Top 6 Reasons for OIG Exclusions – new regulations proposed for 2016

Top 6 Reasons for OIG Exclusions – new regulations proposed for 2016

David Letterman had his Top 10 Countdown, Ryan Seacrest has the countdown at 11:59 p.m. News Year Eve. The OIG has its Top 6 reasons for, and by number, excluding a person or entity. The top reasons are in order as follows.

Keep in mind, there are two types of exclusions: Mandatory and Permissive. The key factor is whether it is for a felony or misdemeanor.

1. License Revocation/Suspension

To avoid the conundrum of license revocation or suspension in your organization, ask for a copy of the license (or better yet, ask for the original and make a copy) and then verify it with the state Board of Nursing that issued it.

Check to see if the Nurse claims to have a multi-state license. If so, double check at this site to make sure the state issues and/or recognizes a multi-state license. If an individual presents a multi-state license, their primary state must be the state where they obtained the license.When verifying the license at the state Board of Nursing, determine if there are any current sanctions, disciplinary actions or limitations on the license. To avoid accepting a fraudulent license, or one that has been stolen through identity theft, you should conduct a Social Security Death Master Index search and confirm the with IRS the SSN belongs to the individual.

2. Program related convictions

“No payment may be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity.

What are the Penalties for allowing services to be performed by and billed to CMS by an excluded individual or entity?

Civil fines and monetary penalties can be assessed by the OIG. They include:

  1. $10,000 per each item claimed or services provided
  2. Treble (3 times the amounts claimed to CMS for reimbursement) damages
  3. Possible Program exclusion of the company
  4. Possible loss of right to bill CMS for services rendered
  5. Possible additional fines for filing false claims under False Claims Act (Penalties up to $11,000 per claim, and possible placement in a Corporate Integrity Agreement with the OIG- audits compliance).
  6. Possible criminal fines and/or jail time.

3. Abuse/neglect (of a patient)

In most cases the state licensing board has a mandatory obligation to exclude or sanction a provider for a minimum of five years to a period up to indefinite for felony convictions that result from patient abuse.

4. Felony healthcare fraud conviction

Congress passed the Bipartisan Budget Act of 2015, signed into law Nov. 2, 2015.  One of the many provisions in this new legislation has the effect of increasing civil monetary penalties to account for inflation by August 2016. It is interesting to note these healthcare fraud fines have not increased since 1987.

It’s better to be safe than sorry when it comes to preventing healthcare fraud and abuse. Make sure to monitor your employees for such unlawful activities or it can result in exclusions and can cost your company hefty fines.

5. Substance Abuse

In most cases the state licensing board has a mandatory obligation to exclude or sanction a provider for a minimum of five years to a period up to indefinite for felony convictions that result from substance abuse.

6. HEAL- Federal Student Loan Default

Seems kind of harsh doesn’t it?  You work so hard to earn your degree and pass an examination to prove your competency in order to get licensed. Then, for whatever reason, you stop paying back your federal student loan – and you run the mistake, in most states, of getting your license revoked. Even more, the OIG can also exclude you based on its discretionary OIG exclusion authority.

New Regulations –

Also, note in 2014 the OIG announced it was reviewing and promulgating new and expansive regulations. It authorized new OIG exclusions investigational inquiries – requirements to provide documents or face obstruction of an audit (and for failing to provide payment information requested), failure to timely provide access, if an individual orders or prescribes while excluded, making a false statement on an enrollment application or to an investigator, failure to return an over payment, Medicare Advantage and Part D plan sponsor misconduct.

In addition, new and expanded civil fines and penalties are proposed. It is expected that the OIG should release its final regulations in 2016.

Now is the time to review your compliance plan for 2016 and make sure you are prepared to monitor for possible fraud and abuse as well as make sure that you are adequately training your staff on the do’s and dont’s on how to report possible infractions.

Michael Rosen, ESQ

Written by Michael Rosen, ESQ
ProviderTrust Co-Founder,

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as: Inc Magazine’s Inc 500 Award and Nashville Chamber of Commerce Small Business of the Year
Connect with Michael on Linkedin

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