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OIG & State Exclusions

Medicare exclusion will have devastating effects for you and your practice. Once you have been notified that you are excluded from Medicare, you must cease billing all Federally funded health programs and consult with an experienced Medicare exclusion attorney. Our attorneys defend providers nationwide during Medicare exclusion and Medicare reinstatement proceedings and can guide you through every step to ensure that you have the best possible chance at reinstatement. Our Medicare exclusion attorneys are familiar with what information the OIG will want to see in your statement to improve your chances of a favorable Medicare reinstatement decision. Medicare exclusion will likely 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 (Medicare, Tricare, etc)
    • GSA exclusion (debarment) from Federal contracts

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 health care 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 Stark violations can be excluded whether it results in a conviction or not.

How to Appeal Medicare Exclusion Decision

You have only sixty (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. An experienced health law attorney can help you navigate the hearing and appeal process. 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 to Apply for Medicare Reinstatement

Medicare reinstatement is not automatic. If you have been 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 re-apply 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 their 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.

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Reduction of a Medicare and Medicaid Exclusion Period

A pharmacist was convicted of a controlled substance violation. As a result, he was excluded from participation in Medicare and Medicaid by the Office of Inspector General (“OIG”). His exclusion period was increased beyond the mandatory minimum time period of five years.

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