Exclusion from Medicare and Medicaid

Exclusion from Medicare and Medicaid can have devastating consequences for doctors, nurses, pharmacists, and other healthcare professionals. 

Exclusion results in the inability to submit claims to federal healthcare programs.  It also means that you cannot work for any healthcare providers that accept payment from such programs.  In addition, many private insurance companies, providers, and suppliers will not do business with an excluded professional.

Unfortunately, too many medical professionals and their lawyers do not think about exclusion and its career-destroying potential until it is too late.  When faced with a billing dispute or a fraud investigation, they tend to focus exclusively on avoiding criminal charges or reducing the financial exposure.

Even if they avoid criminal charges, however, they still may face exclusion from Medicare, Medicaid, and other federal healthcare programs.

Under federal law, there are two types of exclusion:  mandatory and permissive.

Mandatory exclusions:  The Office of Inspector General (OIG) at the Department of Health and Human Services (HHS) must exclude individuals and entities from participation in all federal health care programs if they are convicted of certain criminal offenses.  The types of criminal offenses that result in mandatory exclusion from Medicare and Medicaid are:

• Medicare or Medicaid fraud;
• other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs;
• patient abuse or neglect;
• felony convictions for other health care-related fraud, theft, or other financial misconduct; and
• felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

Permissive exclusions:  The OIG may, but is not required to exclude individuals and entities that engage in other conduct, including conduct that does not involve Medicare or Medicaid.  For example, a misdemeanor conviction for submitting false claims to a private insurance company may result in exclusion from federal healthcare programs.  Even defaulting on student loans may result in exclusion.  The grounds for permissive exclusion include:

• misdemeanor convictions related to health care fraud other than Medicare or a State health program;
• fraud in a non-healthcare program that receives funding from any Federal, State or local government agency;
• misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances;
• suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity;
• provision of unnecessary or substandard services;
• submission of false or fraudulent claims to a Federal health care program, even if no criminal charges are filed;
• engaging in unlawful kickback arrangements;
• defaulting on health education loan or scholarship obligations; and
• controlling a sanctioned entity as an owner, officer, or managing employee.

If you are facing a dispute over claims submitted to Medicare, Medicaid, or even a private insurance company, then you should consult with an experienced Medicare and Medicaid fraud attorney who understands all the implications, including the possibility of exclusion and the potential impacts on your professional license.

To arrange a free and confidential consultation, call John Howley, Esq. at (212) 601-2728 or click here to reach our offices via email.

John Howley, Esq.

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