The Exclusion Statute

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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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