OIG Exclusions

As many healthcare providers know, the OIG has the authority to exclude individuals and entities from federally funded health care programs such as Medicare and Medicaid. The exclusions fall into two categories, mandatory and permissive. OIG is required by law to exclude any healthcare providers from participation who have been convicted of criminal activity falling under those categories. Mandatory exclusions include convictions for fraud under any federal or state health care programs and patient abuse or neglect, just to name a few. Permissive exclusions include healthcare licensure suspensions, revocations or surrenders for reasons of professional competence or performance and misdemeanor  convictions for fraud in a program funded by any federal, state or local government  but can also include things unrelated to healthcare like defaulting on education loans. With permissive exclusions, the OIG can, at their discretion, choose to exclude individuals or entities.


If you are a health care licensee participating in any federally funded program, or employed by such an entity, you should be aware of the possible consequences of a guilty plea or verdict, or even a no contest plea to felony or misdemeanor charges. Similarly, licensing actions by the state may also have the effect of adversely affecting federal participation. Though OIG does provide for a hearing or appeal process, it is crucial to understand the possible exclusion effects prior to any guilty plea or conviction, deferred disposition or other type agreement.


Currently, the OIG is trying to expand its permissive exclusion authority not only on the types of offenses included for exclusion, but also authority on the period of exclusion for certain types of offenses. The period for public comment ends July 8, 2014. If you would like to comment on the proposed rules, please visit: http://www.regulations.gov/#!documentDetail;D=HHSIG_FRDOC_0001-0394.


If you would like to read more about OIG’s proposal to expand exclusion authority, you can read this article (http://www.americanbar.org/publications/aba_health_esource/2013-14/june/oigs_proposal_to_expand.html).