How Can a Medical Provider Avoid Being on the OIG Exclusion List?

 Posted on April 28, 2021 in Medical License Defense

Around 28% of all health care services in the United States are paid for through Medicare, Medicaid, or other federal programs. Because of this, health care providers need to comply with all applicable requirements, since being unable to provide services through these programs can eliminate a major source of revenue. The Office of Inspector General (OIG) for the federal Department of Health and Human Services (HHS) maintains a List of Excluded Individuals/Entities (LEIE), and any providers or organizations that are included on this list cannot receive payments from federal healthcare programs. Medical providers will want to understand the issues that could cause them to be included on this list and the actions they can take to prevent exclusion from Medicare or Medicaid programs.

Reasons for Exclusion

In many cases, a provider may face exclusion by the OIG due to charges of health care fraud or other offenses. The OIG has the discretion to issue a permissive exclusion if a provider is convicted of misdemeanor health care fraud or a misdemeanor related to illegal prescribing or dispensing of controlled substances or if their medical license has been suspended or revoked. Felony convictions for healthcare fraud or controlled substances, convictions related to abuse or neglect of patients, or any convictions for fraud against Medicare or Medicaid will result in a mandatory exclusion.

Effects of Being on the OIG Exclusion List

A provider who is on the LEIE will be barred from receiving payments for services through federal programs. If an excluded person submits a claim for payment through a federal program, they may face a civil monetary penalty (CMP) of up to $10,000 for each service furnished. In addition, an organization that employs or contracts with an excluded person may face a CMP if any services provided by the person were payable through Medicare or Medicaid. These services may include direct or indirect patient care, administrative services, or other prescriptions, items, or services provided at the direction of the excluded person. Because of these penalties, many hospitals and medical offices will not hire or contract with a service that employs a person who is on the LEIE.

Preventing Medicare/Medicaid Exclusion

Before adding a person to the exclusion list, the OIG will send the provider a Notice of Intent to Exclude. After receiving this notice, the person will have 30 days to respond and provide information about whether the exclusion is appropriate and whether there are mitigating circumstances that affect the case. If the OIG chooses to exclude a provider, this decision can be appealed and reviewed by an HHS Administrative Law Judge (ALJ). If necessary, further appeals can be pursued through the HHS Departmental Appeals Board (DAB) and in federal courts.

Contact Our Illinois Medicare/Medicaid Exclusion Lawyer

If you are facing exclusion from Medicare or Medicaid or any other issues that may affect your medical license and your ability to practice, The Law Offices of Joseph J. Bogdan, Inc. can provide you with legal help and representation. We will work to help you avoid OIG exclusion or pursue a reinstatement after a period of exclusion has ended. Contact our Illinois medical license defense attorney at 630-310-1267 to set up your free consultation.

Sources:

https://oig.hhs.gov/exclusions/files/sab-05092013.pdf

https://oig.hhs.gov/exclusions/authorities.asp

https://oig.hhs.gov/faqs/exclusions-faq.asp#