The Office of Inspector General (OIG) plays a critical role in safeguarding federal health care programs. A key tool in this effort is the authority to exclude individuals and entities from participation in these programs. This article delves into What Excludes You From Participating In Federal Health Care Programs, focusing on the grounds for exclusion and the implications for providers and beneficiaries alike. The OIG maintains the List of Excluded Individuals/Entities (LEIE), and being placed on this list carries significant consequences, including potential civil monetary penalties (CMPs) for anyone employing an excluded party.
Mandatory Exclusions: When Exclusion is Required
Federal law mandates the OIG to exclude individuals and entities convicted of certain serious offenses from all Federal health care programs. These mandatory exclusions are triggered by convictions related to:
- Medicare or Medicaid Fraud: Any criminal offense related to fraud against Medicare or Medicaid.
- Offenses Related to Health Care Delivery: Crimes connected to the provision of items or services under Medicare, Medicaid, SCHIP, or other state health care programs.
- Patient Abuse or Neglect: Convictions for mistreating or neglecting patients.
- Felony Health Care Fraud: Felony convictions for fraud, theft, or other financial misconduct in connection with health care.
- Felony Controlled Substance Offenses: Felony convictions related to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
These mandatory exclusions reflect the government’s commitment to protecting federal health care programs from the most egregious forms of misconduct.
Permissive Exclusions: Discretionary Grounds for Exclusion
Beyond mandatory exclusions, the OIG also has the permissive authority to exclude individuals and entities based on a broader range of actions. These permissive exclusions are discretionary and may be imposed for various reasons, including:
- Misdemeanor Health Care Fraud: Misdemeanor convictions related to health care fraud outside of Medicare or state health programs.
- Fraud in Other Federal Programs: Fraudulent activities in any program funded by federal, state, or local government agencies (not just health care).
- Misdemeanor Controlled Substance Offenses: Misdemeanor convictions related to unlawful activities involving controlled substances.
- License Revocation or Suspension: Suspension, revocation, or surrender of a health care license due to concerns about professional competence, performance, or financial integrity.
- Substandard Care: Providing unnecessary or substandard health care services.
- False Claims: Submitting false or fraudulent claims to a federal health care program.
- Kickback Arrangements: Engaging in unlawful kickback schemes related to health care services or referrals.
- Defaulting on Health Education Loans: Failing to meet obligations related to health education loans or scholarships.
- Controlling Sanctioned Entities: Holding a position of ownership, officer, or managing employee in an entity that has been sanctioned or excluded.
These permissive exclusion authorities allow the OIG to address a wider spectrum of potentially harmful behaviors within federal health care programs.
The Importance of Checking the LEIE and Consequences of Exclusion
To avoid CMP liability, it is crucial for health care organizations to routinely consult the LEIE. This list is a definitive resource for verifying whether current or prospective employees are excluded from federal health care programs.
The primary consequence of exclusion is straightforward: no federal health care program payment will be made for services or items furnished, ordered, or prescribed by an excluded individual or entity. This prohibition extends across Medicare, Medicaid, and all other federal plans and programs providing health benefits funded by the U.S. government (excluding the Federal Employees Health Benefits Plan).
Navigating the Exclusion Process and Appeals
It’s important to understand that receiving a Notice of Intent to Exclude (NOI) does not automatically result in exclusion. The OIG carefully reviews all information provided by the individual or entity receiving the NOI before making a final decision.
For those who are ultimately excluded, the process includes avenues for appeal. All OIG exclusions can be appealed to an HHS Administrative Law Judge (ALJ). Unfavorable decisions at this stage can be further appealed to the HHS Departmental Appeals Board (DAB). Finally, judicial review in federal court is available after a final DAB decision, ensuring a multi-layered process of review and due process.
Understanding what excludes you from participating in federal health care programs is essential for all stakeholders in the health care industry. By being aware of the grounds for exclusion and proactively checking the LEIE, organizations and individuals can ensure compliance and maintain the integrity of these vital programs.
