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Working With Federal and State Partners on Health Care Exclusions

The HHS Office of Inspector General (HHS-OIG) has authority to exclude individuals and entities from participation in Federally funded health care programs for specified reasons, including criminal convictions and certain adverse licensing actions.

An excluded individual or entity may not receive payment from Federal health care programs for any items or services they furnish, order, or prescribe.

Federal agencies, State partners, Medicaid Fraud Control Units (MFCUs), and certain prosecutorial offices may refer individuals or entities to HHS-OIG for consideration of exclusion.

Referrals Based on Licensing Actions

State health care professional licensing authorities (including licensing boards, commissions, and health departments) may submit referrals to HHS-OIG when qualifying licensing actions occur.

Basis for Exclusion

HHS-OIG may exclude an individual or entity if a State licensing authority has taken one of the following actions related to the individual’s or entity’s authority to provide health care:

  • Revocation of a license;
  • Suspension of a license;
  • Loss of the right to apply for or renew a license; or
  • Acceptance of a license surrender while a disciplinary proceeding was pending.

The licensing action must be based on concerns related to:

  • Professional competence;
  • Professional performance; or
  • Financial integrity.

Actions that do not qualify as a basis for exclusion include probation, letters of censure, reprimands, or other conditions that do not result in revocation, suspension, surrender, or loss of licensure. These actions should not be referred to HHS-OIG.

Referrals for Exclusion Based on Criminal Convictions

Mandatory Exclusions

HHS-OIG is required to exclude individuals and entities convicted of the following offenses:

  • Medicare or Medicaid fraud, or other offenses related to the delivery of items or services under Medicare, Medicaid, CHIP, or other State health care programs;
  • Offenses related to patient abuse or neglect in connection with the delivery of health care items or services;
  • Felony offenses involving fraud, theft, embezzlement, breach of fiduciary duty, or other financial misconduct related to the delivery of a health care item or service or involving a government health care program; and
  • Felony offenses related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances by a health care-related individual or entity.

Permissive Exclusions

HHS-OIG may also exclude individuals and entities based on:

  • Misdemeanor convictions for health care-related fraud, theft, embezzlement, breach of fiduciary duty, or other financial misconduct; or
  • Misdemeanor convictions related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

For exclusion purposes, an individual or entity is considered convicted when:

  • A judgment of conviction has been entered by a Federal, State, or local court, regardless of appeal status or expungement;
  • A court has made a finding of guilt;
  • A plea of guilty or nolo contendere has been accepted; or
  • The individual or entity has entered a deferred adjudication, first-offender, or similar program where judgment is withheld.

Required Documentation

Based on Licensing Actions

Required Information
  • The official order or document imposing the revocation, suspension, surrender, or other qualifying licensing action; and
  • The charging document(s) that formed the basis for the licensing action.
  • If the above documents do not clearly establish that the action was based on professional competence, performance, or financial integrity; you may submit additional supporting materials, such as investigative reports, hearing transcripts, meeting minutes, or other relevant records.

Based on Criminal Convictions

 Required Information
  • Defendant’s name;
  • Court name and case or docket number;
  • Offense(s) of conviction and date of conviction and/or sentencing; and
  • Referring agency point of contact.
Supporting Documentation
  • Judgment and sentence order;
  • Plea agreement (if applicable);
  • Charging documents (indictment, complaint, or information);
  • Any amendments to the above; and
  • Investigative reports, police reports, or factual summaries.

Submit your referrals

Step 1. Gather your documentation.
Make sure your referral includes the necessary required and supporting documentation. Refer to the section above for requirements based on licensing actions and criminal convictions.

Step 2. Submit your referrals.

  • For High Volume Referrals (Federal agencies, MFCUs, and other state partners), use the Exclusion Referrals portal.
    • Non-MFCU State and local prosecutors submitting a significant volume of referrals can register to use the portal.

If documents include PII or PHI, do NOT email documents. Contact HHS-OIG to arrange secure submission.