May 9, 2013

Exclusion From Federal Health Care Programs: New Guidance From The United States HHS OIG

The United States Department of Health and Human Services Office of the Inspector General (OIG) has issued a Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs (“the Bulletin”).  The Bulletin replaces the previous OIG bulletin on this topic issued in 1999.  Exclusions from federal health care programs (including but not limited to Medicaid, Medicare, TRICARE, and veterans’ programs) often result from criminal and civil actions taken by governmental entities against providers.

The Bulletin details the consequences of exclusion from federal health care programs.  Guidance is also provided regarding civil monetary penalty liability for a provider who employs an excluded individual. The Bulletin provides guidance to the health care industry on the scope and frequency of screening employees and contractors against the OIG’s List of Excluded Individuals and Entities (LEIE) to determine whether they are excluded persons.  The Bulletin also recommends using the OIG’s recently revised self-disclosure protocol to disclose any employees who are excluded individuals.

Additionally, the Bulletin describes the scope and effect of the legal prohibition on payment by Federal health care programs for items or services furnished by an excluded person, or at the medical direction, or on the prescription of, an excluded person. For purposes of OIG exclusion, payment by a Federal health care program includes amounts based on a cost report, fee schedule, prospective payment system, capitated rate, or other payment methodology. The Bulletin also describes how exclusions can be violated and the administrative sanctions OIG can pursue against those who have violated an exclusion.

The new US HHS OIG Special Advisory Bulletin can be found at http://oig.hhs.gov/exclusions/advisories.asp.

The 1999 version can be found at http://oig.hhs.gov/exclusions/effects_of_exclusion.asp.

For more information, please contact the author, David R. Ross, who served as Acting Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG).