» Medicare and Medicaid Exclusions for Health Care Fraud Convictions
OIG also has the discretion to exclude individuals for certain other types of criminal offenses, including misdemeanor convictions relating to controlled substances. These are known as “permissive exclusions.” There are at least 16 grounds for permissive exclusions, and not all relate to a criminal conviction.
The following criminal convictions can give rise to a permissive exclusion of a minimum of 3 years:
- Misdemeanor convictions relating to health care fraud
- Fraud conviction related to non-health care programs financed by federal, state, or local government agencies
- Convictions relating to obstruction of a health care fraud investigation
- Misdemeanor convictions related to controlled substances
For certain criminal convictions, known as “mandatory exclusions”, OIG is required to exclude an individual for at least 5 years.
Mandatory exclusions include:
- Conviction related to the delivery or an item or service under Medicare or Medicaid
- Convictions related to patient abuse or neglect in connect with the delivery of a health care service or item
- Felony conviction relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other misconduct in connection with the delivery of health care items or services
- Felony conviction relating to controlled substances
Exclusion means that Medicare, Medicaid, and other government health programs will cease making payments for items or services provided or ordered by the excluded practitioner. This applies even if the provider does not directly provide patient care.
For health care providers, the most serious collateral consequence of a conviction for health care fraud is likely to be “exclusion.” In this context, exclusion means that the health care provider can no longer participate as a provider in federal and state health care programs such as Medicare and Medicaid.
Exclusion refers to an administrative action undertaken by the Office of Inspector General (OIG) of the U.S. Department of Health & Human Services. OIG has the authority to exclude individuals and entities from participation in government health care programs when those people or entities have engaged in prohibited conduct.