Beware of Excluded Individuals and Entities

By: Anne Novick Branan

One of the recent enforcement trends landing practitioners in hot water is the federal government’s pursuit of those who employ Medicare or Medicaid excluded individuals or entities. Federal statutes allow the Office of Inspector General for the Department of Health and Human Services (OIG) to exclude individuals and entities from participating in federal healthcare programs if they have been convicted of fraud or engaged in other misconduct. State Medicaid programs are required to exclude from participation any person or entity that has been excluded by the OIG. As of April 2016, more than 60,000 individuals and 3,000 entities were excluded from participation in federal healthcare programs.

Federal healthcare programs are prohibited from paying for items or services that have been furnished by someone who has been excluded from participation in these programs. Providers must ensure that they do not bill for services furnished by excluded persons. An excluded individual or entity engaged by a provider directly or even indirectly, such as through a staffing agency can raise concern. Companies, like home health agencies and labs, that bill federal programs for services prescribed or ordered by an excluded physician are also at risk. Excluded individuals may include nurses, physicians, or x-ray technicians, among others. Excluded individuals in administrative roles, like coders or marketers, who do not directly furnish healthcare services can also cause trouble for providers.

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