One of the more significant consequences of certain civil and criminal cases is being excluded by the Office of Inspector General (OIG). This is set forth in the Exclusion Statute, 42 United States Code Section 1320a-7.
OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses:
(1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid;
(2) patient abuse or neglect;
(3) felony convictions for other health-care-related fraud, theft, or other financial misconduct; and
(4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
OIG has discretion to exclude individuals and entities on several other grounds, including misdemeanor convictions related to health care fraud other than Medicare or Medicaid fraud or misdemeanor convictions in connection with the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance,
or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; and defaulting on health education loan or scholarship obligations.
If you are excluded by OIG from participation in the Federal health care programs, then Medicare, Medicaid, and other Federal health care
programs, such as TRICARE and the Veterans Health Administration, will not pay for items or services that you furnish, order, or prescribe.
Excluded physicians may not bill directly for treating Medicare and Medicaid patients, nor may their services be
billed indirectly through an employer or a group practice.
In addition, if you furnish services to a patient on a private-pay basis, no order or prescription that you give to that patient will be reimbursable by
any Federal health care program
You are responsible for ensuring that you do not employ or contract with excluded individuals or entities, whether in a physician practice, a clinic, or in any capacity or setting in which Federal health care programs may reimburse for the items or services furnished by those employees or contractors. This responsibility requires screening all current and prospective employees and contractors against OIG's List of Excluded Individuals and Entities.
This online database can be accessed from OIG's Exclusion Web site. If you employ or contract with an excluded individual or entity and Federal health care program payment is made for items or services that person or entity furnishes, whether directly or indirectly, you may be subject to a civil monetary
penalty and/or an obligation to repay any amounts attributable to the services of the excluded individual or entity. This can be an expensive penalty and it is critical that you screen the OIG Exclusion List on a regular basis and prior to hiring employees if your practice receives any federal or state funds for payments (including federal or state HMOs).