The Office of the Inspector General can exclude any party from providing Medicare, Medicaid and other health services under the following circumstances:
• Felony or misdemeanor conviction for fraud or other offences committed during provision of health care services,
• Felony or misdemeanor conviction for manufacturing, distributing or prescribing illegal or controlled substances,
• Abuse or neglect of patients,
• Suspended or revoked medical license due to incompetence, underperformance, lack of financial integrity or other circumstances,
• Failure to pay healthcare education loans or to honor obligations of a scholarship program,
• Providing unnecessary services,
• Accepting or promising kickbacks.
Exclusion period varies based on offence, but it’s important to note that multiple convictions (up to 3 times) of the above offences can result in permanent exclusion.
The names of excluded providers are entered in a list maintained by the OIG, known as the List of Excluded Individuals and Entities (LEIE).
Once excluded, a provider who continues disbursing healthcare services may be liable to a criminal or civil suit, steep fines and reduced chances of a waiver or reinstatement. Billings made to Medicare, Medicaid or other health programs by an excluded provider will not be paid and may actually result in a fine.
As well, hiring or engaging individuals and entities listed in the LEIE for service provision could result in fines.
Waiver of an Exclusion
Sections 1128(c)(3)(B) of the Social Security Act (Act) and 42 C.F.R. 1001.1801(b) give the Office of the Inspector General the authority to waive the exclusion of any entity or individual from providing health care services.
A waiver is issued if the excluded provider is the only provider of healthcare in a community or if excluding that individual or entity will deny the community of specialized health services.
The Social Security Act however prohibits waivers for entities or individuals excluded due to circumstances involving abuse or neglect of patients.
How to get a waiver
An excluded individual or entity cannot request a waiver directly from the OIG, but can only do so through a state or federal administrator of a health program.
Once a waiver is granted, the excluded provider can resume provision of Medicare, Medicaid.
There are limitations to every waiver and providers should observe these limitations when participating in health care programs. For instance, a waiver applies to a specific medical service or geographical location and payment will only be made for those services covered within the scope of the waiver.
A waiver does not mean a provider is no longer excluded, nor does it result in automatic reinstatement at the end of the exclusion period. In fact, the office of the Inspector general can rescind a waiver any time, if advised by state or federal administrators that the excluded party is no longer the sole provider of the medical service.
To see examples of waivers currently in effect across the US, visit https://oig.hhs.gov/exclusions/waivers.asp