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Don’t get excluded from Medicare payments—make sure your billing is up to code!.

The Office of Inspector General (OIG) is tasked with monitoring the federal agencies that are governed by the Department of Health and Human Services (HHS). It is responsible for audits, evaluations, investigations, and compliance in an effort to fight fraud and abuse of all government programs.

The OIG has the authority through Sections 1128 and 1156 of the Social Security Act to penalize and exclude individual healthcare providers and healthcare entities from participating in any federal funded programs—this is referred to as the “Exclusion Program.”

Exclusion: What Does That Mean to a Provider?

“Exclusion” means that a provider will not be able to render services to any patients who have Medicare, Medicaid, or any other federally funded healthcare program, and also excludes the provider from referring any of their patients to other providers who participate in these healthcare programs. Providers who have engaged in any form of fraud or abuse will be placed on what is called the List of Excluded Individuals and Entities (LEIE).

Being placed on the LEIE can be devastating to a practice. It is the practice’s responsibility not to engage in business with (or hire) any individuals or entities that are on the LEIE because this can lead to civil monetary penalties or placement on this list. The LEIE includes all types of healthcare providers and entities, from physicians and coders to laboratories and billing companies. The LEIE is maintained by the OIG and can be located at www.oig.hhs.gov.

Types of Exclusions

There two types of exclusions—mandatory and permissive.

Mandatory Exclusions

OIG is required by law to exclude from participation in all federal healthcare programs individuals and entities convicted of certain types of criminal offenses. Examples include:

• Medicare, Medicaid, or other state healthcare programs fraud;
• Abuse or neglect of patients;
• Felony convictions of any other healthcare related fraud or theft; and
• Illegal manufacture, distribution, prescription, or dispensing of controlled substances that leads to a felony conviction.

Permissive Exclusions

At its discretion, OIG can exclude individuals and entities on a number of groups. Examples include:

• Misdemeanor convictions related to healthcare fraud that do not include Medicare, Medicaid, or other state healthcare programs;
• Illegal manufacture, distribution, prescription, or dispensing of controlled substances that leads to a misdemeanor conviction;
• Criminal kickback arrangements involvement; and
• Failure to repay health education loans or neglecting scholarship obligations.

Being placed on the LEIE not only excludes providers from federal healthcare programs but also can lead to civil monetary penalties being levied on a practice. The HHS Secretary has been authorized by the Social Security Act to assign civil monetary penalties (CMPs). The HHS Secretary will often hand these cases over to the OIG, which can also add exclusion for the provider.