Exclusion Authorities
Scope
| Social Security Act | 42 USC § | Amendment |
|---|---|---|
| 1128 | 1320a-7 | Scope of exclusions imposed by OIG expanded from Medicare and State health care programs to all Federal health care programs, as defined in section 1128B(f)(1). |
Mandatory Exclusions
| Social Security Act | 42 USC § | Amendment |
|---|---|---|
| 1128(a)(1) | 1320a-7(a)(1) | Conviction of program-related crimes. Minimum Period: 5 years |
| 1128(a)(2) | 1320a-7(a)(2) | Conviction relating to patient abuse or neglect. Minimum Period: 5 years |
| 1128(a)(3) | 1320a-7(a)(3) | Felony conviction relating to health care fraud. Minimum Period: 5 years |
| 1128(a)(4) | 1320a-7(a)(4) | Felony conviction relating to controlled substance. Minimum Period: 5 years |
| 1128(c)(3)(G)(i) | 1320a-7(c)(3)(G)(i) | Conviction of second mandatory exclusion offense. Minimum Period: 10 years |
| 1128(c)(3)(G)(ii) | 1320a-7(c)(3)(G)(ii) | Conviction of third or more mandatory exclusion offenses. Permanent Exclusion |
Permissive Exclusions
| Social Security Act | 42 USC § | Amendment |
|---|---|---|
| 1128(b)(1)(A) | 1320a-7(b)(1)(A) | Misdemeanor conviction relating to health care fraud. Baseline Period: 3 years |
| 1128(b)(1)(B) | 1320a-7(b)(1)(B) | Conviction relating to fraud in non-health care programs. Baseline Period: 3 years |
| 1128(b)(2) | 1320a-7(b)(2) | Conviction relating to obstruction of an investigation or audit. Baseline Period: 3 years |
| 1128(b)(3) | 1320a-7(b)(3) | Misdemeanor conviction relating to controlled substance. Baseline Period: 3 years |
| 1128(b)(4) | 1320a-7(b)(4) | License revocation, suspension, or surrender. Minimum Period: Period imposed by the state licensing authority. |
| 1128(b)(5) | 1320a-7(b)(5) | Exclusion or suspension under federal or state health care program. Minimum Period: No less than the period imposed by federal or state health care program. |
| 1128(b)(6) | 1320a-7(b)(6) | Claims for excessive charges, unnecessary services or services which fail to meet professionally recognized standards of health care, or failure of an HMO to furnish medically necessary services. Minimum Period: 1 year |
| 1128(b)(7) | 1320a-7(b)(7) | Fraud, kickbacks, and other prohibited activities. Minimum Period: None |
| 1128(b)(8) | 1320a-7(b)(8) | Entities controlled by a sanctioned individual. Minimum Period: Same as length of individual's exclusion. |
| 1128(b)(8)(A) | 1320a-7(b)(8)(A) | Entities controlled by a family or household member of an excluded individual and where there has been a transfer of ownership/control. Minimum Period: Same as length of individual's exclusion. |
| 1128(b)(9), (10), and (11) | 1320a-7(b)(9), (10), and (11) | Failure to disclose required information, supply requested information on subcontractors and suppliers; or supply payment information. Minimum Period: None |
| 1128(b)(12) | 1320a-7(b)(12) | Failure to grant immediate access. Minimum Period: None |
| 1128(b)(13) | 1320a-7(b)(13) | Failure to take corrective action. Minimum Period: None |
| 1128(b)(14) | 1320a-7(b)(14) | Default on health education loan or scholarship obligations. Minimum Period: Until default or obligation has been resolved. |
| 1128(b)(15) | 1320a-7(b)(15) | Individuals controlling a sanctioned entity. Minimum Period: Same as length of entity's exclusion. |
| 1128(b)(16) | 1320a-7(b)(16) | Making false statement or misrepresentations of material fact. Minimum period: None. |
| 1156 | 1320c-5 | Failure to meet statutory obligations of practitioners and providers to provide medically necessary services meeting professionally recognized standards of health care (Quality Improvement Organization (QIO) findings). Minimum Period: 1 year |
Note: except those imposed under section 1128(b)(7) (42 USC 1320a-7b(b)(7)), and those imposed on rural physicians under section 1156 (42 USC 1320C-5), all exclusions are effective prior to a hearing.