Medicare Program Exclusion Can have Devastating and Far-reaching Effects

Wednesday, April 18, 2012

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Few health care practitioners really understand the significance that being excluded from the Medicare Program may have.  Exclusion usually occurs as a direct result of disciplinary action being taken by the state board of medicine, board of nursing, board of psychology, board of pharmacy or other health care licensing entity.  If revocation, suspension, restriction or limitation of a license occurs, this is reported to the National Practitioner Data Bank (NPDB).  What few understand is that if the licensed individual or business entity voluntarily surrenders the license after charges have been filed or an investigation has been opened, this is treated the same as a disciplinary revocation and is reported out to the NPDB the same way.  This occurs, even if the professional has similar valid licenses in other states or a different type of license.

This will result in action being initiated by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), to exclude the individual from the Medicare Program for a certain number of years.  This will come to the person who is the subject of the action in a simple, innocuous looking letter from the OIG's Office.  DO NOT IGNORE THIS!  DO NOT TREAT IT LIGHTLY! TREAT IT AS A SERIOUS MATTER!

Exclusion from the Medicare Program can have devastating and far-reaching consequences that an individual may not even contemplate happening. These include, for example:

-Termination for cause from all state Medicaid Programs.

-Loss of state professional licenses in other states and jurisdictions.

-Loss of hospital, ambulatory surgical center (ASC), and nursing home clinical privileges.

-Removal from the provider panels of health insurers.

-Loss of ability to contract or work for any individual or entity that contracts with the Medicare Program in any capacity (officer agent, shareholder, director, employee or independent contractor, even for non-Medicare products and services such as office supplies, building and construction services, software and systems support, etc.), including physicians, medical groups, hospitals, healthcare systems, ambulatory surgical centers, skilled nursing facilities, health insurance companies, etc.

-Placement on the General Services Administration (GSA) Exclusions List (or "Debarred" List) from government contracting.

-Loss of ability to contract or work for any individual or entity that contracts with the federal government in any capacity (officer agent, shareholder, director, employee or independent contractor, even for such services as construction projects, janitorial contracts, computer equipment and software services, real estate brokers on federally underwritten housing loans, sales of motor vehicles, products and services to the government, etc.

It is important to fight any action commenced to suspend or terminate your participation in the Medicare Program or to exclude you.  It is important to attempt to petition to have your exclusion from the Medicare Program lifted if this has happened.  It is extremely important to have representation by a competent, effective health care attorney with experience in these matters to represent you.

Furthermore, reinstatement is not automatic.  Even after a revocation for a period of time is over, the individual still must apply to the OIG for reinstatement.

For an example of a letter from the Office of the Inspector General (OIG) granting a request for reinstatement to the Medicare Program after exclusion and granting removal from the List of Excluded Individuals and Entities (LEIE), from an application that we submitted for a health professional to the OIG, click here.

The attorneys of The Health Law Firm have experience in dealing with the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), ind defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

About the author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com

Tag words:  Office of Inspector General (OIG) Exclusion, Application for Reinstatement, Medicare Exclusion, OIG Hearing, Request for Reinstatement, Removal from List of Excluded Individuals and Entities (LEIE), Application to OIG, Medicare Reinstatement

4/18/2012

Comments:

Response to: Medicare Program Exclusion Can have Devastating and Far-reaching Effects
Monday, August 13, 2012
Jaswinder says:

Has any physician who has been convicted of health care fraud and has been put on the list of excluded individuals mandatorily for 5 years been able to get reinstated with medicare

Response to: Medicare Program Exclusion Can have Devastating and Far-reaching Effects
Thursday, October 4, 2012
Name Omitted says:

Perhaps we should have contacted you before when we still had a little money left. My wife is a Geriatrician. Because of a "Consent Order" by the [state omitted] Medical Board Medicare says that her license was suspended and revoked her privileges. Her license was never suspended and is in fact clear and unrestricted. The Medical Board has written a letter confirming this. We have lost all income and are entering a time of great crisis. We asked our Senator [name omitted] to help and they did contact Medicare. The bottom line, it may be months more before this case is even heard. Just wanted to add some info for the kind of articles you publish on the web. Thanks for the opportunity.

Response to: Medicare Program Exclusion Can have Devastating and Far-reaching Effects
Monday, January 14, 2013
robbed says:

I am not a physician, but I was an aide. Another woman and myself shared a client and while I worked through an agency she had an IP number which meant many hoops for her anytime there were changes to the schedule. This being the case she and I would swap hours on occasion if one of us needed to, but still bill what was scheduled. For instance if I was working 8-12 and she 12-4 and she had an afternoon appointment we would swap. Same number of hours, just at a different time on the same day. I understand now that this wasn't good practice, but when she went to Florida on vacation with her family and continued to bill, my life ended upside down. I spent a weekend in jail, plead quilty to a misdemeanor and lost my job. I am ashamed and embarassed and do my best to make sure no one knows about what has happened. I only made 10 per hour but it was a job and it kept a single mother of 3 off welfare. I never took anything from anyone and I feel the weight of this everyday! I only w

Response to: Medicare Program Exclusion Can have Devastating and Far-reaching Effects
Thursday, October 16, 2014
George Lazopoulos says:

Dear Sirs, I am a dentist in the state of Illinois and was excluded from the Medicare/Medicaid programs due to a conviction in 2002. I would like to be reinstated. Would you be able to refer me to someone who could help me in this area. Thank you,

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