Exclusions and Debarment.

Exclusions from federal or state funded health care programs occur for a number of reasons. Federally excluded or debarred entities are governed by the Office of Inspector General (OIG) and included on the List of Excluded Individuals/Entities (LEIE). Any health care professional or business who hires a participant of this list may be subject to civil liability. Further, the Centers for Medicare and Medicaid Services (CMS) may debar or revoke entities that fail to follow the laws, regulations, and rules that cover government-funded health programs. G2Z Law Group, PLLC is dedicated to helping your health care business meet the challenges of compliance with the OIG and the CMS.

What are the reasons for exclusion and debarment?

The main reasons for exclusion are classified as either mandatory exclusions or permissive exclusions. Mandatory exclusions occur when an entity has a felony conviction of Medicare or Medicaid fraud, patient abuse or neglect, health-related fraud or abuse, or the unlawful manufacture, prescription, distribution, or dispensing of controlled substances.

Permissive exclusions give the OIG the discretion to exclude entities based on misdemeanor convictions and other undesirable behavior. This behavior may include health care fraud or violations relating to controlled substances. The OIG may also exclude a health care business for professional incompetence, failures in personal integrity, incidents of fraud or abuse, substandard care, and defaulting on loans, among other things.

The CMS may debar an entity for a variety of reasons. Much like the OIG, the CMS has discretion in determining what behavior requires debarment. Some of the most common reasons for debarment include noncompliance with enrollment procedures, fraudulent behavior, failures in reporting and documentation, failures upon on-site appraisals, felony convictions (or other crimes that are deemed to be detrimental to the interest of the health care program), and others.

For example, if the CMS discovers that a health care business is not in compliance with its enrollment requirements or has submitted fraudulent information during the enrollment process, it may revoke the entity’s enrollment. Additionally, if the CMS determines that an entity is knowingly falsifying Medicare claims or selling Medicare billing numbers, it has the authority to debar the entity.

What can G2Z Law Group do for my health care business?

G2Z Law Group recognizes that the best way to avoid exclusion and debarment issues is by preventing them. Our legal professionals can help your business address enrollment questions before they become cause for concern. Health care entities must diligently check the LEIE for conflicts and must aggressively pursue compliance programs and plans to prevent issues with the CMS. Our professionals are highly qualified from years of experience, and our firm can provide the legal guidance you need to comply with issues of exclusion and debarment from government-funded health care programs.

Contact us.

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