Did you know that you could be on the Medicare/Medicaid exclusion list and not be allowed to take care of Medicare or Medicaid patients? If you were placed on this list, where would you work? In this day and age, pretty much every health care entity cares for Medicare or Medicaid patients.
So, what is the exclusion list?
The Office of the Inspector General (“OIG”) is responsible for maintaining this exclusion list. When the OIG is considering excluding an individual or entity, the process varies depending on the basis for the proposed exclusion.
There are two types of exclusions: mandatory and permissive. In either case, the health care provider will receive a written Notice of Intent to Exclude, which includes the basis for the proposed exclusion as well as a statement about the potential effect of the exclusion.
The person or entity has 30 days to provide the OIG with any relevant information and mitigating circumstances to show that the exclusion is not warranted. Mandatory exclusions are for a minimum 5-year period and do not come off automatically but requires a written request be provided for that. If the OIG proceeds with the exclusion, a Notice of Exclusion will be issued.
So, how do people get on the exclusion list?
With mandatory exclusions, the OIG is required by law to exclude from participation in Medicare/Medicaid programs certain types of criminal offenses such as:
- fraud as well as any other offenses related to the delivery of items or services under Medicare/Medicaid or other State programs;
- patient abuse or neglect;
- felony convictions or other health care related fraud;
- theft or other financial conduct;
- felony convictions related to unlawful manufacture, distribution, prescription or dispensing of controlled substances.
Under permissive exclusions, the OIG has discretion to exclude individuals for:
- misdemeanor convictions relating to health care fraud other than Medicare or a State health program;
- misdemeanor convictions relating to the unlawful manufacture, distribution, prescription of controlled substances;
- suspension, revocation or surrender of a license to provide health care for reasons bearing on professional competence, professional performance or a financial integrity provision of
- unnecessary or substandard services;
- defaulting on health education loan or scholarship obligations.
Nurses can be placed on this list if:
- you are convicted of:
- prescription fraud or;
- any criminal offense regarding Medicare or Medicaid or;
- withholding of services to Medicare or Medicaid patients;
- your license is:
- placed on suspension or;
- revoked or;
- surrendered for reasons bearing on certain enumerated circumstances.
You’re probably wondering how you can find out if you are on the exclusion list. Just go to https://exclusions.oig.hhs.gov and you can see if you are listed.
If you are on the list (and you may even not have known that you were), check for guidance on the special advisory bulletin on the effect of exclusion. One thing you can do is to immediately contact the HHS OIG in Washington, D.C. to ask for reinstatement.
Also, your employer could face serious consequences if you are on the Medicare/Medicaid list and they allow you to work at their facility. Therefore, it is important to ensure you are not on the exclusion list if you had any action taken against your license or have had any criminal action.