Broad “In Connection With” Nexus and Fraud-Related Character of § 843(a)(3) Drug Diversion Trigger Mandatory Exclusion Under 42 U.S.C. § 1320a‑7(a)(3)

Precedents Cited and Their Influence

• Falge v. Apfel, 150 F.3d 1320 (11th Cir. 1998): The court cited Falge to confirm that the DAB’s decision is reviewable as the Secretary’s final decision. This frames the appellate lens: the Eleventh Circuit reviews the Secretary’s final action directly.
• Florida Medical Center of Clearwater, Inc. v. Sebelius, 614 F.3d 1276 (11th Cir. 2010): Provided the Administrative Procedure Act-style standard: the court upholds agency action unless arbitrary, capricious, an abuse of discretion, contrary to law, or unsupported by substantial evidence. This highly deferential review shaped the outcome, especially on the “reasonableness” of the seven-year term.
• Mendoza v. Secretary, DHS, 851 F.3d 1348 (11th Cir. 2017): Reinforced the deferential posture. The court emphasized that it does not substitute its judgment for the agency’s and only sets aside decisions that fail basic rationality checks.
• Rine v. Imagitas, Inc., 590 F.3d 1215 (11th Cir. 2009): Guided the court’s textual approach: start with the statutory language and presume Congress said what it meant. This supported construing “relating to” fraud and “in connection with” health care delivery according to their ordinary breadth.
• United States v. James, 135 F.4th 1329 (11th Cir. 2025): The court drew from James’s “expansive interpretation” of the phrase “in connection with,” describing it as satisfied by a contextual, causal, or logical relationship. Leveraging this broad reading, the court found Meeks’s professional access to Oxycodone sufficient to establish the requisite nexus to health care delivery.
• Loper Bright Enterprises v. Raimondo, 603 U.S. 369 (2024): Meeks’s argument invoking Loper Bright (which curtailed Chevron deference) failed because, as the court observed (citing James), Loper Bright concerns deference to agency statutory interpretations, not interpretations of an agency’s own regulations. The court implicitly affirms that deference to an agency’s regulatory interpretations (Auer/Kisor-type deference) remains intact in this context.
• Access Now, Inc. v. Southwest Airlines Co., 385 F.3d 1324 (11th Cir. 2004): The court declined to consider an argument raised for the first time on appeal—i.e., that the statute requires proof of economic harm to a protected program—reiterating the circuit’s preservation rule.

Legal Reasoning

1) “Relating to” fraud or theft under § 1320a‑7(a)(3)

The statutory trigger requires a felony “relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.” Meeks’s conviction under § 843(a)(3) demanded proof that he knowingly and intentionally acquired a controlled substance by “misrepresentation, deception, or subterfuge.” The court found a “nexus or common sense connection” between Meeks’s conviction and fraud/deceit because misrepresentation and deception are integral to the offense’s elements. The opinion emphasizes that the very structure of § 843(a)(3)—offering misrepresentation, deception, and subterfuge as the operative means—ties the offense to fraud-related conduct.

Importantly, the court rejected Meeks’s argument that he could not have committed “theft” as the pharmacy’s owner, deeming the theft inquiry unnecessary. It sufficed that his felony “relates to” fraud or deceit; the statute lists fraud and theft disjunctively and permits inclusion of other financial misconduct. Because fraud-related conduct alone satisfied § 1320a‑7(a)(3), the absence or impossibility of theft was immaterial.

2) “In connection with the delivery of a health care item or service”

The court adopted an “expansive interpretation” of “in connection with,” following James. The nexus is satisfied by a contextual, causal, or logical relationship. Meeks’s professional status as a pharmacist supplied him access to Oxycodone within the pharmacy’s controlled-substance supply chain. That access existed because of his role in delivering health care items to the public. Consequently, the offense bore both a contextual and causal link to health care delivery—even though the controlled substances were diverted for personal use rather than billed or dispensed to patients. The court thus signaled that no billing-to-Medicare/Medicaid or direct program-dollar nexus is required to meet the “in connection with” element.

3) Standard of review and application

Applying the APA-style standard, the Eleventh Circuit reviewed whether the Secretary’s final decision (via DAB) was arbitrary, capricious, contrary to law, or not supported by substantial evidence. The court observed no improper factors, no failure to consider important aspects, no discord with the evidentiary record, and no implausibility suggestive of a lack of expertise. On the core statutory predicates (“relating to” fraud and “in connection with” health care delivery), ample evidence—including the plea’s factual basis—supported the Secretary’s conclusions.

4) Length of exclusion and regulatory factors

Section 1320a‑7(c)(3)(B) sets a five-year mandatory minimum. The regulation at 42 C.F.R. § 1001.102 authorizes extensions for specified aggravating factors and allows consideration of enumerated mitigating factors. The ALJ found, and the DAB agreed, that two aggravating factors applied:

• Duration (42 C.F.R. § 1001.102(b)(2)): The acts occurred for one year or more. Meeks admitted in his plea that the conduct spanned at least January 1, 2017, to on or about July 1, 2018.
• Prior sanction record (42 C.F.R. § 1001.102(b)(6)): Meeks’s license surrender constituted an administrative sanction. The record reflected that his voluntary surrender was a public disciplinary action by the Georgia State Board of Pharmacy.

The ALJ and DAB found no applicable mitigating factors under § 1001.102(c). The court upheld the seven-year term as reasonable in light of the aggravating profile and the absence of enumerated mitigators. Notably, certain equitable or rehabilitative facts—self-admission to treatment; reinstatement of licensure; early termination of probation—were not among the regulation’s mitigating categories and thus could not reduce the period as a matter of law.

5) Deference after Loper Bright and issue preservation

Meeks invoked Loper Bright to challenge deference to the agency. The court, citing James, clarified that Loper Bright addresses deference to agency interpretations of statutes (Chevron), whereas here the relevant deference pertains to an agency’s interpretation of its own regulations (Auer/Kisor). Thus, the district court’s deference framework remained intact. The court also refused to consider a newly raised argument that the statute requires a showing of economic impact on the protected programs, invoking circuit precedent on preservation (Access Now).

Impact

Although unpublished and nonprecedential, this decision has meaningful persuasive value within the Eleventh Circuit and practical guidance nationally for health care exclusions:

• Drug diversion as a fraud-related felony: A conviction under 21 U.S.C. § 843(a)(3) will generally qualify as a felony “relating to” fraud or deceit for § 1320a‑7(a)(3) purposes, even absent proof of theft or program-dollar harm.
• Broad “in connection with” nexus: The nexus to “delivery of a health care item or service” is satisfied when access to controlled substances arises from professional duties. The offense need not involve billing or distribution to beneficiaries; professional access alone can supply the contextual/causal link.
• Exclusion length and risk indicators: The two aggravators used here—one-year duration and prior administrative sanction—are common in licensing contexts. Providers should anticipate that licensure discipline will weigh heavily and that rehabilitation evidence may not count unless it fits within the regulation’s enumerated mitigating factors.
• Deference landscape post-Loper Bright: Counsel should distinguish between challenges to statutory interpretations (implicating Loper Bright) and regulatory interpretations (still subject to Auer/Kisor-type deference). Meeks underscores that Loper Bright does not upend the latter.
• Issue preservation is critical: Arguments about program-economic harm or other narrowing glosses on § 1320a‑7(a)(3) must be preserved before the agency and district court. Failure to do so will preclude appellate consideration.
• Policy signal: The opinion reinforces OIG’s protective mandate: exclusions serve prophylactic ends—protecting program integrity and patient safety—rather than re-punishing. That purpose justifies broad constructions of threshold terms and the use of structured aggravating/mitigating factors.