The Exclusion Statute

Posted on Jul 25, 2019 in Medicare Fraud

Your Anesthesia Compliance Tip for today is on the

Exclusion Statute:

Through the Exclusion Statute, the Office of Inspector General has the authority to exclude individuals and entities from Federally funded healthcare programs. In addition, it also maintains a list of all presently excluded entities and individuals. This list is commonly known as the List of Excluded Individuals/Entities (LEIE). Most importantly, all organizations who hire an individual or entity that your foresee will participate in a government program must review this list.

Initially we must focus on Mandatory exclusions:

First of these are the exclusions by which the OIG is required by law to exclude from participation in all Federal health care programs individuals convicted of the following types of criminal offenses:

  1. Initially, Medicare or Medicaid fraud, or any offenses related to the delivery of services under Medicare, Medicaid, or State programs
  2. Secondly, patient abuse or neglect
  3. Next, felony convictions for health care-related fraud, theft, or other financial misconduct
  4. Finally, felony convictions relating to unlawful manufacture, distribution prescription, or dispensing of controlled substances

 Secondly there are Permissive exclusions:

These are exclusions in which the OIG has discretion to exclude individuals and entities on a number of grounds,

  1. First, are misdemeanor convictions related to health care fraud other than Medicare or a State health program
  2. Fraud in a program funded by any Federal, State or local government agency
  3. Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
  4. Suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity
  5. Provision of unnecessary or substandard services
  6. Submission of false or fraudulent claims to a Federal health care program
  7. Engaging in unlawful kickback arrangements
  8. Finally, defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee

Most important, to avoid Civil Monetary Penalty liability, health care entities need to routinely check the (LEIE) List of Excluded Individuals and Entities to ensure that new hires and current employees are not on the excluded list. Above all it is perilous to ignore the Exclusion Statute. For any questions feel free to contact us.

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The Anti-Kickback Statute

Posted on Jun 24, 2019 in Billing, Medicare Fraud

A Criminal Law

The Anti-Kickback Statute is a criminal law that prohibits the knowing and willful payment or “remuneration” to induce or reward patient referrals.  It also applies to  the generation of business involving any item or service payable by the Federal health care programs. Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. Learn more.


Criminal penalties and administrative sanctions for violating the Anti-Kickback Statute include fines, jail terms, and exclusion from participation in the Federal health care programs. Under this law, physicians who pay or accept kickbacksalso face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.

Target for Kickbacks

As a physician, you are an attractive target for kickback schemes because you can be a source of referrals for fellow physicians or other health care providers and suppliers. You decide what drugs your patients use, which specialists they see, and what health care services and supplies they receive. Many companies will attempt to take advantage of this relationship. They will attempt to pay you for the referrals.

Moreover, just as it is illegal for you to take money from providers and suppliers in return for the referral of your Medicare and Medicaid patients, it is illegal for you to pay others to refer their Medicare and Medicaid patients to you.

In addition, Medicare and Medicaid programs require patients to pay copays for services and you are required to collect them. Waiving these copays could implicate the Anti-Kickback Statute. Of course it is OK to waive if the patient cannot afford or if you have made efforts to collect.

Contact us for more information on these important topics and anesthesia compliance training for you and your company.

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