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Exclusion Authorities & Effects of Exclusion

OIG explains Exclusion Authorities and Effects of Exclusion.

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My name is Geeta Kaveti and I am an attorney with the Office of the Inspector General. Our office is often asked to define exclusion.

What does it mean? How does it impact my business? What is the impact on my employees? I am going to answer these questions and more for you today.

So, what is exclusion? Exclusion is when the IG prevents an individual or entity from participating in Medicare, Medicaid, and other Federal health care programs.

But the question is, what does this actually mean in practice? What is the practical effect of exclusion?

Exclusion means that no program payments will be made for items or services furnished, ordered, or prescribed by the excluded individual or entity.

For example, a home health care agency can't employ or contract with an excluded home health care aide or they may have to pay back all of the Federal health care payments associated with the work of that aide. Nobody wants that to happen.

The Federal health care programs will not pay for any items ordered or prescribed by an excluded physician.

For example, if an excluded physician orders a series of tests at a hospital for a Federally-insured patient, the hospital cannot receive reimbursement for any of the tests ordered by the physician, unless the hospital can show that it did not know or have reason to know about the exclusion.

How does exclusion impact an individual's employment at a healthcare entity? Well, no one can submit claims to a federal health care program for items or services furnished by an excluded individual. Essentially, exclusion extensively narrows an individual's employment options with entities that receive Federal health care payments.

The question is, what can an excluded individual do in a health care setting? Excluded individuals can work in non-Federal health care program payment settings or provide care to non-Federal health care program beneficiaries. Also, there are some non-patient care employment options which wouldn't give rise to liability, such as facilities management or graphic design services.

Now that we have covered the basics, let's move to the two types of exclusion.

Mandatory and Permissive

In certain circumstances, the IG is required to exclude individuals and entities. Such as when an individual or entity is a convicted of a program related crime or patient abuse and neglect. Or if an individual is convicted of a felony relating to controlled substances or, obviously, a felony relating to health care fraud. These are mandatory exclusions.

Permissive exclusions are discretionary. The IG may choose to exclude individuals or entities under 16 different statutory authorities, such as when an individual lies on an enrollment application, for certain misdemeanor convictions, loss of state license to practice, failure to repay health education loans, and failure to provide quality care.

In fact, just about anyone can be excluded, from licensed clinicians to unlicensed personnel such as administrators, billers and secretaries. The IG may also exclude corporate entities and officers.

So how long does an exclusion last? Well, the length varies depending upon the case and the basis for the exclusion. The term is generally for a set period of time, except that the period is indefinite for exclusions based on licensure actions. The minimum period for a mandatory exclusion is for a term of 5 years.

At the end of an exclusion term, reinstatement is not automatic. An individual must apply for reinstatement and must receive notice from the OIG that reinstatement has been granted.

There are a number of resources related to the topics I have covered today available to you on the Exclusion Page of the OIG website. The resources on our website make it easy for you to protect yourself from the consequences of exclusion.