testimony from patients who saw [appellant]
              regularly, who although praising [appellant] for the
              treatment he provided to them, denied that they saw him
              on consecutive days despite medical and billing records
              to the contrary. It is alarming that the plethora of
              instances of fraud and dishonesty are extracted from but
              a small sample of [appellant's] patients. The J.C.
              intercept provides an additional example of fraud where
              an office visit did, indeed, occur, but where the
              Progress Note claims a thorough and complex history
              and examination that actually was much briefer.

                                                                          A-3308-15T3
                                        11
     The ALJ also found that appellant

           engaged in gross negligence and gross incompetence
           and negligence and incompetence pursuant to N.J.S.A.
           45:1-21(c) and (d) for: his repeated failure to obtain
           valid informed consent; his failure to provide proper
           monitoring and documentation of monitoring for
           patients under conscious sedation; administering a
           cervical epidural upon a patient taking Plavix; and
           failing to refer patients for alternate treatment after
           prolonged use of his treatments did not bear positive
           results. A physician acts in a grossly negligent manner
           when his conduct is a patently wide departure from the
           accepted standards of care and/or demonstrates a
           conscious, reckless indifference to the risk of harm to
           the patient. In re Heller, 73 N.J. 292 (1977); State v.
           Gooze, 14 N.J. Super. 277, 282 (App. Div. 1981).

Applying that standard, the ALJ concluded:

           The pro forma consent process used by [appellant],
           absent proof that true pre-procedure and post-
           discussion informed consent was otherwise confirmed,
           improperly deprives patients appearing because of pain
           and discomfort from having a real opportunity to weigh
           the consequences of the procedures. It sadly reflects a
           physician with an apparently busy practice who is
           trying to cut corners in order to save time. The failure
           to hire appropriate personnel to monitor patients under
           conscious sedation is inappropriate as the physician,
           himself, should be concentrating on the very delicate
           and precise intervention procedures and not distracted
           by also monitoring vital signs.

     In addition to recommending that appellant's medical license be revoked ,

the ALJ imposed a $50,000 monetary penalty. He also determined that the

                                                                      A-3308-15T3
                                     12
State's request for costs should be submitted in the first instance to the Board.

Both parties filed exceptions to the ALJ's initial decision.

      Following oral argument, the Board unanimously adopted the ALJ's

findings of fact and conclusions of law, with certain amplifications and

modifications. The Board adopted the ALJ's conclusion that appellant had a

practice of performing injections without taking an adequate history or

performing a physical examination.       However, the Board made clear that

appellant's actions constituted "a gross deviation from all acceptable medical

practices, and create[d] a significant potential for harm to patients." The Board

also determined that appellant "committed gross negligence for his repeated

administration of steroid-containing injections despite the lack of apparent

benefit to the patient."

      Relying on the collective medical expertise of its members, the Board

rejected the ALJ's conclusion that there was no standard of practice in the field

of anesthesiology concerning the administration of repeated Kenalog injections

to patients over a short period of time in order to relieve spinal pain. The Board

noted that Dr. Yanow "cautioned against the use of Kenalog, a particulate

                                                                          A-3308-15T3
                                       13
steroid, in neuraxial procedures." 2 Dr. Yanow based her opinion on her training

and experience, as well as several medical journal articles she cited during her

testimony. The Board agreed with Dr. Yanow "that the use of Kenalog in

neuraxial procedures for the cervical spine is contraindicated, especially with

the lack of informed consent" provided by appellant's patients due to his failure

to review the consent forms with them. Thus, the Board found that appellant's

indiscriminate use of Kenalog constituted gross negligence.

      Turning to other examples of improper medical care appellant provided to

his patients, the Board held:

                   [The ALJ] found that [appellant] violated several
            statutes and regulations but did not quantify the level of
            misconduct. After careful review of the entire record
            in this matter, and in our medical expertise, we amplify
            the Initial Decision and find that the following
            violations constitute repeated and gross negligence:
            allowing and billing for unlicensed employees to render
            physical therapy; performing conscious sedation
            without an appropriately certified person present and
            without appropriate written policies and procedures (a
            "major deviation" . . .); indiscriminate prescribing of
            opiates to patient J.R. without documentation of
            medical necessity; and failing to perform and then
            billing for alcohol and substance abuse counseling.
            [Appellant's] haphazard and self-serving manner of

2
  Neuraxial anesthesia is a type of regional anesthesia that involves the injection
of medication in the fatty tissue that surrounds the nerve roots in the spine (also
known as an "epidural") or into the fluid that surrounds the spinal cord, also
known as a "spinal."
                                                                           A-3308-15T3
                                       14
            practicing medicine put vulnerable patients at very real
            risk of harm. [Appellant's] shocking disregard for
            patient safety and welfare supports our conclusion that
            [appellant] is a fundamentally corrupt and/or
            incompetent practitioner.

      Based upon the foregoing, the Board adopted the ALJ's recommendation

that appellant's medical license be revoked. The Board found that appellant

            systematically and flagrantly ignored Board statutes
            and regulations, engaged in gross negligence and
            placed his patients at risk of harm while defrauding
            payors for years. The ALJ described [appellant's]
            grossly negligent care of the six patients that were the
            subject [of] . . . this matter to be representative of
            [appellant's] general practice. We also accept that these
            six patients are merely a reflection of [appellant's]
            pattern of misconduct and gross negligence.

The Board further explained that appellant's

            duty to accurately record his patient's conditions and
            treatment rendered is not a technicality. [Appellant's]
            patients do not have a medical record; they have
            documentation supporting [appellant's] massive,
            fraudulent billing scheme.          Third[-]party[]payors,
            whether the government through Medicare or Medicaid
            or private insurers, as well as private persons paying for
            medical treatment out of pocket, [were] all victimized
            by false records. [Appellant] has betrayed the trust of
            his patients, the public, and the regulated community,
            and has raided the public coffers.

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                                       15
      Under these circumstances, the Board determined that a $130,000 civil

penalty was more appropriate than the $50,000 sanction suggested by the ALJ.

The Board stated that it was imposing that penalty because

            the record before us shows that, over a period of three
            years, [appellant] created false records on a minimum
            of 132 occasions, allowed unlicensed employees to
            administer physical therapy modalities which he billed
            as if they were licensed on at least eight occasions, and
            improperly subjected at least four patients to repeated
            injections when the treatments he administered were
            clearly not working. If we were to count each of these
            instances as a separate violation[,] we would be
            justified in imposing a civil penalty in excess of $2
            million pursuant to N.J.S.A. 45:1-25.

The Board also reviewed the State's documentation concerning the prosecution

costs it incurred, including attorney fees, and ordered appellant to pay the State

$308,749.53. This appeal followed.

                                       II.

      On appeal, appellant argues that: (1) the Board's decision that appellant

"did not provide numerous services flies in the face of clear documentation and

reality"; (2) "the Board's finding that the use of Kenalog in [neuraxial]

procedures for the cervical spine is contraindicated is not supported by the

record"; and (3) the ALJ "demonstrated prejudice against appellant thereby

depriving him of due process of law." Based upon our review of the record and

                                                                          A-3308-15T3
                                       16
applicable law, we conclude that appellant's contentions are without sufficient

merit to warrant extensive discussion in a written opinion. R. 2:11-3(e)(1)(D),

(E). We therefore affirm substantially for the reasons stated by the Board in its

comprehensive final decision, which incorporated the findings of fact and

conclusions of law set forth in the ALJ's initial decision. We add the following

comments.

      Our scope of review of an administrative agency's final determination is

limited. In re Herrmann, 192 N.J. 19, 27 (2007). A "strong presumption of

reasonableness attaches" to the agency's decision. In re Carroll, 339 N.J. Super.

429, 437 (App. Div. 2001) (quoting In re Vey, 272 N.J. Super. 199, 205 (App.

Div. 1993), aff'd, 135 N.J. 306 (1994)). The burden is upon the appellant to

demonstrate grounds for reversal. McGowan v. N.J. State Parole Bd., 347 N.J.

Super. 544, 563 (App. Div. 2002); see also Bowden v. Bayside State Prison, 268

N.J. Super. 301, 304 (App. Div. 1993) (stating that "[t]he burden of showing the

agency's action was arbitrary, unreasonable[,] or capricious rests upon the

appellant").   To that end, we will "not disturb an administrative agency's

determinations or findings unless there is a clear showing that (1) the agency

did not follow the law; (2) the decision was arbitrary, capricious, or

unreasonable; or (3) the decision was not supported by substantial evidence." In

                                                                         A-3308-15T3
                                      17
re Virtua-West Jersey Hosp. Voorhees for a Certificate of Need, 194 N.J. 413,

422 (2008).

      It is not our place to second-guess or substitute our judgment for that of

the agency and, therefore, we do not "engage in an independent assessment of

the evidence as if [we] were the court of first instance." In re Taylor, 158 N.J.

644, 656 (1999) (quoting State v. Locurto, 157 N.J. 463, 471 (1999)).

Additionally, we give "due regard to the opportunity of the one who heard the

witnesses to judge . . . their credibility[,]" and therefore accept their findings of

fact "when supported by adequate, substantial and credible evidence[.]" Id. at

656. (first quoting Close v. Kordulak Bros., 44 N.J. 589, 599 (1965); and then

quoting Rova Farms Resort, Inc. v. Investors Ins. Co., 65 N.J. 474, 484 (1974)).

Applying these principles, we discern no basis for disturbing the Board's well-

reasoned determination that appellant submitted numerous fraudulent bills,

created fictitious treatment records, and provided "grossly deficient" and

"grossly negligent" medical care to patients that constituted a "gross deviation"

from the required standard of care.

      Appellant first contends that the ALJ should have given more weight to

the testimony of his witnesses, specifically Malana Green, who claimed that she

was not always present in the office and, therefore, could not be sure whether

                                                                             A-3308-15T3
                                        18
all of the patients signed in when they arrived at the office. He also alleges that

it made no sense for patients who were in pain to take the time to sign consent

forms. Therefore, appellant argues that the ALJ should not have accepted

Galloni's testimony that if the patient did not appear on the schedule, sign in

upon arrival, or complete the consent form, this meant the visit never occurred

and that appellant fraudulently billed for the services he claimed he rendered.

      However, appellant's contention on this point ignores the fact that the

ALJ, who had the opportunity to observe the witnesses as they testified, credited

the testimony of the State's witnesses, and found that the contrary assertions

presented by appellant's witnesses were not credible. As stated above, we are

required to defer to the credibility determinations made by the trier of fact.

Taylor, 158 N.J. at 656. Accordingly, there is ample evidence in the record,

including the testimony of the patients, to support the Board's conclusion that

appellant billed for services he never provided.

      Moreover, even if appellant provided some of the services he could not

verify with documentation, he still placed the patients at serious risk of harm by

the fact that he did not adequately document their treatment, or obtain the

consent necessary to enable the patient to weigh the possible benefits and risks

of the proposed treatment and to make an informed choice whether to undergo

                                                                           A-3308-15T3
                                       19
it. Therefore, we have no basis for disturbing the Board's determination to

revoke appellant's license to practice medicine.

      For similar reasons, we reject appellant's argument that the Board should

not have concluded that he improperly administered Kenalog during neuraxial

procedures of the cervical spine. The overuse of this medication was just one

example of the many instances where appellant provided grossly negligent care

that warranted the revocation of his license. Among other things, appellant

directed unlicensed employees to render physical therapy; performed conscious

sedation procedures without having a certified person present to monitor the

patient; prescribed opiates to a patient without any documentation that the

medication was medically necessary; and failed to perform alcohol and

substance abuse counseling when required. These examples of misconduct, and

the others noted above, which are not specifically challenged by appellant in his

brief, were more than enough to warrant the revocation of appellant's license

and the imposition of the monetary penalty and costs without the need to

consider appellant's misuse of Kenalog in the treatment of his patients. Thus,

any error in the Board's consideration of the Kenalog issue would have been

harmless.

                                                                         A-3308-15T3
                                      20
       That having been said, however, we discern no basis for disturbing the

Board's determination to accept Dr. Yanow's expert testimony over that of Dr.

Weingarten that there was an established standard of care for the administration

of Kenalog in neuraxial cervical spine procedures.        Contrary to appellant's

contention, Dr. Yanow grounded her opinion in the facts and data she obtained

by reviewing the patient files, and she based her determination that appellant

improperly used Kenalog on her training, experience, and review of applicable

medical journals. Townsend v. Pierre, 221 N.J. 36, 55 (2015) (stating that an

expert's testimony does not constitute a net opinion when the expert is "able to

identify the factual bases for [his or her] conclusions, explain their methodology,

and demonstrate that both the factual bases and the methodology are reliable").

In addition, appellant concedes that in assessing the record, the Board is

permitted to rely on the expertise of the physicians who comprise the majority

of its membership. In re Kerlin, 151 N.J. Super. 179, 185 (App. Div. 1977).

Therefore, we affirm the Board's finding that in addition to the many other cases

of gross negligence discussed in its decision, appellant also acted improperly by

using Kenalog so often, especially where he did not first obtain the informed

consent of the patients to this procedure.

                                                                           A-3308-15T3
                                       21
      Finally, appellant argues that the ALJ was biased against him. In support

of this claim, appellant points to several evidentiary rulings made by the ALJ

during the course of the seventeen-day hearing that went in the State's favor. He

alleges that when he attempted to introduce similar evidence, the ALJ ruled

against him. This argument lacks merit.

      A judge's decision to admit or exclude evidence is "entitled to deference

absent a showing of an abuse of discretion, i.e., [that] there has been a clear error

of judgment." Griffin v. City of E. Orange, 225 N.J. 400, 413 (2016) (alteration

in original) (quoting State v. Brown, 170 N.J. 138, 147 (2001)). "Thus, we will

reverse an evidentiary ruling only if it 'was so wide [of] the mark that a manifest

denial of justice resulted.'" Ibid. (quoting Green v. N.J. Mfrs. Ins. Co., 160 N.J.

480, 492 (1999)).

      In this section of his brief, appellant never specifies how any of the

evidentiary rulings made any difference in the ALJ's ultimate conclusions.

Indeed, there is no principled analysis of, or citation to governing case law

concerning, any of these alleged errors. 3 Instead, appellant's argument is simply

3
  Therefore, we are unable to conclude that the ALJ abused his discretion in regard to
any of the rulings that are briefly mentioned in appellant's brief.
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that because the rulings went against him, it could only have been because the

judge was biased against him.

      However, "[b]ias cannot be inferred from adverse rulings against a party."

Strahan v. Strahan, 402 N.J. Super. 298, 318 (App. Div. 2008) (citing Matthews

v. Deane, 196 N.J. Super. 441, 444-47 (Ch. Div. 1984)). Thus, the mere fact

that the ALJ made adverse rulings against appellant does not suggest that the

ALJ was biased against him. Instead, the record demonstrates that the ALJ was

patient with appellant throughout the lengthy proceedings, and made rulings,

some in favor of appellant and some that were not, that were fair to both parties

and based on the facts developed at the hearing.

      We also reject appellant's claim allegation, improperly raised by him for

the first time in his reply brief, that the ALJ improperly barred him from

testifying at the hearing. See L.J. Zucca, Inc. v. Allen Bros. Wholesale Distribs.,

Inc., 434 N.J. Super. 60, 87 (App. Div. 2014) (holding that "[a]n appellant may

not raise new contentions for the first time in a reply brief"). As appellant is

fully aware, he decided to proceed with the administrative hearing even though

there were criminal charges pending against him.         He then discharged his

attorney before the hearing, and represented himself. Because of the pending

                                                                           A-3308-15T3
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criminal charges, appellant advised the ALJ at the beginning of the hearing that

he was not going to testify, although he reserved his right to do so.

       Thereafter, appellant never asked to testify and the ALJ never prevented

him from doing so. However, appellant bases his newly-minted contention on

a brief colloquy that occurred on the last day of the hearing, while the Deputy

Attorney General (DAG) was cross-examining Dr. Weingarten.              Appellant

objected to a question, and asserted it was "misleading." The ALJ instructed

appellant to let the expert testify, rather than attempting to testify himself in

response to the DAG's questions. Appellant then stated that if he were to testify,

the DAG was "not going to like what I say." The DAG responded by saying she

"would be anxious" to have appellant testify.

       After replying that he was "willing to do it by the way[,]" appellant agreed

with the ALJ that "that ship has sailed" and was "not going to happen."

Appellant then explained his objection, which the ALJ sustained. The DAG

rephrased her question to Dr. Weingarten and the hearing concluded later that

day.

       Under no circumstances could this brief exchange be interpreted as a bona

fide request by appellant to testify or an improper refusal by the ALJ of this

request. Clearly, appellant would not have been permitted to testify in the

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middle of his own expert's testimony. When Dr. Weingarten completed his

presentation, however, appellant called no further witnesses, and never sought

to testify himself. Appellant never raised this issue before the ALJ in his

summation, and did not raise it in the exceptions he filed with the Board.

Therefore, we reject appellant's baseless allegation.

      Affirmed.

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