OIG Issues Proposed Rule Related to Health Care Exclusion Authority

The Health and Human Services Office of Inspector General (OIG) issued a proposed rule related to its authority to exclude individuals and health care entities from participation in federal health care programs, such as Medicare and Medicaid.  The proposed rule codifies changes made by the Affordable Care Act of 2010 (ACA), which significantly expanded the OIG’s authority to protect federal health care programs, and other updates pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).  This includes the OIG’s authority to exclude individuals and entities for (i) conviction of an offense in connection with obstruction of an audit; (ii) failure to supply payment information for items or services for which payment may be made under a federal health care program; and (iii) making, or causing to be made, a false statement, omission, or misrepresentation of a material fact in an application to participate as a provider of services or supplies under a federal health care program.  Visit this OIG website for additional background on the OIG’s exclusion authority.

The proposed rule also seeks to implement procedures for early reinstatement for exclusions related to the loss of a health care license and to make certain technical and clarifying changes.  For example, the OIG seeks to fix the inconsistency between the regulatory and statutory language related to repeat offenders by clarifying that if an individual has been previously convicted of an offense that would have mandated exclusion, regardless of whether the individual was previously excluded, the OIG must exclude for a minimum 10-year period or permanently if the individual has been convicted on two or more previous times.  Other key topics addressed in the proposed rule include exclusion of entities owned or controlled by a sanction person; exclusion of individuals with ownership or control interest in sanctioned entities; and scope and effect of exclusion.

Health care entities should carefully review the proposed rule and consider submitting comments to the OIG.  Comments to the proposed rule must be submitted by July 8, 2014 through the Federal eRulemaking Portal, mail or hand delivery.  Submissions should reference file code OIG-403-P2.

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Filed under Fraud and Abuse, OIG Guidance

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