OIG & State Exclusions: Being Removed from Medicare, Medicaid, TriCare Billing

How Devastating Can Medicare Exclusion Be for Your Healthcare Practice?

Very devastating. If your healthcare practice (general physician, dentistry, pain management clinic, ophthalmology) is notified of its Medicare exclusion, you must cease billing all federally funded health programs. That can cause:

    • Termination from all state Medicaid programs
    • Loss of professional licenses in some states
    • Loss of hospital privileges
    • Exclusion from health insurance provider panels
    • Exclusion from all federally funded health programs, such as Medicare and TriCare
    • GSA exclusion (debarment) from federal contracts

What Are Some of the Reasons for Medicare Exclusion?

You can be excluded from Medicare for a variety of reasons outlined in 42 U.S.C. §1320a-7.

Some felony convictions can result in Medicare exclusion, especially those arising from healthcare fraud or the unlawful manufacture, distribution or prescription or dispensing controlled substances (drug trafficking).

You also can be excluded from Medicare for a misdemeanor conviction related to obstruction of an investigation or controlled substances.

State professional license suspension also can result in Medicare exclusion. Additionally, any individual who has engaged in fraud, kickbacks and/or self-referral violations (Anti-Kickback and Stark Law/self-referral) can be excluded — even if it does not result in a conviction.

How Can I Appeal a Medicare Exclusion Decision?

You have only 60 days from your notice of Medicare exclusion to appeal the HHS OIG decision. Given that Medicare exclusion can be career ending, you should appeal your Medicare exclusion by requesting a hearing before an Administrative Law Judge as soon as possible.

As with reinstatement, you essentially have one shot at an appeal, and you should consider hiring a Medicare exclusion reinstatement attorney to appeal the Medicare exclusion decision. Pursuant to 42 CFR 402.214, you must request a hearing within 60 days from the receipt of the notice of exclusion. The request for a Medicare exclusion hearing should be completed by an experienced health law attorney and must include:

    1. A statement as to the specific issues the individual takes with the Medicare exclusion
    2. Basis for the disagreement of the Office of Inspector General’s decision
    3. Reasons why the proposed length of exclusion should be modified
    4. Reasons, if applicable, why the health or safety of Medicare beneficiaries does not warrant exclusion

If you do not file a timely request for a hearing, you may lose your right to appeal. Therefore, it is imperative that you file your request for a Medicare exclusion hearing within 60 days and ensure that it contains all the necessary information. Failure to properly petition for a Medicare exclusion hearing will result in loss of your right to appeal.

If you are granted a hearing, your attorney will be able to present arguments to an Administrative Law Judge and seek reinstatement.

If the Medicare exclusion was in error, you will be reinstated.

How Can I Apply for Medicare Reinstatement?

Medicare reinstatement is not automatic. If you are notified of exclusion from Medicare by the OIG, you must understand that you are prevented from working for any individual or entity that contracts with Medicare, TriCare or other federally funded programs until you receive notice of reinstatement.

If a health care provider is excluded from Medicare, he/she can reapply within 90 days of the expiration of the Medicare exclusion. It can take up to six months or more for the OIG to rule on your Medicare reinstatement application.

To apply for Medicare reinstatement, you must send a written request to the OIG and provide a statement with the relevant authorization forms. The information in your statement and forms will be evaluated, and the OIG will send you written notification of its decision, which could take up to 120 days or longer.

If the OIG denies your Medicare reinstatement application, you will not be able to apply for Medicare reinstatement for one calendar year.

Two surgeons oporating on a patient.

How Can the National Medical Compliance Lawyers at Chapman Law Group Assist with Medicare Reinstatement?

Our Medicare exclusion lawyers at Chapman Law Group defend health care providers nationwide during Medicare exclusion and Medicare reinstatement proceedings. With strong experience in health care compliance strategies and Medicare audit process representation, we can guide you through every step to ensure that you have the best possible chance at reinstatement. We know what information the OIG will want to see in your statement, thus improving your chances of a favorable Medicare reinstatement decision.

With four national healthcare law office locations to serve you, our health care compliance lawyers will provide the advice and expertise your practice needs.

Chapman Law Group has four national compliance practice offices: Detroit, Michigan; Miami and Sarasota, Florida; and Los Angeles/Southern CaliforniaContact us today.

Need an Attorney? Contact us now!

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