What Causes Exclusion

What Causes Exclusion 2017-06-02T16:09:57+00:00

What Causes Exclusion

As outlined in the Code of Federal Regulations, the OIG may exclude an individual from participation in federal and state health care programs for a variety of offenses. Mandatory and permissive exclusions are as follows:

Mandatory Exclusions (no less than 5 years)

  • Conviction of healthcare program-related crimes

  • Conviction relating to patient abuse

  • Felony conviction relating to health care fraud

  • Felony conviction relating to controlled substance

Permissive Exclusions (period varies according to nature of offense)

  • Conviction relating to fraud

  • Conviction relating to obstruction of an investigation or audit

  • Misdemeanor conviction relating to controlled substance

  • Healthcare license revocation or suspension

  • Exclusion/suspension under a federal or state health care program

  • Claims for excessive charges or unnecessary services, and failure to furnish medically necessary services

  • Fraud, kickbacks, and other prohibited activities

  • Entities controlled by a sanctioned individual

  • Failure to disclose required information

  • Failure to supply information on subcontractors and suppliers

  • Failure to supply payment information

  • Failure to grant immediate access

  • Failure to take corrective action

  • Default on health education loan or scholarship obligations

  • Individuals controlling a sanctioned entity

Federal and state regulations/guidances indicate that health care institutions are expected to perform sanction screenings for their employees, both current and new hires. Any vendor organizations or contractors (e.g., referring physicians) that provide services to the health care institutions must also be screened, not only for exclusion of those entities, but for exclusion of any individual employees working for them. As stated in multiple places in the regulations, the OIG has the ability to sanction an individual on the basis of whether the person “knows or should know” of the actions constituting the basis for the exclusion. In October 2010, the OIG released a “Guidance for Implementing Permissive Exclusion Authority Under Section 1128(b)(15) of the Social Security Act”, giving OIG the authority to exclude an officer or managing employee of an entity that has been excluded or has been convicted of certain offenses. Click here to review the details.

To support health care organizations in their compliance efforts, various federal and state organizations provide online, searchable databases and updated database downloads, including: